Category Archives: Eating Disorders

Pinkalicious

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Mondays are our kindergartener’s “media day,” which means she and her classmates visit her elementary school’s library and have an opportunity to borrow a book for the upcoming week. During one Monday afternoon walk home from school, she gave me a synopsis of the book she was taking home, something along the lines of, “She [the main character] eats a lot of pink foods and turns pink, then she eats more pink food and turns red, and then she eats green foods and her color turns back to normal.”

Uh-oh.

Right off the bat, I had a feeling where this was going. My intuition proved correct once I read the book myself. Pinkalicious is a funny and cute book, but it is problematic in certain ways. If your child is going to read it, an accompanying and clarifying conversation will be important in order to mitigate harm.

The story begins with the main character, a young girl named Pinkalicious, baking pink cupcakes on a rainy day. She disregards her parents’ commands and eats so many of them that she wakes up in the morning and discovers that she has turned pink. Her doctor diagnoses her with a case of “Pinkititis” and advises her, “For the next week, no more pink cupcakes, pink bubble gum, or pink cotton candy.” The doctor continues, “To return to normal, you must eat a steady diet of green food.” Immediately thereafter, the book reads, “(YUCK!)”

The accompanying illustration shows several pink foods crossed out, indicating that Pinkalicious is to abstain from them. While the picture does include strawberries, grapefruit, and watermelon, the vast majority of the foods are desserts: lollipops, jelly beans, cotton candy, ice cream, donuts, milk shakes, jello, and cupcakes.

Following her trip to the doctor, Pinkalicious suffers various consequences as a result of her altered color: Her friend cannot spot her because she is camouflaged among the pink peonies, a bee mistakes her for a flower and lands on her nose, and she cries for her mother to take her home after bees, butterflies, and birds surround her.

Back at home, Pinkalicious requests and is denied another pink cupcake. After pretending to eat her dinner of “mushy, dark vegetables,” she sneaks back into the kitchen in the middle of the night and devours a cupcake that her mother had hidden. In the morning, a horrified Pinkalicious awakens to discover that her condition has worsened: She is now red.

Desperate to return to her normal self, Pinkalicious says, “I opened the fridge, held my nose, and squeezed a bottle of icky green relish onto my tongue. I ate pickles and spinach, olives and okra. I choked down artichokes, gagged on grapes, and burped up Brussels sprouts.” The accompanying illustration shows a few fruits – limes, honeydew, green apple, and grapes – and a bunch of vegetables, including broccoli, cucumber, celery, asparagus, cabbage, and peas. After ingesting these green foods, Pinkalicious loses her discoloration and becomes “beautiful.”

Left to their own devices to interpret this story, a child has likely internalized the following messages: (1) Pink foods are almost exclusively sweets. (2) Too many sweets will make them sick. (3) Sweets have an addictive-like quality. (4) The way to get healthy is to completely avoid sweets and to instead eat green foods. (5) Green foods are almost exclusively vegetables. (6) Vegetables are yucky. (7) Vegetables make them pretty.

Unfortunately, all of these messages are problematic. Let’s take a look.

Problematic Message 1: Pink foods are almost exclusively sweets.

Plenty of pink foods exist that have zero to mild sweetness, including corned beef, edible flowers, beets, dragon fruit, rare steak, and Himalayan salt, yet the only examples of pink foods that the authors cite are sweets because the former is really just code for the latter.

Problematic Message 2: Too many sweets will make them sick.

Sure, too many sweets can make someone sick, a lesson that I learned on Halloween many years ago. However, we tend to single out and villainize sweets, as if they are somehow the only food group that can sicken us in excess, while ignoring the reality that too much of anything can be detrimental to our health. Remember that even water, when consumed excessively, can kill someone.

Problematic Message 3: Sweets have an addictive-like quality.

Admittedly, this message is more subtle than the others, and I can imagine that it will go over the heads of some children. However, for those of us familiar with the apparent fallacy of sugar “addiction,” we can see its theme in the way that Pinkalicious eats another cupcake despite already having turned pink and gone to the doctor as well as in the lengths that she goes to – deceiving her family, waking up in the middle of the night, and sneaking around – in order to obtain the cupcake. Nevertheless, research suggests that sugar “addiction” is not a true addiction, but rather a byproduct of how we tend to demonize and restrict sugary foods.

Problematic Message 4: The way to get healthy is to completely avoid sweets and to instead eat green foods.

If this general sentiment sounds familiar, maybe that is because our culture oftentimes splits foods into dichotomies and presents one side as sin and the other as salvation. Whole30®, detoxes, “clean eating,” etc., are all based on this basic – and flawed – premise.

Alan Levinovitz, a religion professor who has taken to writing about nutrition because of the intersectionality of spirituality and food, sums up the situation very well, “It’s terrifying to live in a place where the causes of diseases like Alzheimer’s, autism, or ADHD, or the causes of weight gain, are mysterious. So what we do is come up with certain causes for the things that we fear. If we’re trying to avoid things that we fear, why would we invent a world full of toxins that don’t really exist? Again, it’s about control. After all, if there are things that we’re scared of, then at least we know what to avoid. If there is a sacred diet, and if there are foods that are really taboo, yeah, it’s scary, but it’s also empowering, because we can readily identify culinary good and evil, and then we have a path that we can follow that’s salvific.”

Sickness and health are never entirely within our control and are certainly way more complex than eat this, not that.

Problematic Message 5: Green foods are almost exclusively vegetables.

To acknowledge the obvious, yes, many vegetables are green. However, for all the green veggies in the world, we also have pistachios, pumpkin seeds, avocados, and other fruits that the book excludes. Are sweets, such as lime jello and green apple jelly beans included? What about – gasp – green cupcakes? Of course not, and I think we all know why.

Problematic Message 6: Vegetables are yucky.

The attitude that we have towards various foods shapes how our children come to see them. In our culture, adults often teach children to view eating vegetables as a chore. For example, earning dessert by first eating vegetables teaches the child that consuming vegetables is the suffering that one must endure in order to be able to eat what they really want.

My first job as a dietitian was a traveling research position that sent me all over the country examining the foods and eating behaviors in elementary school cafeterias. All these years later, I still remember two specific schools. In one suburban Chicago school, the kids saw eating vegetables as uncool and would not eat them, so the cafeteria monitors would proactively remove the vegetables from the trays for fear that the uneaten veggies would be ammunition for a food fight. Peas were on the menu the day I was there, and I remember seeing the bottom of the trash bin lined with confiscated peas. Meanwhile, eating vegetables was the in thing to do in one northern Tennessee school. The problem the cafeteria workers faced there was that kids were taking too many vegetables from the self-serve salad bar, thereby exceeding the allowed serving sizes. The contrast between these two schools stuck with me because it illustrates how cultural views of a food shape its consumption.

Of course we all have our own unique food preferences and aversions, and some people genuinely just do not care for vegetables, but teaching kids that they are “yucky” is mostly a self-fulfilling prophecy.

Problematic Message 7: Vegetables make them pretty.

“I was me, and I was beautiful,” says Pinkalicious after eating green foods and returning to her normal hue. With beauty being the subjective entity that it is, the use of the first-person perspective is significant and raises questions to which we will never know the answers.

On the surface, this quote reads as a self-affirming statement, but does Pinkalicious – who loves the color pink – really think she looks better now than she did when she was pink, or is she rather expressing relief that her color now matches the necessary criteria for societal beauty standards? In other words, does she really think she is beautiful in her own eyes, or because others – her parents, her doctor, and society as a whole – have taught her that being pink was wrong?

Unsaid but certainly implied is the message that if Pinkalicious returned to her beauty after eating green foods, then she must have been less than beautiful when she was eating pink foods, which tells kids that eating sweets makes them less attractive. If that sounds like too much of a stretch, consider the multitude of my adolescent patients (and sometimes their parents, too) who scapegoat sweets for their acne.

Given how many people – including kids – learn to dislike their bodies and yearn to conform to whatever media, peers, doctors, family, friends, etc., say they should look like, the notion that vegetables can make someone beautiful is surely enticing. The problem is that this message is false. Regardless of what one considers beautiful, no food group has the power to dramatically alter appearance.

Do you really want to indoctrinate your kindergartener into diet culture? If not, make sure that enjoying a reading of Pinkalicious is accompanied with a conversation discussing these messages.

The End Is Near!

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Seven years ago, when I saw Chic in concert for the first time, Nile Rodgers used the interlude in one of their songs as an opportunity to tell the crowd about his recent cancer battle, which he ultimately won. The songwriter and producer explained that receiving the news inspired him to go on a music-making binge, as he figured he only had a short window of time left to express his art.

Earlier today, as I was driving home from the beach with our daughter, that memory crossed my mind. Since she will soon be restarting school, we have been trying to cram in as many daddy-daughter activities and outings – the Museum of Science, the Butterfly Place, farms, the zoo, fruit picking, restaurants, train rides, the aforementioned beach, etc. – as we can before the start of the school year interferes and forces these bonding experiences from frequent occasions to relative rarities. Before we have even left the parking lot of one activity, I am already thinking about the next one and all of the others that I hope to shove into our remaining time before it runs out. We have fun, but part of me is distracted, anxious, and sad as I think about the end.

Deadlines have their upsides because they can push us to accomplish tasks and achieve goals that might otherwise remain unfulfilled, but they bring with them stress and general feelings of unease that detract from the experience.

Life-threatening illnesses and the school calendar are examples of deadlines imposed upon us, realities that we just have to do our best to roll with, but sometimes we needlessly impose deadlines upon ourselves. A person who wants to get married by a certain age may settle because the timing is right even though the partner is wrong. Someone I know recently spent a hot summer evening in the emergency room with heat exhaustion and dehydration because they stubbornly kept hacking away at a tree they really wanted to cut down before dinnertime rather than conceding they should take an additional day to complete the project. When we were adolescents, a friend of mine wanted to bench press a particular weight before a school dance, and he ended up having to fight to free himself as the much-too-heavy bar laid across his chest.

Because this is a nutrition blog, I am of course thinking about the predicaments we can put ourselves and our relationships with food in due to self-imposed deadlines. An obvious example is the melancholy and frantic overconsumption that precedes a scheduled diet. Trying to lose weight before a wedding or another similar function is a common – yet problematic – behavior that is most likely to result in eventual weight gain and increased risk for developing a wide range of health woes. Someone I know severely dehydrated himself on his birthday and spent much of it at the gym because he had set a goal to be at a particular weight by his new age, and while he did survive and recover, he put himself in a dangerous situation for the sake of an arbitrary goal.

Imagine what these scenarios could look like instead without the needless deadlines. No diet on the horizon could mean more peaceful and intuitive eating without the threat of self-imposed food insecurity looming. Foregoing an attempt to lose weight before an event reduces the chances of harmful and discouraging weight cycling and creates space for the person to focus their time and attention on the big day itself and to go into it full of energy instead of depleted. Personally, I can think of more fun ways to spend a birthday than sweating out as much fluid as possible on an elliptical machine.

Time and opportunities are finite resources, and while we never know when they will run out, we can make life easier for ourselves by leaving self-imposed deadlines in the past.

When Family and Friends Lose Weight

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It’s the beginning of summer, and one theme in particular has been popping up a lot lately in my appointments with patients. It seems like everyone’s mother/uncle/friend from college/cousin has gone on a “weight loss journey” since the winter. As you might expect, witnessing your loved ones and/or friends and acquaintances engage in intentional weight loss can stir up a lot of feelings in those of us who are trying to embrace the bodies that we have. Research on intentional weight loss has found “almost complete relapse” after three to five years. Other data are more specific and suggest 90% to 95% of dieters regain all or most of the weight within five years, while other research has found that between one third and two thirds of people end up heavier than they were at baseline. It can be hard to watch others receive the praise and acceptance that often comes along with these “weight loss journeys.” It’s difficult to watch these folks gain more and more privilege while we remain in bodies that often put us at a disadvantage in our fatphobic society. So what are we supposed to do with all of these feelings?

First off, I try to remind my patients that their mother’s/uncle’s/friend’s/cousin’s bodies are not our business. I firmly believe in body autonomy, or as Ragen Chastain calls it, “The Underpants Rule.” In essence, what someone chooses to do with their body is up to them (as long as it is not harming others). Our family and friends will often make choices that we don’t agree with. And those of us who are trying to fight the near-constant onslaught of fatphobia we are fed on a daily basis feel strongly that these friends/family members are doing harm to themselves and perpetuating diet culture. But at the end of the day, we aren’t in charge of others’ bodies. Just like we wouldn’t want someone telling us how to live in our own bodies, we can’t police others.

That being said, I think there is nothing wrong with protecting oneself and setting boundaries around diet and weight loss talk. If you are active on social media and the friend/family member is an active poster of weight loss updates, befores and afters, or touting their new “healthy lifestyle,” it might be time to either snooze them for a short while or hide them from your timeline indefinitely. This can be done by clicking the “unfollow” button on someone’s Facebook profile or clicking the “mute” button on Instagram. By doing this, you are removing the element of surprise from seeing these things popping up on your timeline. It’s hard to look away or unsee some of these posts, so preventing them from appearing on your social media from the start can be helpful.

Another way that you can set a boundary is by being up front with the friend/family member about how their diet/weight loss talk is affecting you. Sometimes I will help my patients role play what they would like to say to the friend/family member who brings up their diet/weight loss. In these types of situations, I encourage patients to try to give their friend/family member the benefit of the doubt. That is, it is very unlikely that they are intentionally causing you harm or distress; they just are unaware of how this kind of talk can be triggering. Here’s an example of how these conversations can be broached: “Hey, I know that you aren’t intending to, but when you talk about your diet/lifestyle/weight loss journey with me, it makes me feel uncomfortable. I am happy that you are happy with what you are doing, but hearing about it is unhelpful for me as I’m working on accepting my body and letting go of diet culture.” If you are struggling with an eating disorder (and this person knows about it), it could be helpful to also say, “Part of my eating disorder recovery is not engaging in diet/weight loss talk as it can make my symptoms worse.”

If after these tactics, the message is still not getting through, it is within your right to limit your exposure to these individuals. This might mean doing shorter meet-ups rather than long, drawn-out hangouts, limiting your time spent at family gatherings, or getting together less often. If this is not an option, you can take space when you need to at these events, excusing yourself from the room or going for a walk by yourself, for example. I also highly recommend cultivating your own “anti-diet” community either online or in person if you are able to. There are many fat-positive folks all over the world, and it can feel less lonely when you are around those who “get it.” Instagram and Facebook can be helpful in finding these people and connecting with them.

At the end of the day, I hope that the one thing you will remember is that just because your
friend/family member is actively engaging in diet culture, you do not have to go that route. You deserve to embrace and live in the body you have, and you do not have to change it. Your body has never been the problem – our fatphobic culture is.

The Problem With Fat Shaming Professional Athletes

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Felger: If we ever get to the point where we can’t fat shame athletes, I quit.

Massarotti: It’s coming.

Felger: It is coming.

Massarotti: It might already be here already.

Felger: It’s not. We’re not talking about a teenage girl. We’re talking about professional athletes whose job it is is to be in shape. We are allowed to call them fat and tease them for being fat. If that becomes off limits, I’m done.

The aforementioned exchange, which took place in the context of discussing Kyle Lowry of the Miami Heat, occurred between co-hosts Michael Felger and Tony Massarotti near the end of their Felger & Mazz sports talk show on May 17, 2023. Much like the fat shaming directed at Pablo Sandoval seven years ago, this problematic dialogue misses the mark and causes harm.

Felger asserted that part of a professional athlete’s job is to be in shape, but what constitutes “in shape” should not be defined by anthropometrics, such as weight or body fat percentage, but rather by an athlete’s readiness to perform their given sport at the level their employers expect of them. If an athlete lacks the strength, endurance, or flexibility to perform, the deficiency in their fitness is the real issue regardless of how their body is built; otherwise, teams would just fill their rosters with bodybuilders and models and call it a day.

“In shape” is also context dependent, as the physical abilities necessary to perform at a high level vary from sport to sport. A gymnast who lifts weights and runs but never stretches, a shot putter who stretches and runs but never lifts, and a marathoner who stretches and lifts but never runs would all have serious issues with their performance regardless of how their bodies look.

Besides, Kyle Lowry is actually quite a good basketball player. Lowry is in the midst of finishing his 17th season in the NBA, he earned spots in six straight All-Star games from 2015 to 2020, he started all 65 regular season and 24 playoff games that his team played on their way to winning the 2019 championship, and he was a member of the USA Olympic team that won the gold medal in 2016. Sure, his statistics dropped off a bit this season, but blaming the dip on his physique – which looks to be the same now as it did four years ago – is a bit of a head-scratcher considering the 37-year-old is the seventh oldest player (out of approximately 450) in a league where the average player is 26.01 years old. According to basketball-reference.com, Lowry’s career performance arc is thus far most similar to those of Terry Porter, Vince Carter, and Allen Iverson, the latter of whom is already enshrined in the Hall of Fame, and another – Carter – will likely get in too once he is eligible.

Lowry is far from the only “fat” athlete to outperform many of his leaner peers. The aforementioned Sandoval made over $73 million during his 14 years in the major leagues, and the two-time All-Star was named Most Valuable Player in one of the three World Series that his teams won. Pat Maroon was fat shamed despite winning three straight Stanley Cups. Back in Lowry’s realm of basketball, Luka Doncic’s own boss criticized him for his weight despite winning Rookie of the Year, then being named an All-Star and making the All-NBA first team in the four seasons he has played since then.

However, the most concerning part of Felger’s opinion is that he seems ignorant of the impact that his sentiments have on people other than professional athletes. “We’re not talking about a teenage girl,” he said, but the reality is that fat shaming anybody breeds fat shaming in general. Discussing the reasons why criticizing Donald Trump for his weight is harmful, Ragen Chastain explained, “And make no mistake, when you engage in fat-shaming, your victim is every single fat person.” The ramifications of fat shaming athletes are clear, as I discussed in the Boston Baseball article I wrote about Sandoval back in 2016.

“Fans and media have labeled Sandoval ‘disgusting,’ ‘lazy,’ and ‘pathetic,’ implying that those same terms apply to everyone who has a body type similar to his.

The message is that fat is to be loathed, that larger individuals are not worthy of the respect enjoyed by the rest of us. We reject stereotypes based on race, religion, ethnicity, or sexual orientation but we inexplicably tolerate those based on body size.

The idea that we can tell how someone eats or exercises based on his shape or weight is a myth. Some people built like linebackers never lift weights. Some skinny-as-a-rail folks subsist on fast food. And some obese individuals are more active and have a healthier relationship with food than any of them, but inhabit bigger bodies for other reasons.

As we all know, pressure to be thin leads to dieting, which can lead to a variety of problems, including eating disorders. These life-threatening illnesses are so common in Massachusetts that if the crowd at a sold-out Fenway Park represented a random sample of the state’s population, those in attendance with a diagnosed eating disorder would fill section 41.”

Sounds like Felger’s intent was to focus his fat shame on professional athletes while sparing others – and good thing it was, for his behavior would be even more problematic if his intent was otherwise – but we all know that intent and impact are two different entities. Felger certainly should know this, as his co-host was suspended just three months ago for making a poor attempt at humor that came off as racially insensitive. Like Massarotti, Felger should have known better.

If Felger is unwilling to forego fat shaming professional athletes, then the time for him to quit truly has arrived.

Gentle Nutrition

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What is gentle nutrition? Imagine a Venn diagram. In one circle, we have intuitive eating, which is an approach to making decisions about what, when, and how much to eat centered around our body’s internal cues. In the other circle, we have medical nutrition therapy, which is the use of nutrition to treat various health problems. In the area in the middle where the two circles overlap lives a concept that we call gentle nutrition.

For my patients who are working to rebuild their intuitive eating skills, getting a firm handle on what gentle nutrition means and how to implement it in their lives are often two of the trickiest steps they face. The most common reason is that people oftentimes do not trust that their body’s internal cues will steer them in the direction of eating in a way that is conducive to their health. This fear, which I otherwise think of as the “If I allow myself to eat whatever I want, all I will do is have [insert the name of your taboo food] all the time” expectation, implies that eating for health means overriding intuitive eating cues.

My counter to that concern is to cite the food journal analyses that I perform on some of my patients. When I look at the intakes of my seasoned intuitive eaters, their nutrient consumption almost always falls within their estimated needs because their body naturally guides them towards the food it requires. In other words, my clinical experience suggests that when we eat intuitively, the eating-for-health part largely takes care of itself.

But what if our body is an imperfect guide? What if we face a gap between how far our intuitive eating takes us and where medical nutrition therapy suggests we should be?

For starters, take a step back and remember that our behaviors have limited influence on our health. One of my patients recently told me about a colleague who was diagnosed with cancer, and as word spread around the office, her co-workers reacted with surprise because the woman is so “thin and healthy.” (And as my patient astutely pointed out, if her colleague was fat rather than thin, people likely would have felt that she brought her health woes upon herself, which is a whole other problem.) Hearing the story reminded me of a fellow healthcare practitioner who was diagnosed with cancer herself despite being clearly orthorexic. For people who erroneously believe that they can control their medical fates if only they engage in certain behaviors, counter examples like these can rock their world.

Given that we may suffer whatever ailment we hope to avoid regardless of our best efforts to steer clear of it, we have to consider the lengths that we are willing to go to – and what we are willing to sacrifice – in hopes of reducing our risk. Focusing on medical nutrition therapy may sound sensible in theory, but doing so can come at the expense of our relationship with food. Consider the following scenarios that someone with hypertension might face.

  • What if you feel like you should never have salty food because of your high blood pressure, or when you do allow yourself to have it, you feel like you are being “bad”?
  • What if you have a history of restriction and the mere thought of cutting down on salt feels traumatic?
  • What if you are a recovering binge eater and stocking salty foods is an important step in your treatment?
  • What if you are on the road and happen upon a restaurant famous for a high-salt dish you really want to try, but you feel like if you do, you are asking for a cardiac event?

Who wants this level of angst interwoven with their eating when the fact of the matter is they could die of a heart attack no matter how much or how little sodium they consume? Unfortunately, stress, guilt, second-guessing, and inner turmoil can be significant issues when we practice not-so-gentle nutrition.

We advocate for gentle nutrition because of the downsides that come with focusing too hard on medical nutrition therapy and because of the upsides of taking a more moderate approach that still respects intuitive eating. Consider how someone practicing gentle nutrition would approach the same scenarios that I listed earlier.

  • What if you feel like you should never have salty food because of your high blood pressure, or when you do allow yourself to have it, you feel like you are being “bad”? They understand that complete abstinence of salty food is neither necessary nor practical, and they can enjoy such foods without guilt.
  • What if you have a history of restriction and the mere thought of cutting down on salt feels traumatic? Before even tackling gentle nutrition for their blood pressure concerns, they first do the necessary work to heal their relationship with food, thereby making medical nutrition therapy feel less triggering.
  • What if you are a recovering binge eater and stocking salty foods is an important step in your treatment? They recognize that in order to make peace with salty foods and get to a place where “a little” does not automatically turn into “a lot,” they have to practice unconditional permission and abundance, which entails exposure, continuous access, and predictable overconsumption for a period of time.
  • What if you are on the road and happen upon a restaurant famous for a high-salt dish you really want to try, but you feel like if you do, you are asking for a cardiac event? They understand that no single eating experience is going to save nor doom their health, that food is part of culture and travel, and that they would probably regret forgoing a rare opportunity.*

How then is the nutrition part of gentle nutrition implemented? That same person with hypertension may use their intuitive eating cues to determine that they feel like having a piece of fruit for a snack, but both the apple and the banana sound equally appealing, so they opt for the latter since it has more potassium than the former. On the other hand, if they feel like solely the apple would hit the spot, they eat it, enjoy it, and look for other places in their day to get their potassium. If the whole day goes by without consuming much potassium, they do not worry, but rather trust that their intuitive eating cues guide them in different directions day to day, and tomorrow they could very well find themselves taking in a high amount of potassium.

After reading all this, you might be thinking to yourself, “Yeah, okay, I get that my health is not entirely within my control, but I want to do everything I can to minimize my risk.” If so, that is entirely your right. You are the expert in your own life, nobody is in a better position to decide your path forward than you are, and I commend you for weighing the pros and cons and making an informed decision that feels right for you.

However, that same autonomy applies to each of us, and many people conclude that not-so-gentle nutrition is just not worth its cons and that gentle nutrition is the way to go.

* Speaking from personal experience, I remember spending a night at a church on a Native American reservation in Montana during my Seattle-to-Boston bicycle trip. My hosts offered me one of their traditional dishes – something that I can only describe as a French-fried donut, although I am sure that is not at all what it was – and it turned out to be literally the best tasting food I have ever had in my life. Sometimes I think about what I would have missed had I turned down the food due to nutrition concerns.

Pancakes

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Some months, coming up with a newsletter topic is unusually challenging. For the last few weeks, Joanne and I were both scratching our heads, as the ideas we had were for research pieces that would demand more time than either of us is able to dedicate at this point in time. Being silly, I facetiously asked our four-year-old daughter what I should write about this month. “Pancakes,” she responded, “Pancakes and maple syrup.” Joanne and I laughed, and I walked out of the room, but I quickly returned and told them I was going to use her idea.

Our daughter’s suggestion reminded me of a quote from one of my earliest patients many years ago, and what the latter said to me felt significant enough that I wrote it down as soon as she left my office. “One day, you will have a baby boy who will love you,” my patient said, “and then he will grow up to hate you. But then one day he will love you again and say, ‘Hey, Dad, let’s go out to breakfast, just us guys,’ and then you will go to Bickford’s, and you will have an apple pancake, too.”

At that point in my career, I was still doing the kind of work that most people figure dietitians do: putting people on diets in the pursuit of weight loss. My prescribed diets were low in carbohydrates, especially grains, and so restrictive of calories that if my patients were living in a different region of the world, the United Nations would have sent cargo ships full of food to help them. While I did not author these diet plans, which seemed concerning to me at the time because of their restrictive nature and the good/bad food dichotomy they established, I did dole them out as instructed, and for that I have nobody to blame but myself.

These diet plans typically “worked” in the sense that my patients lost weight, but rarely – if ever – did the weight suppression last long term. At the time that I left the medical center where I was working and stopped doing that kind of work, I did have some patients who had maintained their weight loss thus far, but I have no idea what happened to them later. Given that most weight regain happens two to five years after baseline, I can only assume that at least some of these patients, if not all of them, regained weight after I was out of the picture.

Diets fail for a number of reasons. Most significantly, the physiological mechanisms that kept our ancestors alive through periods of starvation kick in when we restrict and promote weight regain. Another factor, the one that my patient was trying to make me aware of via her aforementioned quote, is that diets are incompatible with real life. After all, if I were following the low-carb, low-grain, low-calorie diet that I had put her on, I would be unable to both remain on the plan and partake in her breakfast scenario. The dietary expectations I had set out for her were unrealistic, which was exactly the point she was trying to get me to see. Point taken.

Now that I am a dad myself, I have greater first-hand life experience to reinforce my theoretical understanding. Numerous times over the last few years, I have eaten foods I was not in the mood for because sharing an eating experience with my daughter was more important to me than eating exactly what I wanted. For example, the food at Chick-fil-A rarely sounds good to me, and I certainly would have preferred something else for dinner last Tuesday night, but I took her there because she loves it, she asked me if I would take her, and I prioritized making her happy and sharing one of her favorite meals over eating what I really wanted.

If I was on some diet plan that restricted foods like Chick-fil-A, such as the plan I had given to the patient in question, I would have had to choose between breaking the diet or missing out on a family bonding experience. When I was a young adult and somewhat orthorexic, I prioritized “healthy behaviors” to the detriment of other important areas of my life. After turning down plans with friends so I could exercise after work and go to bed early, some of them began to distance themselves from me and stopped extending invitations. My insistence on only eating food I had brought from home kept me from joining co-workers for lunch, and my rapport with them weakened. If you have ever been on a diet yourself, consider the ways in which sticking to the plan came at the expense of other facets of your life. My guess is that if you look back, you will find examples in your own life similar to the ones I just described.

Furthermore, remember how you felt when you inevitably deviated from your diet. In Reclaiming Body Trust, authors Hilary Kinavey and Dana Sturtevant succinctly describe the pattern of dieting with a diagram that they entitle “The Cycle.” At the 12 o’clock position, the circular diagram begins with “The Problem,” which then leads to “The Shame Shitstorm” at three o’clock, followed by “The Plan” at six o’clock, then “Life” at nine o’clock, and then back to “The Problem” as the pattern indefinitely repeats. Delving into the particulars of these positions is beyond the scope of this blog, but the overall pattern is one to which many of us can relate: We identify a problematic eating behavior, feel bad about it, desperately grab for a plan that will supposedly rescue us from ourselves, abandon the plan when it proves itself to be incompatible with life, and the cycle repeats.

If a diet puts us in a position to choose between (A) sacrificing important parts of life, such as sharing a bonding experience with our kids, in order to remain on the plan, or (B) breaking the diet and perpetuating a cycle of shame and unsustainable attempts to deal with our problems, then perhaps dieting and living a full life are simply incompatible.

Mindful Eating vs. Intuitive Eating

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In one of my recent blogs, I mentioned in passing that mindful eating and intuitive eating are different concepts, a topic that I am circling back to now because I frequently meet new patients who mistakenly believe they are synonymous.

Intuitive eating is an approach that leans upon our body’s internal cues and uses them to drive decisions regarding what, when, and how much to eat. People who eat intuitively generally use sensations of hunger and fullness to determine when to eat and the quantity of food to consume at a given time, and they may utilize a series of matching questions to determine which foods are going to best hit the spot. (Note the words “generally” and “may,” which I have included to reflect that intuitive eating is a set of guidelines that one can use to the extent that they find helpful, not a set of rules that must always be followed.)

Mindful eating, on the other hand, is broader and simply entails paying attention to one’s eating. Intuitive eating falls under the umbrella of mindful eating, but plenty of other versions of mindful eating exist. For example, one could mindfully portion out their dinner as they carefully strive to stay within the day’s points budget. One could be mindful of the texture and flavor of their Halo Top while wishing it were Ben & Jerry’s. One could mindfully savor every bite of their 100-calorie snack pack while knowing they are hungry for more food than they are going to allow themselves to have.

One must be mindful in order to notice internal cues, but one can be mindful of other things while completely ignoring what their bodies are telling them. In other words, one can eat mindfully without eating intuitively, but one cannot eat intuitively without eating mindfully.

If you have thought to yourself that you wish you ate more mindfully, consider looking deeper to discover what it is that you are ultimately hoping to achieve. If weight loss is the motivation, then mindful eating is likely just code for dieting, an attempt to put a rosier package around restriction while the contents remain the same. On the other hand, if recovering from disordered eating or establishing a more peaceful and healthy relationship with food is the goal, then intuitive eating specifically – not mindful eating in general – is the path forward.

Continuous Glucose Monitoring

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“We start to, you know, numbers start to be overlaid onto everything like we’ve got some kind of headset on and we’re looking through it and there’s little value numbers attached to our foods and to the actions we take in our lives, and that’s tremendously unhealthy, I think, and can descend – you know, people I’ve interviewed and I’m sure people that you work with – can descend into pathology, right, where you’re constantly afraid that that equation is not right and you need to keep upping it and the output needs to be better and that you’re falling short. That’s not a good place to be.”

Dr. Alan Levinovitz, PhD, to Christy Harrison, MPH, RD, CEDS, in Food Psych #94

Earlier this month, a friend asked me about an email he received from a company trying to sell him a subscription to their continuous glucose monitoring (CGM) service. Since some of you are likely unfamiliar with it, CGM technology allows its user to automatically track their blood sugar levels around the clock. The monitor itself is a small sensor typically placed on someone’s abdomen or arm, and it contains a needle that measures sugar concentration in the skin’s intercellular fluid. A transmitter attached to the sensor sends the information to a separate device, such as a smartphone, on which the user can view their blood sugar data. As the American Diabetes Association discusses, CGM is a legitimate medical tool that diabetics can utilize to help manage their condition.

What was surprising about the email that my friend received is that the solicitor was not marketing their CGM service to diabetics, but rather to the general population. Their subscription service provides users with CGM devices, tools for tracking their food consumption, and access to a team of dietitians who analyze the data and help clients to examine the link between their eating and blood sugar levels. That may sound innocent enough, but I have concerns.

Their website (to which I am purposely not linking in order to avoid driving traffic their way) features enticing language like “Reinforce Good Habits,” “Promote Longevity,” “Manage Weight,” and “Gain Energy.” With approximately 51% of adults wanting to lose weight and some estimates claiming that 45% of the general population experiences fatigue, these calls to action seem designed for mass appeal. Their pitch continues, “While each journey is unique, we’ve found that remarkable improvement to your health and well-being can be achieved in just a single year,” and includes alluring testimonials, such as, “I was really in a place where I thought I kind of knew my body and I know what I’m feeling. I WAS WRONG.”

When I clicked on the “Get Started” link, the following page presented me with a multiple-choice question regarding my goals. This is the first of approximately a dozen questions, each on its own page, that opened up for me to answer. Between questions, a quote from one of their staff dietitians affirmed – based on my answer to the preceding question – that I was in the right place and they could help me. Using the back button, I changed my answers a bunch of times to see if I could produce a different result, one in which they would say their service is not appropriate for me, but that never happened. My impression is that they welcome everyone as a customer, which must make for a great business model.

Dangers exist in overemphasizing a single parameter of health and insinuating that everyone can benefit from focusing on it. While people may debate the quantity and identities of the various aspects of health, all of the models that I have seen agree that health is multifaceted. Depending on the particular model in question, categories may include emotional health, social health, and physical health, among others. Taking a closer look at physical health yields subcategories, such as anthropometric, biochemical, and clinical measures, and each of these has numerous parameters within them. Casting a bright light on one variable, such as blood sugar, while leaving the others in the twilight is an oversimplification of health, and to suggest that everyone – not just those with a known issue with their glycemic control – would benefit from doing so is at best misleading.

An overarching danger is that someone could pursue better blood sugar levels at the expense of other aspects of their health. For example, a user could adopt eating behaviors that may keep their blood sugar in check, but create or exacerbate issues with their cholesterol or blood pressure. Perhaps someone else begins to view foods that spike their blood sugar as “bad” and others as “good,” thereby bringing about or worsening disordered eating. Others may pursue better blood sugar at virtually any cost, eliminating or severely restricting certain foods, socially isolating themselves so they can eat exactly as they think they should, all the while feeling that what they are doing is not good enough and they need to be more diligent, thereby taking their disorder up a notch with each iteration.

Thinking about this CGM service reminds me of the debate surrounding full-body CT scans that some suggest could enable doctors to catch budding diseases in their infancy. Check out this 2017 Food and Drug Administration article, particularly the following quote, and note the parallel between the problem with these scans and what this CGM company is doing.

“CT is recognized as an invaluable medical tool for the diagnosis of disease, trauma, or abnormality in patients with signs or symptoms of disease. It’s also used for planning, guiding, and monitoring therapy. What’s new is that CT is being marketed as a preventive or proactive health care measure to healthy individuals who have no symptoms of disease. Taking preventive action, finding unsuspected disease, uncovering problems while they are treatable, these all sound great, almost too good to be true! In fact, at this time the Food and Drug Administration (FDA) knows of no scientific evidence demonstrating that whole-body scanning of individuals without symptoms provides more benefit than harm to people being screened.”

Similarly, while CGM can certainly be a helpful tool for some people with known blood sugar stability issues, whether the potential benefits outweigh the potential risks of applying the technology to someone without such a diagnosis is murky. In essence, this pros-vs.-cons question is what Dr. Levinovitz seemed to be getting at in his quote that kicked off this blog. It’s not that applying quantitative measures to our bodies and behaviors is always a negative; it’s that doing so is not always a positive either. Oftentimes, whether signing up for a CGM subscription service, buying a Fitbit, or downloading a calorie-tracking app, people go into such endeavors based solely on sales pitches and what they hope to get out of the experience while unaware of the risks that come along for the ride.

“You have permission to not eat.”

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Some of my patients who are relearning how to eat intuitively find it helpful to utilize a mantra, a phrase they can say to themselves to help them through a challenging situation. Because we often discuss the concept of unconditional permission, “You have permission to eat” is a refrain that my patients commonly use. One of my patients though flipped it on its head and began to use “You have permission to not eat.” At first, I was a bit perplexed, but the more I listened to her and reflected on these words, the more I realized their power.

Having the freedom to allow ourselves to eat whatever we want, whenever we want, and however much we want – otherwise known as unconditional permission – is central to intuitive eating. Without this foundation, everything else we study can easily warp into dieting tools. Given that, I initially bristled at “You have permission to not eat” because I thought it might be a veiled attempt at restriction, but that is not the case at all. Rather, the power in these words comes from acknowledging the times when we feel obligated to eat even when our bodies are saying no and freeing ourselves from the burden of feeling powerless.

As a first example, consider the scenario that my patient told me about when she was explaining the power of her mantra. She was at dinner with her extended family, and all of the latter were leaning towards ordering dessert. While my patient did not feel like having dessert, she also felt a social obligation to order it since others were. Then she reminded herself, “You have permission to not eat,” which reaffirmed that whether or not to order dessert was her prerogative, and she could act in her own best interests regardless of how the rest of her family went about their eating.

Thinking about other possible applications, I realized how helpful this mantra can be for people who feel pressure to not “waste” food. We are familiar with guilt-inducing refrains to clean our plate, such as “There are starving children in the world,” as if whether or not we finish the food in front of us has any impact whatsoever on the global politics of food insecurity. In these moments, “You have permission to not eat” reminds us that we do not have to be human garbage disposals for the sake of some theoretical benefit to others.

My thoughts then went to how this phrase could be useful for people working through compulsive overeating. Recovery is, of course, more complex than simply reciting a mantra, but just as the concept of unconditional permission is essential for diet survivors who are building healthy relationships with food, “You have permission to not eat” reminds compulsive overeaters that they have the freedom to move away from the urges to overconsume that have felt so irresistible.

Lastly, I considered how “You have permission to not eat” can aid those who overconsume due to habit or tradition. Maybe we eat to the point of physical discomfort every Thanksgiving because we have come to accept that this is the norm on the holiday, or maybe we buy popcorn every time we go to the theater regardless of whether or not we are hungry or feel like popcorn just because eating the snack feels like an intertwined and essential component of movie watching. “You have permission to not eat” reminds us that even if we have long engaged in certain eating behaviors, we have the freedom to move away from them if we feel that they no longer serve us.

You may discover other applications in which “You have permission to not eat” is a helpful mantra, but guard against the temptation to use it as a tool to restrict because that would likely backfire and be counterproductive. If you feel yourself tempted to go down that road, remind yourself of the phrase from which this mantra came: “You have permission to eat.”

An Open Letter to Daycares, Preschools, Nursery Schools, and Elementary Schools

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We so appreciate the care you take of our little ones. In fact, I am sure that most parents would agree being able to send our kiddos to daycare, preschool, and/or elementary school is a huge factor in maintaining our sanity. The way that you help our children learn, grow, and adapt is amazing, and we are grateful for you. Having said all this, we need to talk about the policing of our kids’ food in school.

Lately, I have begun hearing more and more from parents whose kids are being sent back home with notes about their packed lunch. One parent received a phone call from a daycare saying that they were not going to give her daughter the 10 M&Ms that she had packed in her daughter’s lunchbox because they were “unhealthy.” Keep in mind, this mom had the forethought to pack in her daughter’s lunch The Feeding Doctor’s lunch box card stating that she did not want the staff to interfere with her daughter’s eating of lunch and that her daughter is allowed to eat any or all (or none) of the foods packed in the lunch in any order she wants. The staff overruled these directions and said that candy is “frowned upon” in their program.

Listen, I get it. In our fatphobic, diet culture world, we’ve been taught that sugar is the enemy. That if we give it to our kids, they will turn into sweets-addicted, hyperactive lunatics who will be out of control, that their bodies will balloon up like Violet Beauregarde in Willy Wonka’s Chocolate Factory, and that their teeth will fall out due to cavities. As a registered dietitian who has a Master of Science in Nutrition and Health Promotion with over a decade of experience in the dietetic field, I’m here to tell you that all of this is false.

Kids are naturally born intuitive eaters. Newborn babies cry when they are hungry and drink breastmilk (or formula) provided by their caregivers until they are satiated. They are perfectly in tune with their bodies’ cues and eat in response to them.  As babies grow and they start eating solids, they continue to eat intuitively. If you’ve ever tried to get a baby to eat anything they don’t want to eat (I’m looking at you, strained peas.), you know they just won’t have it. As kids reach toddlerhood, often their eating habits become erratic. Some days, it seems like my daughter barely eats anything, but on other days, she appears to eat more than a grown adult. Despite this seeming chaos, our kids’ bodies know what they are doing. While meals might seem hit-or-miss during one day, it’s best to look at our kids’ eating over a period of days as things will usually average out.   

Kids usually remain intuitive eaters until the adults in their lives start interfering with their food. Whether it be pressuring kids to take “one more bite” at dinner even if they are no longer hungry, limiting their access to sweets and other highly palatable foods because they are “unhealthy”, or expressing concern about their eating “too much,” parents and other adults can really throw a monkey wrench into their kids’ relationship with food.  Many parents worry about their kids gravitating towards foods that are high in fat, sugar, and/or salt because they themselves have a complicated relationship with those foods. In reality, if we relax around these foods and include them regularly with more “nutrient-dense” foods, we can neutralize them and take the “shine” off of them as well. In my work with kids and families, it’s the kids who are the most restricted around highly palatable foods that end up bingeing on them when they get the chance, sneak eating them in their room, or being hyperfixated on them at their friends’ houses. If we teach our kids that food has no moral value (i.e., eating vegetables doesn’t make you a “good” person and cookies aren’t the devil’s food), they will be able to make choices about what and how much to eat based on their internal hunger and fullness cues.

In addition to being natural-born intuitive eaters, young kids have very binary thinking. That is, when we present them with the idea that there are “good” foods and “bad” foods, they take this information quite literally and are unable to see the gray. So many children feel guilt or shame for enjoying “bad” foods because they feel like they are bad for eating them. This is setting our kids up to have a very charged emotional experience around these foods which can continue on into adulthood for many of them.  If we teach kids that all foods fit and that the most important thing is getting a good variety of all sorts of foods, we can help foster their relationship with food and their bodies.

Another thing to consider is the concept of helping our kids become “competent eaters.” Coined by child feeding therapist and dietitian Ellyn Satter, competent eaters are those who eat in accordance with their hunger and fullness cues while taking into consideration their bodies’ needs and preferences. Parents’ (and caregivers’) role in this process is to be in charge of certain aspects of meals and snacks. Satter’s Division of Responsibility further clarifies that parents are in charge of what food is being served, when and where this food is offered. Meanwhile, kids are responsible for whether they choose to eat the food provided and how much they want to eat of said food. Ideally, parents offer their kids a variety of foods, including both highly palatable foods and foods that are more nutrient dense, and then let their kids eat in accordance with their bodies. This model posits that interfering with kids’ eating by cajoling them to eat more vegetables, discouraging them from eating other foods, or even praising them for eating more nutrient-dense foods will lead to power struggles at the dinner table.

So what can we adults do to help our kids develop a healthy relationship with food and their bodies? Here are some strategies:

  1. Avoid categorizing some foods as “junk” or “bad” and others as “good” or “healthy.” Food is just food and does not have moral value. Food is only “bad” if you are allergic to it or it is rotten or spoiled.
  2. Parents need to provide a wide variety of foods to their kids, including regular access to highly palatable foods in order to take these foods off the pedestal and make them morally equivalent to more nutrient-dense foods.
  3. Caregivers at school should refrain from pressuring kids to eat certain parts of their lunch before letting them eat other parts (e.g., “You need to finish your sandwich before you can have your cookies.”) If a child wants to eat their cookies first, please let them.
  4. Caregivers at school should also avoid confiscating food from kids’ lunchboxes unless those foods are an allergy or choking risk. If the parents packed the lunch, please respect that they know how to feed their kids.  
  5. Finally, school caregivers, please be mindful about sharing your own food anxiety with kids. Kids should not be hearing about your latest diet or how you don’t allow yourself to eat X, Y, or Z. Children are like sponges and absorb all of this information.

Again, thank you for everything you do for our little ones. We are so grateful to have you in our kids’ lives. Let’s help our children develop a healthy relationship with food and their bodies by setting a good example and not letting diet culture into the classroom.