Category Archives: Exercise

Thoughts on the New Weight Loss Drugs

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I’ve been meaning to write a blog about the new weight loss drugs for months now, but every time I start, I find myself having trouble with what I want to say, especially since so many of the anti-diet and fat-positive activists I admire have already written such important and insightful pieces on these drugs. For anyone looking for some in-depth research study analysis, I want to point you towards Ragen Chastain, a speaker, writer, and amazing fat activist, in addition to being a certified “statistics nerd” (her words, not mine!). Her Weight and Healthcare Substack is an invaluable resource that takes a hard look at “weight science, weight stigma and what evidence, ethics, and lived experience teach us about best healthcare practices and public health for higher weight people.” Ragen is adept at sifting through the research studies that the drug companies publish to sell the efficacy of these drugs and finding the myriad issues, conflicts of interest, and straight-up bad statistics that these studies exhibit. So please read what she has written on the topic of GLP-1 agonists.

In this piece, I am not going to get into the science behind how GLP-1 agonists such as Ozempic and Wegovy actually work. Instead, I want to talk about how these drugs (and the weight loss drugs that came before them) have become such a lightning rod in the discussion of weight. I was a teenager in the 90s, and I clearly remember when the drug Fenfluramine/Phentermine (Fen-Phen) entered the weight loss scene. There was such a fervor about it on the nightly news, and the marketing by the drug companies was intense. It was touted as a “miracle drug” that could “cure” o*esity, and everyone was going to their doctor to get a prescription. I also remember the news stories that came out. Famously, there was one in the Boston Herald about how Fen-Phen was linked to mitral valve dysfunction, pulmonary hypertension, and other cardiac abnormalities. Subsequently, it was removed from the market due to these risks. It took years before people were convinced that the harms that these medications caused outweighed the “benefits” of weight loss for higher weight people.

There has been a seemingly significant theoretical shift in the medical community over the past few years regarding higher weight (the “o” words”) and weight loss. Unlike previous decades, when people were told that their high weight was their “fault” and was caused by their “unhealthy lifestyle behaviors,” many medical professionals are now putting forth the message that one’s weight is largely out of one’s control (true) and is not necessarily due to “unhealthy lifestyle behaviors” (also true). Most physicians acknowledge that the BMI is a flawed measurement and that there are many factors that play into health other than weight (true again). But instead of pivoting away from using weight as an indicator of health, there has been a push by the medical community to classify o*esity and o*erweight as “chronic health conditions” that must be managed over one’s lifetime. In essence, the medical community is saying that while being fat isn’t your “fault,” it is still a problem and one that needs to be managed.

In our fat-phobic, image-obsessed culture, it makes sense why these new “miracle weight loss drugs” are creating such a stir. Higher weight people are being told, “Hey, we know that your weight is out of your control, but we can help you manage your ‘condition’ with these medications!” In addition, there is a lot of pressure on higher weight people to “get healthy” (even if many of them are healthy by every measure other than weight), and losing weight is still seen as something that will improve people’s health. The marketing that the drug companies have put forth is simply astounding. I feel like I can’t watch a TV show, peruse social media, or even read the New York Times without sponsored content popping up about these drugs. Add to this all of the celebrities and influencers who have been publicizing their weight loss “success,” I would be surprised if any person in a larger body wouldn’t be affected. Currently, I am in a small-mid fat, abled body, and I’d be lying if I said that I hadn’t thought about turning to these drugs. I can only imagine how those who are in much larger bodies than mine and/or in disabled bodies are tempted to try them.

The studies that have been put forth by Novo Nordisk (the drug company who makes Wegovy and Ozempic) have shown that while participants lost about two pounds per month over a 68-week time period (during which they were also dieting and exercising 30 minutes per day, six days per week), at 60 weeks, those who were still taking the medication experienced a plateau in their weight loss, and in a follow-up study the following year, two thirds of the weight they had lost was regained. Conveniently, the studies all concluded at the second year of testing, as we know that the majority of weight regain occurs between two to five years post weight loss attempt. Novo Nordisk also reported that taking their medication leads to positive health outcomes, but a closer look at their studies shows that there were no statistically significant improvements in HBA1C (a measure of diabetes), triglycerides, cholesterol, or inflammation markers.

I don’t blame anyone who feels like they need to try these drugs. For some folks, losing 10-15% of their body weight (the average weight loss reported by researchers) could feel like it makes a huge difference in their quality of life. What I find distressing about these drugs is how hard they are being pushed by the media and medical community despite the long list of side effects and potentially harmful health outcomes that can occur. Wegovy has a Boxed Warning (the FDA’s most serious warning) due to it increasing one’s risk for thyroid cancer, acute pancreatitis, acute gallbladder disease, stomach paralysis, as well as an increase in suicidal ideation, among other risks. But it seems that the medical community feels that losing weight is worth the risk to fat people’s lives. That even though folks report nausea, diarrhea, vomiting, constipation, and stomach pain while on these drugs, it’s okay as it is just the price to pay for one to become “healthy.”

I wish that instead of telling higher weight people that their weight is a problem that can be “solved” by taking these medications, the medical community could instead focus its energy on reducing weight stigma in healthcare, as this (along with weight cycling or yo-yo dieting and healthcare inequalities) has been found to have much more of a profoundly negative effect than weight on one’s health. I wish that we lived in a society that didn’t prize thinness so much. And I wish that everyone could see that weight is just another human characteristic that exists on a continuum and that bodily diversity is a real thing, not something that has to be “managed” or “controlled.”

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.

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.

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.

A Few Scattered Thoughts

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A few scattered thoughts as we settle into 2023 . . .

Caroline Garcia, a French professional tennis player ranked fourth in the world as of this writing, recently went public about her struggles with bulimia. She reportedly explained, “Everyone is different. Some don’t eat anymore, I was the opposite: I took refuge in food. These were times of crisis. You feel so empty, so sad, that you need to fill yourself up. It was the distress of not being able to do what I wanted on the court, no longer winning and suffering physically. Eating calmed me down for a few minutes. We all know it doesn’t last, but . . . It was an escape. It’s uncontrollable.”

She and I have never worked together, met, nor communicated with each other in any way, nor am I familiar with the particulars of her medical history and eating disorder history, so of course I am only speculating, but it sure sounds to me like she still has a ways to go in her recovery. For example, her discussion of “temptations” in the players’ restaurant suggests that she still might have some trigger foods and/or a dichotomous view of foods in which her mind sorts them into groups of good and bad.

Having said that, one of the positive steps she has taken towards recovery is allowing herself more freedom in her eating. For example, she is quoted as saying, “Now, if for two days, I want a pizza, I’ll take my pizza and it will stop obsessing me.” With every eating disorder – whether bulimia nervosa, anorexia nervosa, binge eating disorder, or anything else – removing restrictions is always part of the solution.

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While I was lifting weights at the gym earlier this month, I overheard two high school boys questioning the bench press technique that their muscle-bound trainer was teaching them. Seeking a second opinion, the trainer asked another young man who responded to the boys, “This guy knows everything! Look at him; he’s a beast!” The boys were right to second-guess their trainer, whose directive to bounce the bar off their chest increases the risk of harm and decreases the exercise’s effectiveness.

The more macroscopic problem exemplified here is that some people continue to make the mistake of confusing appearance with expertise. Nearly a decade ago, I gave a presentation that I called “Looking the Part: Patients’ Size-Based Biases Toward Their Practitioners and How to Handle Them” at the 2015 Association for Size Diversity and Health (ASDAH) conference. As I prepared my talk, I found research indicating that patients make all sorts of appearance-based judgments about their practitioners. For example, patients indicated they were much more willing to discuss sensitive issues like their psychological, sexual, and social problems if their doctor was wearing a white coat. Research also shows that patients make assumptions about their caregivers’ abilities based upon age, gender, hairstyle, and even whether or not the practitioner is wearing a name tag. If some patients prejudge a practitioner’s expertise based upon something as silly as the presence/absence of a name tag, then it should come as no surprise that research shows that patients also make assumptions based upon a practitioner’s size.

Having been a personal trainer myself, I can tell you that clients and potential clients hold similar biases based upon a trainer’s size, physique, athletic achievements, and other factors, when really none of that has anything to do with a given trainer’s expertise and capacity to help the client at hand. My client load grew immensely after I rode my bicycle from Seattle to Boston because people assumed that I must be a great trainer if I could accomplish something like that. While I appreciated the uptick in business, the premise behind it was ridiculous, as I was certainly not a better trainer upon my return than I was before I left for my trip. If anything, I was probably worse due to the exercise science knowledge I forgot while I was away.

Trainers often – but certainly not always – have lean and/or muscular builds, but that does not mean they hold some secret that will help their clients to attain similar results. Because of their biases, potential clients tend to gravitate towards trainers who have the type of bodies they want for themselves, while other trainers, who might be great trainers in actuality but fail to look the part, starve for clients before ultimately switching professions. Furthermore, size-based bias also prevents some potential trainers from entering the field, such as a patient of mine who wanted to be a CrossFit coach, but she did not think she would be successful because of her body size.

The truth is that appearance and expertise are independent entities. Conflate the two at your own risk.

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Back in November, I wrote a piece about a college buddy who recently died after being hit by a car. Shortly after publishing it, and thanks to some feedback that I received from a longtime friend, I realized that I made a mistake similar to the very one that I was criticizing. Whereas some people jump to blaming the victim without enough information, I did basically the same thing by blaming the perpetrator without taking into account the bigger picture.

We live in a society in which following the law is a suggestion that can be disregarded with little fear of consequence. Examples are numerous, but for the sake of brevity, here are a few that immediately come to mind: doctors who blatantly and knowingly commit insurance fraud yet are still impaneled; above-the-law politicians who are still in office instead of prison; maskless police officers, train conductors, and transit drivers who defied the mask mandate rather than enforce it; ubiquitous underage drinking; and dog owners who behave as if their pet is too special for the leash law.

My daughter used to like to watch cars and trucks, and I would see many drivers holding their phones despite the hands-free law that had gone into effect. Drive the speed limit and watch the line of tailgating traffic elongate behind you. Do pickup trucks even come with turn signals?

Sometimes I wish we had a list of the laws that we are actually supposed to abide by and those that are just for show so everyone could be on the same page. As it stands, each of us picks and chooses which laws to follow and those from which we rationalize our special exemption. The absence of both consistent enforcement and appropriate modeling from our leadership has neutered our system of laws. We tolerate this, and I have no idea why.

We also seem to be okay with huge billboards that are designed to literally distract drivers from the task at hand for the sake of capitalism. We could have floodlights that illuminate a crosswalk when a pedestrian pushes a button, but we do not. Instead of crosswalks, we could have underground passages or overhead walkways to avoid the risk of a car and pedestrian ending up at the same place at the same time, but such structures are rare. Instead of blinking little yellow lights or flashing red lights, we could have normal traffic lights that turn solid red for pedestrians in crosswalks, but I only see these at intersections where cars have to stop for each other anyway. Better yet, we could install the kind of solid red lights that have white strobe lights in the center for increased visibility, but these are few and far between. Guys, things do not have to be this way.

So, here comes my friend, a father of two young girls, entering a crosswalk unequipped with any of these aforementioned safety measures, on his way to meet his wife for dinner. And here comes the teenager – who has grown up and learned to operate a vehicle in a society that has normalized careless driving and repeatedly set the example that following the law is a personal choice rather than a requirement – who will soon kill him. Maybe it helps us to feel better to condemn the driver, to act as if their behavior is somehow an exception to the norm, and to claim that they alone are responsible for my friend’s death. The truth, though, is that we all are.

My Fat Knee

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About a month ago, I hyperextended my right knee while lying in bed. As a result of this (and a history of knee problems that I’ve had for the past decade or so), I had a very bad flare-up of osteoarthritis. I wish that I could say that I had injured myself doing something much more fun or exciting, but I guess when you are in your 40s, this stuff starts happening to you. Interestingly, aside from the initial sharp pain and chronic aching that ensued for several weeks, I noticed that I had some other feelings as well. The usual feelings of sadness and frustration were present of course, but there was something else too: panic.

When I tried to think about why I might be feeling panic in this situation, I had to wade through a lot of things: history, past trauma, hurt, and fear. Since I have always been in a fat body (although at times it has been straight size through restriction and overexercise), I have had a troubled relationship with medical professionals. Starting from a very young age, I became aware that my larger body was something problematic and to be feared. I have very early memories of feeling ashamed of my body whenever I would be weighed at the pediatrician’s office. I remember my pediatrician warning my mother about my weight percentile on my growth charts, and in turn she would turn her concern into “let’s fix this” mode, keeping an eye on my eating and monitoring my portions. I remember being weighed in my kindergarten class, and everyone’s weights were listed next to their names on the chalkboard, so everyone knew where they “ranked” in body size. I was the heaviest girl, of course.

As I got older, my fraught relationship with medical professionals continued. When I entered my late teens, I switched over from my childhood pediatrician to a family physician who was also a family friend. At one point, I believe he treated at least four of my five nuclear family members. And every year, I would dread going to see him as I knew that my weight would be brought up as an issue.  Of course, there were a few years when I had lost weight that I looked forward to going to the doctor as I knew that I would receive praise and encouragement to keep going (never mind that what I was doing to lose the weight could qualify as an eating disorder). But even occasional weight loss didn’t stop me from feeling anxiety when going to the doctor. Because I knew that my body was still “wrong.”

When I found Health at Every Size (HAES), I felt like I could finally breathe for the first time. At last, here was a paradigm that welcomed my body and encouraged me to take good care of it, no matter what size I was. I stopped my periods of dieting and worked on improving my relationship with food and my body. I found a physician who is weight-inclusive and treats me as a whole entity, not just my weight. I learned how to advocate for myself in medical situations when my weight would be brought up as an issue. I have helped countless patients navigate their own troubled waters of medical weight stigma. I have been in therapy for many years and continue to work on these issues as they arise.

But despite all of this work I have done and continue to do, most medical situations result in that pit-in-my-stomach feeling. I flash back to the decades where I was taught that my ailments or injuries were due to my weight and that feeling of shame and embarrassment that would wash over my face when a doctor would give me the “weight lecture.” All of those years of hearing that my fat body was to blame for almost anything negative occurring to it sunk in deep and etched into my brain. So whenever I have a medical situation, whether it is slightly elevated cholesterol in my lipid panel, a knee injury, or sleep issues, my knee-jerk reaction is to brace for the inevitable “weight lecture.” Never mind that I have found the unicorn of PCPs who not only understands and practices through a HAES lens, but also lives in a larger body herself which makes her even more empathetic. I know that my PCP’s office is a safe space and that my fat body will be treated with care and respect.

And even with all of this knowledge, the past trauma that I have received around my body in medical settings is still present. It makes me sad and also makes me incredibly angry. I think about all of my patients who have been through similar experiences with their healthcare providers. I think about the fact that I hold a lot of privilege (being small-medium fat, white, cis gender, heterosexual, able-bodied, financially stable, etc.) and that those who don’t hold those privileges are treated as less than at best and are downright abused at worst in these medical settings.

It is really enough to make me feel very cynical and jaded about the medical profession as a whole, and as a result, I am hesitant to seek out medical care. But despite this, I know that the only way things are going to change in our medical system is if enough of us stand up and refuse to be treated this way. The more patients that I can help to advocate for themselves in medical settings, the more doctors I can try to educate about the harms of weight stigma, and the more that I can speak up in moments of witnessed weight stigma (along with racism, homophobia, and a plethora of other abuses), the more I feel I can somehow make a difference, even if it is just for one person.

“What should I do for exercise?”

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When the topic of physical activity arises, a common question I get – especially if the patient knows I used to work as a personal trainer – is some version of, “What should I do for exercise?”

Before I get to my answer, a little history: Back when I was in nutrition school and working on the side as a trainer, I began my relationship with a new client by asking about their exercise-related goals. With their answer in hand, I researched the best (in theory, anyway) physical activity approach towards achieving said goals. Whether or not the client enjoyed my exercise prescription was largely immaterial. I offered a means to an end, and they were going to do what I suggested whether they liked it or not.

Furthermore, my clients hardly seemed to mind my approach. They expected trainers to have a no-pain-no-gain mentality, an element of an exercise-as-punishment culture that is so harmful yet prevalent, and I was giving them what they thought they deserved. Clients wanted clear and crisp answers, and I was providing them. Whether I was right, wrong, or somewhere in between seemed a distant consideration to the reassuring comfort that came with being told what to do.

At this point, I should add that I was a fairly horrible personal trainer. With hardly any experience, little oversight, and no mentors, I was on my own to take what I had learned in academia and apply it to the real world. Humans, it turns out, are way more complicated than straightforward case studies in a textbook. Clients became burnt out, got hurt, lost interest, or dropped off for other reasons, and they almost always blamed themselves instead of my flawed approach.

If that sounds similar to how dieters tend to place the blame for weight regain on themselves rather than on the diet, know that the parallel stands out to me too. Just as I cringe at the way I used to train clients, I am embarrassed and ashamed of how I practiced dietetics at the beginning of my career. The difference is that I have been a dietitian long enough to have outgrown those painful beginnings, whereas I worked as a trainer for such a short time that just when I was beginning to recognize my mistakes, it was time to move forward in my career.

When patients ask me about exercise, I now know that the straightforward answers they want and expect – the very kind of answers that I used to provide as a trainer – are not all that helpful even if they would be welcome. Just as is the case when it comes to our relationships with food, our relationships with physical activity are nuanced and unique. The answers come about through discussion and collaboration. Here are five factors that I encourage my patients to consider:

  1. Enjoyment: My decision to lead with a factor that is often shoved towards the end of the priority list or set aside entirely – yet in my eyes is so essential to consider – is a conscious one. If you do not like doing an activity, how likely are you to sustain it? If you repeatedly put yourself through an unpleasant experience, what kind of ripple effects will that have in the rest of your life, whether it be seeking out rewards, being in a bad mood, etc.?
  2. Risk: We can get hurt doing literally anything, but some activities are riskier than others. Injury risk also depends on the person in question. For example, some people can run their entire lives, whereas a friend of mine had to give it up due to a recurring injury that arose whenever he attempted to resume jogging. Risk extends beyond musculoskeletal concerns and includes other factors, such as a maximum heart rate that a cardiologist may suggest their patient not exceed.
  3. Access: If you enjoy swimming but cannot afford a pool membership, or you like walking but live in a mosquito-infested area without sidewalks, or you are into a team sport without a league in your area, you will face more challenges than someone with ready access to the facilities and opportunities they need.
  4. Goals: Choosing activities that advance us towards our goals increase our chances of achieving them. An aspiring strongman will get little benefit from participating in cycling brevets, whereas someone with osteopenia in their hips may be better off skipping both of those pursuits entirely and instead going for a walk.
  5. Options: Remember that physical activity is comprised of more than just “exercise” in that the latter typically conjures images of things like elliptical machines and dumbbells, whereas the former is broader and can include gardening, cleaning, shopping, dancing, hiking, chair yoga, isometric contractions, and anything else that engages the body.

So, what should you do for exercise? Look for a mode that you enjoy, have ready access to, makes you physically feel good, and helps you towards your goals. Whatever your answer is, that is what you should do for exercise.

Exercise Checklist

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Exercise. The word alone carries a lot of meaning for many of my patients. For some of them, exercise is something that feels compulsive, that if they did not do it every day, they would feel panic. For other patients, exercise brings up old memories from childhood, such as when their parents forced them to exercise. One patient told me that when she was just eight years old, her father made her go for a run every weekday for 30 minutes to “help” her lose weight and be “healthy.” Not surprisingly, this patient has an utter hatred for running now. The word “exercise” itself can be triggering for some people as it feels intrinsically linked to diet culture. As we all know (insert sarcasm), exercise is “good for you” and therefore the more the better. “No pain, no gain” is another message that diet culture tells us about exercise. In other words, if it doesn’t hurt, you aren’t doing it right.

In my work with patients who struggle with compulsive dieting, disordered eating, and eating disorders, the question of exercise often will come up after much progress has been made with eating. A great number of my patients feel afraid to start exercising again for fear that they will get sucked back into diet culture. These patients worry that they will not be able to view exercise as something enjoyable and not required. They have concerns that their old thoughts about weight loss will start popping up again as they have associated exercise with changing their body. Some feel just completely overwhelmed at the idea of moving their body in a way that feels good because they had been so used to suffering through boring, pain-inducing workouts. And still other patients are at a loss as to what physical activity they actually enjoy.

One tool that many of my patients have found helpful is a “checklist.” It is a list of questions to consider before engaging in physical activity. The goal of this list is to help the patient check in with their body and decide whether or not they want to be physically active, and if so, what kind of activity would they like to engage in. Here is a basic checklist:

  • Am I injured or sick? If the answer is yes, then it is likely that you should be resting and not pushing yourself to be active.
  • Have I eaten enough in order to do this physical activity? Am I hungry right now? If you have not been consistently feeding yourself, exercising would be contraindicated as doing so could put a lot of stress on the body. If you are hungry, then you should eat.
  • Am I well-rested? If not, you might be too tired to be physically active right now. Perhaps your body needs a nap.
  • What am I looking to get out of this physical activity? Different forms of exercise can help our body improve endurance, strength, or flexibility. And sometimes physical activity can boost one’s mood via stress relief.
  • Do I feel like I have to do this physical activity in order to deserve food today? If you feel the answer is yes, try to reframe this thought. You deserve to eat no matter how much or how little you exercise. You do not have to “burn it to earn it.”
  • Am I using this activity as a way to try to lose weight or change how my body looks? Again, if the answer is yes, then some body image work could be indicated. Instead of asking yourself “how will this activity change my body?” try asking yourself “how will this activity make my body feel?”
  • What kind of activity would I like to engage in right now? Do I want something high intensity like spinning, something low impact like walking, or something very relaxing like yoga nidra?
  • If I don’t feel like moving my body right now, what else can I do? Maybe taking a nap or talking to a friend would feel best right now.

The checklist looks different for each patient, but at its core, it is about checking in with your body and trying to listen to what it is telling you. The more that we can practice checking in with our body around its needs – including but not limited to food, physical activity, sleep, and stress relief – we will be able to develop and foster body trust.

Decision Time

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Shortly after midnight on Saturday, April 14, 2018, I had a dream in which I was at the staging area for that morning’s Newport marathon, but I had not yet checked in for the race or stored my belongings even though it was 7:13 AM, just 17 minute shy of race time. Frantic, I was trying to figure out how I was going to take care of these logistical to-do items and get to the starting line on schedule. Then I woke up.

Approximately seven hours later, I was at the staging area down in Newport for the actual marathon. The truck containing the mobile locker I had rented in advance was mysteriously not there yet. Confused and anxious, I wondered what I was going to do with all of the gear I had planned on locking up, including my wallet, keys, phone, clothes, and post-race snacks. Standing there feeling somewhat paralyzed by uncertainty, I took out my phone and checked the time. It was 7:15 AM. (Premonitions allow for a two-minute margin of error, no?)

Midnight clairvoyance and the subsequent inauspicious sunrise set the tone for the rest of my day. Eventually, I got in line for gear check, an unsecured area for runners to leave their belongings, for I could no longer wait for the mobile lockers to arrive. Good thing I did not hold out for them either, as I found out later that the driver overslept and did not arrive with the lockers until well after my race began.

As I was standing in a long line comprised mainly of runners competing in the 5K and half marathon events that were commencing later in the morning, I heard the national anthem and then saw my fellow marathoners starting down the road. After several minutes, I got the attention of a volunteer and stammered, “I don’t know what I’m doing and my race just started without me.” He told me to drop my bag, that he would take care of it, and from there I hurried to the course and crossed the starting line well after the rest of the field.

While I prepare meticulously for race-day logistics, my pre-race plans went out the window due to the chaos that ensued from the mobile lockers’ absence. About a mile down the road, I realized I had accidentally left two of my three anti-nausea medicines in the bag I checked with the volunteer. Such a mistake was quite concerning, as nausea tends to be my limiting factor in marathons, even more than muscle soreness or general fatigue.

Not having my medication only compounded problems that began with a poor training cycle due to a herniated disc in my lower back, an abdominal hernia for which surgery was scheduled six days after the marathon, and a couple of other medical hindrances. Things were not looking good already, and yet they got worse.

Quickly, my fellow runners and I discovered that hydration was going to be a problem. Unlike most marathons that offer both water and sports drinks regularly along the course, most of the beverage stations on this course featured only water. Moreover, the cups were maybe a quarter full. Subtract from that the fluid that splashed out during the drinking process, and the net amount that made it down my throat was not nearly enough to keep me hydrated. The stations that did offer a beverage other than water had a low-calorie electrolyte drink, woefully insufficient to replenish the carbohydrates expended during such an endeavor.

Despite these challenges, I was inexplicably on pace for my all-time best marathon through mile 18, but by then things were getting ridiculous. We had not had a beverage station since mile 13, no electrolyte drink since probably mile 11, and the course was in the midst of a miles-long uphill stretch that felt more challenging to me than Boston’s Heartbreak Hill ever has.

The nausea, which had been building slowly, was pronounced enough where I felt like the time was right to use the one anti-nausea medication that I remembered to bring out on the course with me. In keeping with the theme of the day, the pills promptly fell out of my Ziploc bag onto the road. The quiet tick of the medication hitting the pavement was likely inaudible to anybody else, but to me it was the thunder of my last hope for a great marathon finish crashing down.

Limited by nausea and dehydration-induced muscle cramping, my pace slowed significantly over the final miles. Around mile 25, a blister that I did not know I had burst on the bottom of my right foot, altering my gait and slowing me even further. Hobbled, I kept running and crossed the finish line limping.

Somehow, out of the day’s nonsense sprang my fastest marathon time in 15 years, but this is less a story of resolve and more a tale of someone struggling in real time to weigh the pros and cons of disregarding or honoring his body’s signals, which in this case were clearly telling me to drop out of the race.

The course was essentially a figure eight with the start, midpoint, and finish all at the center. If I was going to call it a day early, hitting the eject button at the midpoint made the most sense, so I took stock of the situation as I neared the 13.1-mile mark. Inadequate fluids, dehydration and cramping that were already setting in, insufficient medication, and memories of my 2004 Boston marathon – which ended with an ambulance ride to the emergency room – all suggested that dropping out was the sensible and safest play.

On the other hand, my speed was inexplicably fast up to that point and I did not want to take for granted that I would ever have a shot at a marathon personal best again. While I reserve the right to change my mind, I went into this race figuring it was probably my last marathon. While I enjoy the training and racing, impending parenthood had me looking at the situation from a different perspective. Long training runs take a lot out of me, so much so that I am pretty much useless the rest of the day, and I do not think it is fair to put our daughter in a position where daddy cannot play, or go to the playground, or go for a walk, or do pretty much anything at all because he ran far and needs to rest.

Even if I do decide to train for another marathon someday, who knows, I could wake up sick on race day, or sprain my ankle on a Baby Einstein guitar while heading out the door to the starting line, or suffer any item on a tremendously long list of inflictions or mishaps beyond my control that could throw the whole endeavor out the window at any point in my training cycle or at the very last instant.

As I neared the half, I was cognizant of the reality that being 13 miles into a marathon with a chance for a personal best might never happen again. For as much had gone wrong, a lot had also gone right to allow me to be in such a position. Having weighed the pros and cons, I decided to continue on with the race despite all of the reasons to stop.

Disregarding my body’s cues eventually caught up with me. A few minutes after I crossed the finish line, the nausea worsened, I was shivering (a symptom of dehydration) despite the warm temperatures, and my breathing was abnormally rapid. Laying face up in the sun while wearing a hooded sweatshirt and winter jacket did not help. With my condition deteriorating, I made my way to the medical tent.

The paramedics took my blood pressure, which was sky high compared to my norm, and I was having trouble answering their questions. While I have a history of occasionally feeling miserable after long runs, this was worse than my norm. The scariest part to me was that I was aware of my incoherence, yet I could not do anything about it. They asked me what medications I take, but I could not put together an articulate response. In my mind, I was like, “Come on, dude, you know what meds you take, just tell them,” but I was incapable of getting the words out.

The paramedics wrapped me in blankets, put me in the back of an ambulance, and cranked the heat to warm me. They gave me oxygen and placed leads to monitor my pulse, heart rhythm, and oxygen saturation. After two hours of laying on the gurney getting rehydrated and warmed, we agreed that I was well enough – but albeit still far from 100% – to leave the ambulance and make my way back to my car.

Stepping out of the ambulance, I was startled to discover that the finish area was virtually deserted, as the spectators, volunteers, race organizers, and my fellow runners had pretty much all gone home. Watching the few remaining workers disassemble the food tent and the final handful of artifacts from a post-race party that had presumably been so happy and festive just a short time earlier, I felt an eerie and unsettling sensation: loneliness.

Later that evening, Joanne commented over dinner that I looked sad. She was right. Ending up in an ambulance with a health scare is no way to conclude an event. Finishing a marathon normally yields a significant sense of accomplishment, but this time I felt conflicted and somewhat hollow. Even though completing the course was a triumph of sorts, I had mixed feelings for having put myself in unnecessary jeopardy.

Like I tell my patients who are working on listening to and honoring their internal cues: assessing hunger and fullness levels, sorting through matching criteria, checking for humming and beckoning, and utilizing other intuitive eating tools are never meant to be leading questions, and there are no such things as absolute right answers. Decisions made regarding what, when, and how much to eat matter much less than having utilized a thoughtful process to reach them.

Similarly, having considered all of the pros and cons of the options available to me at the moment I had to make a choice, I feel like continuing to run was the best course of action for me despite my body’s cues suggesting that I stop. Ultimately, I am glad I finished the race even if I did pay a price for my decision.

Just after crossing the finish line. Am I having fun or what?

“Sometimes I want to binge so bad.”

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A guy two months removed from spinal fusion surgery has no business moving a 45-pound plate. For that reason, in the late spring of 2014, I introduced myself to a new personal trainer at my gym and asked him to please put away the plate that another member had left on a machine so that I could use the equipment.

Typically, I shy away from new trainers, who tend to pitch themselves to virtually every member they meet in an effort to build their client rosters. As a former trainer myself, I get it, but I also do not like being pressured. This trainer was different though, and once I saw that he was not going to push me for a sale, I began talking with him on a regular basis. That hey-can-you-please-put-this-weight-away interaction turned out to mark the beginning of what has evolved into a friendship of sorts.

In the five years since, we have chatted about superficial matters, such as the rise and fall of the Celtics, as well as issues of more substance, like marriage and fatherhood. Despite the connection we have developed and my opinion that he is generally an excellent trainer, I have never referred my patients to him because of one factor that makes it ethically impossible for me to do so: He unintentionally encourages disordered eating.

Food and eating behaviors are common topics of conversation during his training sessions. Calories, cheat days, tracking apps, Halo Top, junk food, clean eating, intermittent fasting, and willpower are just some of the buzz words and trendy features of diet culture that I frequently hear him and his clients discuss.

My patients and I sometimes talk about these topics too, but the substance of our conversations is entirely different. Whereas I work towards dismantling diet culture and helping my patients understand the harm that comes from relating to food in such a way, this trainer sees these as positives. He tracks his calories, fasts, and weighs himself regularly, and he cites his own weight loss from the past year as evidence that his behaviors are the secrets to success that his clients should replicate.

Last week, one of his clients texted him to say he was going to be a half hour late. With an unexpected chunk of free time on his hands, the trainer came over and struck up a conversation with me while I was stretching. “Do you help people lose weight?” he asked. No, I do not, and I gave him my elevator speech explanation as to why.

His response somewhat surprised me. He told me how difficult weight loss was for him, how exhausting it is to track everything he eats, and how he just cannot keep up the behaviors. “Sometimes I want to binge so bad,” he conceded. The restriction is unmaintainable, he regains the 15 pounds he lost, then resolves to become lean again, reengages in his previous diet behaviors, again loses 15 pounds, and the cycle repeats.

In the last five years, I have overheard literally hundreds of conversations he has had with his clients regarding nutrition, many of which have referenced his own eating behaviors, but never have I witnessed him disclose his struggles and concerns as he did last week when none of his clients were around to hear about them.

So, I told him about the Ancel Keys starvation study and how binge behaviors were commonplace among the subjects once the dietary restrictions placed upon them were lifted. In their excellent book, Beyond a Shadow of a Diet, Judith Matz and Ellen Frankel explain the following:

“What these men [the study’s subjects] experienced as a result of their semi-starvation is typical of feelings and behaviors exhibited by dieters. When the men entered the refeeding portion of the study, the food restrictions were lifted. Free to eat what they wanted, the men engaged in binge eating for weeks yet continued to feel ravenous. They overate frequently, sometimes to the point of becoming ill, yet they continued to feel intense hunger. The men quickly regained the lost weight as fat. Most of the subjects lost the muscle tone they enjoyed before the experiment began, and some of the men added more pounds than their pre-diet weight. Only after weight was restored did the men’s energy and emotional stability return.”

Modern day dieting, I pointed out to the trainer, is really just self-imposed starvation, and it is completely understandable that dieters respond just like the study’s subjects. It is not a matter of willpower, but rather one of biological mechanisms, honed through evolution, that resist weight loss and encourage weight gain in order to help our species survive famines and other times of food scarcity.

Soon enough, our day’s conversation came to a close. He had to get ready to train his client, and it was time for me to head home and prepare for my own day’s work. Just before we went our separate ways, he told me that his clients have no idea how hard it is for him to try to maintain his eating behaviors, and we agreed that we never really know what someone else is dealing with behind the scenes.

Our parting sentiment is also the key takeaway from this blog. Said differently, consider the words of one of our most experienced and knowledgeable colleagues, Dr. Deb Burgard, who once said, “In almost 40 years of treating eating issues, I have found that when someone sits down across from me, I have no idea what they are going to tell me they are doing with food.”

In this trainer’s case, while many of his clients see him as a role model and look to him for nutrition advice, they do not realize that he is struggling and that the behaviors they seek to emulate are actually signs of disordered eating.