He Said, She Said: Health at Every Size®

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Over the last several months, we have been learning more about the Health at Every Size® (HAES®) movement. The HAES® approach to health emphasizes eating intuitively and being physically active for pleasure rather than focusing on weight loss and dieting.

Clearly, the HAES® approach flies in the face of almost everything our society believes about health (i.e., that thin people are innately healthier than heavier people, and that losing weight is the be-all and end-all to being a healthier, happier person). Given the years and years of messages we have received about how dangerous it is to be overweight, the HAES® approach is a pretty revolutionary and scary premise.

He Said

The HAES® approach is most typically brought up in the context of overweight individuals, but health – or lack thereof – at leaner sizes also falls under the topic’s umbrella. In other words, just because someone is thin does not mean he or she is healthy.

Recently, a new patient was talking with me about the pressure she feels to be skinny in her community where so many of the women she sees around town are thin. While some of the women my patient envies no doubt are blessed with a foundation of helpful genetics on top of which they have built healthy lifestyles, some of them keep their figures through unhealthy means: excessive exercise, disordered eating, laxative abuse, anorexia, purging, etc.

The truth is that so many of us are dealing with health conditions invisible to others, such as diabetes, hypertension, depression, arthritis, Celiac disease, eating disorders, HIV, and high cholesterol, just to name a few, that we can judge neither one’s health nor lifestyle based on his or her size alone with any degree of accuracy.

She Said

I find a number of things about the HAES® approach interesting. The aspect I like the most is that it stresses that health is much more than just how much you weigh.

In a previous blog, I discussed the limitations of the BMI, as it does not give us enough information about an individual to determine his or her overall health. the HAES® approach says that health is about eating according to your body’s hunger, fullness, and appetite cues; exercising for pleasure (as opposed to doing so just to burn calories); and recognizing that health comes in all shapes and sizes.

These ideas are things that I try to stress in my sessions with clients – that if you are only focused on calories in vs. calories out, weight, and exercise solely for the purpose of weight loss, you are missing the bigger picture.

Gallo Pinto

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Before the Boston marathon bombings caused me to shift gears, I had intended on writing last week’s blog entry about our recent trip to Costa Rica.  In the very early morning hours of Patriot’s Day, Joanne and I returned from a short vacation there.  As was the case on our honeymoon, we took particular interest in the food.

For better or worse, much of the food at the two resorts where we stayed was Americanized.  In other words, the menus contained several items that were not traditional in Costa Rica, but rather were attempts to provide American tourists with familiar foods: cheeseburgers, pasta, pizza, French fries, etc.

We did, however, learn that rice and beans are prevalent in Costa Rican cuisine and many Costa Ricans start their day with a dish of gallo pinto, a traditional dish made with these two staples.  I had gallo pinto for breakfast a handful of mornings and really enjoyed it.

GalloPinto

I find that when the topic of breakfast first comes up in my sessions, patients initially feel like they are limited to the usual options: cold cereals, hot cereals, bagels, eggs, bacon, waffles, muffins, pancakes, yogurt, etc.

What they come to realize though is that breakfast is just like any other meal of the day and we need not limit ourselves to the traditional breakfast options.  In other words, while breakfast options certainly include the typical options I listed above, they also include salads, sandwiches, entrees, or anything you might have at any other time of the day.  Gallo pinto is a perfect example.  Not too many Americans would typically consider rice and beans a breakfast option, yet they fill that role quite well for millions of Costa Ricans.

What might you consider having for breakfast if you expand your options beyond typical breakfast foods?

Where Dreams Literally Come True

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The following blog entry appeared as a letter to the editor in the Wellesley Townsman on April 25, 2013.

I ran my last Boston marathon years before Joanne and I met.  Since then, she has occasionally asked me if I would ever consider running another one.   My response was always no, I could not envision a reason to do so.

The stretch of Boylston Street where Monday’s bombings occurred is special ground.  Every time I was on the verge of finishing the marathon, I took off my sunglasses as I made the left onto Boylston because I wanted the most raw, unfiltered absorption of the experience and atmosphere as I could have.  The straightaway is long, much longer than it appears on TV.  The finish line, in sight the entire time it takes to cover the distance, cues each runner to remember the reasons why he or she decided to race in the first place.  Throughout their unpleasant, cold, and mushy winter training, runners fantasize about running down Boylston with the crowd roaring, the finish line in sight.

That stretch of Boylston might be the only spot in the entire city where dreams literally come true for thousands of people every single year.

For many runners, finishing the marathon would be impossible without the support and encouragement of those along the route, including not just the volunteers, but also the spectators. They make the day what it is.  Without them, the marathon would not be an event, but rather just a bunch of people going out for a jog.  When I had to drop out of the 2004 race due to a medical problem, a complete stranger ran out her front door after seeing me collapse at the end of her driveway and cared for me until I was loaded into an ambulance.  More times than I can count, I saw struggling racers break out of their shuffling walks and back into jogs because somebody on the side of the road told them they could still do it.

A tragedy like Monday’s bombing would have been wrong no matter where it occurred.  If they blew up the local diner or bus stop instead of the Boston marathon finish line it would have still been wrong, but it would have been a different kind of wrong.  In a city where we tend to keep to our own circles, cut each other off and exchange middle fingers in traffic, and walk past each other without even batting an eye, the marathon is the antithesis: strangers act like best friends in order to build something overwhelmingly positive.  Somebody attacked that and tainted it.  They went after the city at its finest and hit us in the heart.

We need to get that back; we need to make that stretch of Boylston special again.

Many ways exist in which we can make that happen, none of which will be more significant than when thousands of spectators line Boylston Street again for next year’s race.  As for me, I am a runner, I have been my whole life.  It’s what I do.  Given that, I aim to establish a 2014 marathon charity team to fundraise for Monday’s victims, to enter the race as a member of that team, and to run down that Boyston straightaway slapping hands with every spectator I can reach.

George Etzweiler

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I was going to continue “The Interior” series with two more entries in which I discuss foods like baking goods, nuts, and supplements.  However, people seem to already get the point that making sweeping generalizations about where to shop is not necessarily a great strategy, and I am wary of beating a dead horse.  If you are just dying to read what I wrote about almonds and cocoa though, send me an email.

I prefer to switch topics completely in order to share a photo I have been meaning to post for quite some time.

91YearOldThis is George Etzweiler, from State College, Pennsylvania, finishing the Mount Washington road race in 2011.  As he approached the finish line, virtually all of the spectators and runners who were still at the summit turned their attention to him and cheered.  Some of us (including me) took his picture.

At the time of this photo, Mr. Etzweiler was 91 years old.

He finished the race again in 2012, at the age of 92, with a faster time than he ran at age 89.

The Long Red Line

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A TV show that does spotlights on local businesses came down to our office the other day to film an episode about our practice.  After interviewing Joanne and me and filming a couple of mock sessions, the camerawoman took some video of the office itself.  When I noticed she was looking at the large map I have hanging on my wall, I explained to her that I rode my bicycle across the country for charity back in 2006 and the red line on the map snaking from Seattle to Boston is the route that we pedaled.

She was intrigued and asked me why I had not said anything about the bike ride when she was interviewing me.  As I was pausing to consider my answer, she offered, “I guess it doesn’t have much to do with nutrition, right?”  My immediate reaction was agreement; the trip had nothing to do with either our business or nutrition counseling.  Really, I had just put the map up for decoration and perhaps a conversation piece; therefore, I saw no reason to discuss it on a program about our practice.

As I told her more about the map and our ride though, I realized just how wrong my initial reaction was.

I kept that map in my backpack during the ride.  After each day’s trek, I took the map out and drew a short line with a red Sharpie indicating where we had biked that day.  I clearly remember being in Montana, looking at the vast distance from there back to Massachusetts, and having a hard time believing we would ever actually get to Boston.

Nobody bikes from Seattle to Boston overnight, and there are no shortcuts.  It takes waking up each morning and making a conscious decision to put in the work necessary to go to sleep somewhere a little farther east than the night before.  The daily progress sums over time, and with each day’s trip the ultimate destination grows closer.

What began as a short, red segment connecting Seattle to our first stop in Sedro-Woolley, Washington, grew into a gigantic, continent-spanning line because each day we resolved to progress a little bit closer to our goal.  Day after day, we shrunk the transcontinental distance that once seemed insurmountable until we were standing on a Massachusetts beach.

The more I think about it, the more it sounds exactly like the work we do here with our patients.

The Interior, Part 4: The Canned Goods Section

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Canned goods have an often undeserved bad reputation.  True, the sodium is often high, as can be the sugar, and some cans are lined with bisphenol A (BPA).  However, many low-sodium products are available, including vegetables and fish canned without added salt.  Similarly, fruits are available in juice, as opposed to heavy syrup, thereby sparing a considerable amount of sugar.  These days, perhaps due to the BPA concern, several traditionally canned products, such as soups and beans, are now available in boxes instead.

Beans are cheap protein sources that also provide plenty of fiber.  Garbanzo beans, for example, are available in boxes without any added salt, and many people enjoy them on top of a salad as a change of pace from grilled chicken, tuna, or other animal-based proteins.  Canned tuna, sardines, and salmon all provide protein and heart-healthy omega-3 fatty acids in a shelf-stable form that can conveniently wait in your pantry until you need them.  Because sardines and canned salmon often (but not always) contain edible bones, they are great sources of calcium as well.  For those who are concerned about potential BPA in the cans, salmon and tuna also come in packets.

I have seen patients of mine utilize canned/boxed soups in different ways.  One popular method of controlling calorie intake is to begin a meal with a broth-based soup such as minestrone, vegetable, or chicken.  Such soups are relatively low in calories and can help make one feel full without contributing much in the way of calories.  In other words, if someone has a smaller portion of his entrée and substitutes some broth-based soup instead, the overall meal will likely be lower in calories.  I also see patients who will mix together a broth-based soup with frozen vegetables, sprinkle in some nuts or beans for extra protein, add in some frozen brown rice, and bring the concoction to work as a healthy lunch that requires virtually no preparation and nothing but a microwave to heat.

My neighborhood store stocks oils in the canned goods aisle too.  Coincidentally, I write this at the same time as I am preparing for an upcoming guest appearance on Beyond Strong with Jessica R. on which I will be discussing fats.  I could write an entire blog series about fats, but for the sake of discussing them in the context of this blog entry, I will streamline the topic into just a few points.

  1. Olive oil is not the only healthy oil on store shelves; there are plenty of others, too.
  2. Opt for fats that are liquid at room temperature (e.g., olive, canola, soybean, corn) as they tend to have a healthier ratio of unsaturated-to-saturated fat in comparison to those that are solid at room temperature (e.g., coconut, palm, palm kernel).
  3. Fats help the body absorb fat-soluble nutrients, such as vitamins A, D, E, and K, as well as the phytochemical lycopene, so consider skipping the fat-free salad dressing and instead choose one that has some fat in it.  Even better, choose a dressing high in monounsaturated fat (such as one made primarily with olive oil).  One research study I read found that it took just three grams of monounsaturated fat to achieve the same level of vitamin A absorption achieved with 20 grams of other fats.
  4. Not all oils are meant for use at the same temperature, so check the bottle to make sure the one you are selecting fits your intended use.  For example, extra virgin olive oil, with a smoke point (the temperature at which oil begins to break down) of 320-375o F, works well for low-heat cooking and salad dressings.  In contrast, canola oil has a higher smoke point of 468o F, making it a better choice for sautéing and stir-frying.

Next installment, I will discuss the baking goods section . . .

The Interior, Part 3: The Dairy Section

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What are you talking about?  The dairy section is on the perimeter, not in the interior!

Not necessarily.  At my neighborhood store, for example, the dairy section is in the exact middle of the store.  This further emphasizes what an oversimplification shopping just the perimeter is, as there is still no guarantee what you will encounter (and what you will avoid) if you do.

In the dairy section, the two options that immediately caught my eye were Greek yogurt and eggs.  Greek yogurt, which is higher in protein compared to standard yogurt, works well as a component of breakfast, a mid-morning or mid-afternoon snack, or a post-exercise recovery food.  Like yogurt, eggs can also be part of a healthy breakfast.  Some people enjoy hard boiling them and adding them to lunchtime salads.  Contrary to popular myth, eggs are not the cholesterol disaster some people believe them to be.  Furthermore, the yolks are great sources of fat-soluble vitamins and help one to stay satiated.

How could I discuss the dairy section without even mentioning milk, a great source of protein and calcium?  In addition to the typical ways in which people consume milk, its combination of protein, carbohydrate, and fluid make it a good post-workout recovery fuel.  Shelf-stable boxed milk is particularly convenient for this purpose.  Some of my patients who exercise after work will throw a box in their gym bags in the morning and drink it after an exercise session in the evening.  Parents also take them on outings with their kids without worrying about refrigeration, just the same as when they take juice boxes.

Although milk alternatives, such as almond, soy, rice, hemp, hazelnut, and oat, have different macronutrient compositions than cow’s milk (most are lower in protein, for example), people with lactose intolerance or milk protein allergies will find that these products often substitute well for traditional milk.  Oat milk, for example, has similar thickening properties to cow’s milk and can fill in quite well in a pudding mix, while almond milk is popular with cold cereal, and several of my patients like coconut creamer in their coffee.

Next installment, I will discuss the canned goods section . . .

The Interior, Part 2: The Freezer Section

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The freezer section contains some great options for healthy eating.  The standouts to me are the frozen vegetables and fruits, many of which contain neither added salt nor sugar.  Some of my patients use frozen produce either as a cheaper alternative to, or as a supplement to, fresh fruits and vegetables.  For example, if somebody does his weekly shopping on a Sunday in order to prepare for the work week, some of the produce may start to wilt, rot, or mold by late in the week if simply left on the counter or in the refrigerator.  Rather than make do with a small amount, or even zero, fruits or vegetables for the latter part of the week and weekend, he may use frozen fruits and vegetables until his next Sunday shopping trip.

A barrier some of my patients face when it comes to eating whole grains is the time it takes to cook them.  Products like frozen brown rice and frozen quinoa can cut down on cooking time immensely.  Brown rice, for example, might take somewhere in the ballpark of 45 minutes to make from scratch on a stove top, while frozen brown rice is ready after just a couple of minutes in the microwave or on the stove.  Similarly, frozen, pre-cooked steel cut oats can fill a need for somebody who wants a healthy, hot cereal for breakfast, but is too busy getting ready for work or school to do any significant cooking.

I cannot tell you how many new patients with celiac disease have come to me feeling discouraged that they could not find any gluten-free bread at their grocery store.  However, many gluten-free baked products reside in the freezer section, not the bread aisle where people understandably often look.  I found a wide range of gluten-free products in the freezer including not just breads, but also English muffins, waffles, frozen meals, and cupcakes.

Other products marketed towards those with food allergies or intolerances often reside in the freezer section too.  For example, I found a pizza made with a milk-free cheese substitute that I expected to taste, well, horrible.  But I bought it, tried it, and get this: I liked it.

Next installment, I will discuss the dairy section . . .

The Interior, Part 1

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A young couple passed by me in the grocery store the other day.  I heard the woman remind her partner, “Remember, we are only shopping the perimeter.”  You may have heard the same advice that she was presumably referencing, that purchasing foods only from the store’s perimeter is somehow healthier than including the interior aisles.  Like much of pop culture’s nutritional advice, this tip is an overgeneralization that, if followed, can cause people to unnecessarily skip plenty of healthy foods.

The stick-to-the-perimeter advice has some merit in that it encourages people to load up on fruits, vegetables, dairy, seafood, and poultry, which are traditionally located on a store’s borders.  The advice also tends to reduce the temptations to which people are exposed.  In other words, somebody who might buy Oreos on impulse is spared that temptation by entirely avoiding the cookie aisle.

Just because a food resides on the perimeter, however, does not mean it is one of the healthier foods in the store.  For example, guess what my neighborhood Whole Foods has on the perimeter: the bakery section!  Even on the perimeter, we are still subjected to temptations and less healthy foods mixed in with the rest.  In other words, the store’s perimeter is like the rest of life: we have to be able to make sensible and balanced food choices wherever we go.

As I considered what this woman said to her partner, I thought about some of the healthy foods they were missing, foods that not only would they never buy, but that they would never even see.  I went down the interior aisles a bit slower than usual, deliberately taking some time to explore the inventory and to consider some of the healthier options available and how one might choose to utilize them.

Following this entry will be a short blog series in which I am going to share some of my interior aisle reflections with you.  As I write, I will avoid singling out products by name, as I do not want anybody to mistake these musings as endorsements.  I invite you to post comments, including mentions of some of your favorite interior aisle foods and how you use them.

Next installment, we begin with the freezer aisle . . .

Hypotheses vs. Conclusions

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You may have read the blog entry that Joanne recently wrote in which she discusses the dangers of believing everything written about nutrition on the internet without considering the source.  One of the reliable sources of nutrition information online is the blog that Joan Salge Blake, MS, RD, LDN writes for boston.com.  In a recent post entitled “Do Sugar Substitutes Cause Cancer?” she discusses the widely-held belief that artificial sweeteners cause cancer, the historical roots of this belief, and the lack of any credible research whatsoever to support this belief.

Apologies to my former English professors who would frown at my decision to use “belief” three times in a single sentence, but I did so to emphasize my point: one of the main reasons that online nutrition information is often faulty is because the messages being conveyed are really just beliefs, theories, ideals, or hypotheses disguised as facts or well-supported conclusions.

Last month, I attended the Cardiometabolic Health Congress.  For four days, I sat in what might as well have been a series of statistics classes.  The presenters understood that the credibility of information rests on the quality and quantity of research supporting it.  Reliable information, like Joan Salge Blake writes about and Joanne and I use in our counseling, is founded on an evidence-based research approach.  The ethics of our profession demand it.

The authors of most website content, however, are bound to no such standards and are free to write whatever they please.  The result is that hypotheses are often misrepresented as conclusions despite the void of supporting data.  Remember this the next time you read about nutrition online.  Ask yourself who the author is, what his or her credentials are (if any), and be suspicious of claims that are not backed by reputable research.  If you get confused or have questions, ask one of us.  That’s what we are here for, and we are happy to help!