Category Archives: Exercise

He Said, She Said: 1,500-Calorie Diet

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A patient sent Joanne the following email. “I overheard a coworker talking about food/calories/etc. and noted her saying, ‘We should all be on a 1,500-calorie diet as women.’ For some reason this really got to me and I normally don’t let these stupid comments affect me, especially when I know better. Thoughts?”

 

He Said

Yes, I do have thoughts about this, several in fact, but for the sake of time and space, I will leave aside tangential issues of practicing dietetics without a license (If someone without a medical license made a statement along the lines of, “As women, we should all be taking [insert name of a medication] daily,” would you be cool with that?) and the virtually-constant propagation of nutrition myths throughout our culture. Instead, let’s focus on just how incorrect this coworker’s assertion is.

Caloric needs are surprisingly difficult to determine. The most accurate method is direct calorimetry, which utilizes a metabolic chamber in which the subject occupies a compartment that measures the heat that he or she emits during whatever state of activity happens to be taking place at the time. Unless you enroll in a research study that involves one of these chambers, you will most likely never gain access to one in your lifetime.

Indirect calorimetry, which involves measuring oxygen and carbon dioxide intake and expulsion, respectively, is less invasive in some ways and easier to utilize. Large hospitals typically have metabolic carts that can perform such measurements in their research laboratories, and lesser models exist for office settings. The tradeoff, however, is accuracy, as even the best indirect calorimetry tools are a step down from direct calorimetry.

Next we have the Fitbits of the world, devices that use algorithms to estimate caloric needs based on a crude set of variables. Dietitians use similar equations sometimes as well, and when I do, I always stress to patients that the results are just rough estimates that cannot and should not be taken too literally.

These equations have numerous sources of error, such as the reliance on subjective measures of physical activity. Anybody can Google how many calories certain activities supposedly burn, but really these numbers are general rules of thumb at best. Running a mile burns 100 calories, we are told, but is this right? What about the size and body composition of the runner, or his or her mechanics? Does he or she have short, quick strides or long, less frequent steps? What about swings of the arms, point of contact between the foot and the ground, head bobbing, or any number of other factors that can influence the results?

One of my patients occasionally asks me how many calories one burns during sex. Unless you get two people to have intercourse in a metabolic chamber, who knows? Even then, the heat generated would pertain only to those unique individuals in that specific encounter, so what do you do, divide by two and make the assumptions that their efforts were equal and that these results apply at other times and to other people as well? Logistical hurdles and the countless variables involved make estimating caloric expenditure a guessing game not just for sex, but for pretty much any activity.

As a consequence, estimates of caloric needs are just that – estimates – and vary widely from person to person. My degree in mathematics reminds me that I like numbers as much as the next guy if not more, and I can certainly understand the appeal of having a short, sweet, and specific target for which to aim, but really the best method to determine your caloric needs is to set quantifiable data aside and look internally to your hunger and fullness signals. Despite all of the proliferating nutrition myths and overarching messages we are taught from childhood on that we cannot trust ourselves regarding food, our bodies are actually pretty good at telling us what and how much they need. We just need to relearn how to pay attention and trust those signals again.

 

She Said

Ahhh, the 1,500-calorie diet. It’s amazing how some arbitrary number has gotten stuck in the minds of so many people. 1,200 calories is also a popular number. Flip through any of your typical women’s health magazines and you are likely to read that all women should be consuming no more than 1,500 calories per day to be “healthy.” Unfortunately, there really is no such thing as the “perfect” number of calories for each and every person. 1,500 calories (or 1,200 calories or 1,750 calories) is a myth. It makes no sense to say that every woman should be on a 1,500-calorie diet; we all are unique human beings with unique needs.

As I tell my patients over and over – every body has different caloric needs. Age, height, weight, gender, muscle mass, and activity level are just some of the factors that can affect our calorie needs. Even the Mifflin-St. Jeor equation, the equation most often used by most dietitians to determine calorie needs, does not take into account all of these factors. Our caloric needs will vary over our lifespan for a number of reasons. Women who are pregnant or breastfeeding need many more calories, while as we age, we typically need fewer calories. Anyone who has lived with a teenager can attest to the fact that calorie needs go way up during adolescence! When someone is recovering from an injury, his or her caloric needs might be elevated. For instance, the caloric needs of burn patients can be as much as double what the “average” person’s needs are. The best way to figure out what your calorie needs are? Eat as you normally would. If you see no large shifts in your weight (think plus or minus five pounds), you are meeting your calorie needs!

When working with patients who struggle with eating disorders, I try to steer clear of talking about calories. Many of my patients have spent countless hours logging the calories they ate (and burned), and most of these patients would say that they were “obsessed” with doing so. I had one patient who would log her calories daily, and if she consumed more than 1,300 per day, she felt like she had “failed.” Another patient would try to stick to no more than 1,800 calories per day, and if she went over by just a few calories, she would binge because she had “blown it.”

Instead of talking about calories, I try to use the “exchange” system with my patients. Exchanges are groups of foods that have similar nutritional profiles. For instance, a carbohydrate exchange (sometimes called “grain” or “starch” exchange) contains approximately 15 grams of carbohydrate per serving. This might look like an average piece of bread, a ½ cup of cooked pasta or rice or ½ of a large potato. By using exchanges, we can take the focus off of calories and how we need to limit them and instead talk about making sure we get enough carbohydrates, protein, fats, vegetables, etc. Calories have a negative connotation for many of my patients, while exchanges feel a bit more abstract and neutral.

In short, instead of setting an arbitrary calorie goal for oneself, I think it would be much more beneficial to set other goals. Getting five fruits and vegetables per day, being physically active for 60 minutes per day, and eating intuitively would be much better goals (in my opinion) than making sure one never goes over 1,500 calories per day.

Will

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Yesterday, I received word that a childhood friend of mine died suddenly over the weekend from a brain aneurysm. After processing the news for a few hours, I decided to write a letter to his mother. Everybody deals with loss differently so I could be way off base here, but I imagine that after the immediacy of this tragedy passes, she might appreciate hearing some stories about her son and what he meant to the rest of us.

To all of the patients – children, adolescents, and adults alike – who show up in our office looking to manipulate their bodies in hopes of fitting in and gaining acceptance, and to all of our own family and friends who seek to do the same, it is important to keep in mind that in the end we are often not remembered, respected, and appreciated for what made us the same, but rather for what made us different.

He Said, She Said: Marathon Nutrition

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He Said

When I made the decision to leave behind my career as a research analyst for the U.S. Department of Transportation, I began looking for jobs in healthcare and landed a position working on a clinical trial with a kinesiology professor.

Given her background and expertise in exercise science and her personal interest in athletics, I shared stories of my marathon experiences with her and happened to include that I preferred Coke to Gatorade during long runs. “Ugh, that’s the worst thing you could do!” she disgustedly told me. Actually, no, I had figured out through trial and error that my body best tolerated plain old Coca Cola Classic over any other liquid with which I experimented, so I would argue that drinking Coke was the best thing I could do for athletic performance.

Sometimes, quite often actually, approaches that seem most sensible on paper do not function the best in real life. That is why guidelines are nothing more than their name suggests and should not be treated as gospel. Guidelines are helpful because they give us a place to begin, but I always emphasize to runners the importance of experimenting with various nutrition approaches during training to determine which eating and drinking strategy functions best for them and therefore will be used on race day.

In truth, marathoners take all sorts of different approaches to fueling themselves before and during marathons. Gatorade and water are supplied to the masses at various points along the Boston Marathon route, but the elite runners skip those tables and have their own hydration stations where each of them has a custom-made concoction waiting for him or her in labeled bottles. Some runners, for example, drink flat, non-alcoholic beer. A friend of mine used to eat gummy bears during marathons. Another friend made it through the running portion of his Ironman triathlon by alternately consuming oranges and bananas. As for me, I ran most of my marathons fueled by Coke and pretzels.

When Joanne and I first began dating, I was in the midst of a demanding dietetic internship, and I dealt with the stress by going for long runs on the weekends. Although it was clear that she found my behavior a bit odd, only she could tell you which struck her as weirder: the fact that I chose to spend my Saturday afternoons going for 20-25 mile runs, or the fact that I spent my Saturday mornings driving around and stashing bottles of soda and bags of Oreos in various hiding places along my running route. Just because gels, goos, sports jelly beans, and salt tablets exist and work well for some athletes does not mean they will have everybody running their best.

Commonalities do exist among the various approaches that people take, such as the importance of replacing the carbohydrates, electrolytes, and fluids lost during running, but numerous methods of achieving these nutrition goals exist, and that is where the importance of individualization enters the paradigm. Therefore, when you see or hear of another runner taking a different approach to his or her nutrition than you take to yours, remember that multiple “right” answers exist, and stay true to what you know from experience works best for you. Remain confident: Your training, both the running itself and your nutrition experimentation, has gotten you this far, and it will get you to the finish line, too.

 

She Said

April is one of my favorite months of the year. The winter is over (At least it should be!), little green things start sprouting out of the ground, and the promise of warmer days is ahead. Having been born and raised in Massachusetts, I have also come to associate April with the Boston Marathon. As a little girl, I would walk down to Route 16 with my mom, and we would cheer on the runners as they jogged past us. I was always amazed at how these individuals could just go and go and go. And how many of them there were!

From time to time, the subject of marathon running comes up in my work with patients struggling with eating disorders. Many of my patients are exercise enthusiasts who often have to cut back (or completely avoid) exercise in the early stages of ED recovery. As the individual makes progress in his or her ED, the subject of when he/she can start to exercise again will often come up. Of course, when figuring out whether to clear a patient for exercise, the primary care physician really needs to make the final call. Often this means that the patient should be having his or her vital signs taken regularly, and if his or her blood pressure, heart rate, and weight are routinely found to be in the “healthy range” for a good period of time, he or she may be cleared for exercise.

The word “exercise” can have a number of different meanings depending on whom you talk to. For the average person, perhaps going for a 30-minute walk 3-4 times per week would be exercise. But more often than not, for the person dealing with an ED, exercise usually means much more intense activity for more extended periods of time. That’s where the marathon piece comes in. I have had a number of patients state that they would like to resume (or start) running, not with the intent of managing their weight, but to strive for some goals. Usually, it will start with training for a 5K race, then a 5-miler, then perhaps a 10K. In and of itself, these races aren’t a problem vis-a-vis eating disorder recovery as long as the individual is competing and training due to the love of running rather than trying to control weight.

Sometimes I will have a patient announce the plan to run a ½ marathon with the goal of running a full marathon eventually. This is where things can get a bit dicey. As anyone who has run a marathon can attest to, the act is not an easy one. Although I have never run one myself, I have had people tell me it’s a lot like childbirth – after a period of time, one “forgets” the physical agony and only remembers the joy of finishing. In reality, running a marathon takes a huge toll on the body and can be quite grueling. For someone whose body is recovering from a life-threatening ED, training for and running a marathon can put a lot of stress on an already stressed body.

In general, I would suggest that the individual really delve deep into why he or she wants to run a marathon. Is it for the thrill of accomplishment, to check something off on one’s bucket list? Or is it a sanctioned way to exercise excessively, “permitting” the individual to eat with abandon and maintain or lose weight? Personally, I believe that someone needs to be in recovery for a significant period of time before attempting such a demanding physical endeavor. That period of time depends on a number of factors: How long has the individual struggled with an ED, and how long has the individual been in recovery? Has he/she maintained a healthy weight, heart rate, and blood pressure for a significant period of time? Is the patient’s mindset healthy or weight-centered?

If the individual is determined to be healthy in mind and body and the treatment team supports it, I think someone in recovery from an ED could in fact train for and run a marathon. However, it would be advisable for this patient to continue to engage in regular therapy and see his or her doctor weekly to make sure his or her marathon goals aren’t interfering with continued ED recovery. In addition, this patient should consult with a registered dietitian who specializes in both EDs and sports nutrition to make sure that he/she is getting in the right amounts and types of fuel and hydration needed for running a marathon. As long as the above conditions are met, there is no reason why someone who has struggled with ED couldn’t run a marathon.

Day 366

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Today marks the one-year anniversary of my surgery. Because my spirits were so dismal in the days immediately following the operation, on day 11 I began writing a log of the small daily victories that marked my healing and recovery. While I was initially unsure how long I would keep it up, I have maintained the log to this day and have no plans to stop, not when I still have so far to go.

One year ago tomorrow, I strapped on my back brace, leaned on a walker, and shuffled slowly from my hospital room to the nurse’s station and back, flanked by my wife and a physical therapist. Due less to pain and more to my fear that the operation had not worked, I cried the whole way.

Going into the operation, I was under the impression that I would not need a brace. When I found out the surgeon was prescribing one, I angrily and defiantly informed the nurse that I refused to wear the contraption. Over time though, I became attached to it. While the brace was at first just a literal support, over time it took on a figurative role as well, sort of like my version of Wilson the volleyball. During the first two months of healing, my brace and I walked for hours and hours together, and during long walks when I was otherwise alone, unsteady on my feet, unsure of my present, and scared of an uncertain future, my brace was always there to keep me upright and give me the courage to keep moving forward.

On day 67, we walked the entire Boston Marathon route together. Shortly thereafter, my surgeon told me it was time to stop wearing the brace. Truth be told, I was sad to jettison my sidekick. Finding the brace by surprise in the house triggers a similar fondness to randomly running into an old friend in the grocery store.

My surgeon was astonished by how quickly I progressed in the first few months after the operation. “You will be back to your crazy workouts in no time,” my physical therapist told me last summer. Turned out she was way off. As I wrote on day 197, we are only somewhat in control of our destiny and life does not always unfold the way we might expect or wish for ourselves.

Setbacks have been plentiful. Activities that my surgeon said should be fine at the time, like swimming, remained intolerable until seasons after his timetable indicated. Some of the bone grafts were unusually slow to heal and for a couple of months we faced the legitimate possibility that they might never fuse. Once I got the green light to resume weight training, I hurt one shoulder, then the other, and had to leave the weight room once again while I rehabbed them. Raking leaves in the November twilight and rushing to finish before darkness, I swiftly walked into my leaf blower, broke my big toe, and ended up in a walking boot. My most recent MRI showed a bulging disk at the surgical site, a highly unusual complication, and the radiating pain down my leg has returned. What can I say, Robert Smith taught me a long time ago that life is neither fair nor unfair.

Before the surgery, I expected that my healing would plot out a linear trajectory with each week being better than the previous one, but quickly I realized that was unrealistic and a setup for disappointment. Real life has its downs, but thanks to good fortune, hard work, and help from many people, it also has its ups.

Although my ultimate goal remains to resume playing competitive tennis and I am working hard in a physical sense to make that happen, simultaneously I am doing my best to prepare myself emotionally for the possibility that it may never come to fruition. Although I remain light-years away from returning to the court, accepting the latter feels much harder – and much less likely – than ever achieving the former. Past opponents and fictitious foes have contract court time in my dreams and we battle it out several nights most weeks, and my wife does not know that I often tear up when I watch her own matches from the sidelines.

Recovery does not end once the surgical site heals. Despite all that has happened in the past twelve months, in some ways I feel like I am still at the beginning of the journey with a long and unmapped future ahead of me. One year ago, I was bawling on a hospital gurney awaiting my turn in the operating room. Today, I went for my first run outside in 18 months. It was slow, short, uncomfortable, and really, really difficult. And it was totally and completely awesome.

He Said, She Said: “Do Your Job”

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He Said

The main reason I enjoy following sports is not entertainment, but rather because I am fascinated by how athletics reflect life’s themes with such clarity that the lessons are blatantly apparent. Earlier this month, the New England Patriots won the Super Bowl behind Bill Belichick’s “Do Your Job” command. In other words, perform your role as you are taught, trust that your teammates will do the same, and as a result, the team as a whole will experience success.

This same lesson applies to health care. In fact, practitioners actually use the word “team” when describing the collection of providers who collaborate to help a given patient. This treatment team consists of a primary care physician and any number of specialists, including psychotherapists, dietitians, physical therapists, and others who are all essential to the patient’s care.

Equally essential is understanding the importance of each practitioner doing his or her own job, no more, no less. Nobody is an expert in every single facet of health care; consequently, all providers have limits to their scopes of practice. One of the traits that separates the best practitioners from their peers is recognizing where their boundaries lie and taking care not to step over them.

Unfortunately, some practitioners, who no doubt have their hearts in the right places, exceed these boundaries. Quite often, Joanne and I encounter situations where other members of a treatment team have provided the patient with nutritional advice. The result is almost always confusion and a step backward in the patient’s care.

For example, one of my patients recently told me about different pieces of nutritional advice that his primary care physician and his personal trainer had given him. In both cases, the guidance he received was off base. My poor patient, he was so confused that the result was a temporary undoing of progress he and I had achieved together.

The doctor no doubt meant well. Doctors are absolutely critical in health care. Primary care physicians are trained to be first-line responders for conditions ranging from splinters to cancer. Specialists dedicate their lives to their individual disciplines, and their unique expertise oftentimes quite literally makes the difference between life and death. Personally, I owe an unpayable debt of gratitude to my neurosurgeons, Dr. Griffith Harsh and Dr. Jean-Valery Coumans, for giving me the quality of life that I have now.

However, doctors receive a scarce amount of nutrition education in medical school. According to one study, students received only 23.9 hours on average of nutrition instruction in medical school, which amounts to basically a long weekend workshop. That is almost 24 hours more of formal nutrition education than most people, but still nowhere near what dietitians receive.

During a Google search, I came upon a blog entry a doctor wrote in which he attempted to dispel the “myth” that doctors do not receive adequate nutrition training. He cited the mountains of organic chemistry, biochemistry, and physiology that medical students take in addition to learning about the roles that various nutrients play in the body. However, his argument only serves to prove my point. The hard science is of course important, but so is having a solid understanding and appreciation for how food is complexly intertwined with other facets of life, such as social, cultural, and financial factors. Dietitians, not doctors, receive this comprehensive training, which perhaps explains why so many patients come in here having been given rigid, unsustainable, and plainly unrealistic “doctor’s orders” regarding how to eat.

As a former personal trainer who still maintains my certifications even though I no longer practice as one, I can attest to the important functions that trainers serve. Great trainers can put together workout programs that increase safety, effectiveness, and enjoyment while simultaneously reducing the intimidation, confusion, and boredom that sometimes accompany exercise.

Having been through the personal training certification process and having worked in the field though, I can tell you that most trainers have no nutrition knowledge beyond what most laymen hold. Looking through the manual that I studied for one of my certifications, I see that the nutrition chapter is 15 pages long. As I have argued before, sometimes a little bit of nutritional knowledge is worse than none at all. Registered Dietitians hold degrees in the field, complete rigorous internships that include everything from chopping squash in a cafeteria kitchen to ordering intravenous feedings for intensive care unit patients, pass credentialing boards, and hold state licenses to practice dietetics. Fifteen pages versus all of that. From whom would you rather receive your nutritional guidance?

Similarly, we dietitians have limits to our expertise as well, and we must respect them. Because emotions can be so intertwined with food, strong feelings and deep-rooted issues sometimes arise during our sessions. Acknowledging these emotions and taking them into account are important parts of our work, but we cannot address them as effectively as trained therapists can. For that reason, providing the quality of care that our patients deserve sometimes means suggesting that they consider adding a therapist to the team.

Practitioners of all disciplines fill important roles in patient care, but if we want to achieve victory, which in this case means helping our patients to the best of our collective ability, then we need to follow Coach Belichick’s guidance by staying within our scopes of practice and trusting that everybody else on the team will do the same.

From the patient’s perspective, keep in mind that well-meaning practitioners sometimes reach beyond the bounds of their expertise in an effort to help, but the further he or she stretches, the less accurate the guidance is likely to be. If you want reliable expertise regarding a particular issue, then seek it from a practitioner who has dedicated his or her professional life to that specialty and let him or her do his or her job.

 

She Said

What an exciting Super Bowl that was! Jonah and I were on the edge of our seats for the entire game, and the finale was just amazing! It got us thinking about the Patriots’ motto this season: Do Your Job. It was clear that every Pats player had such an important role in that game and that each player did his job extremely well. In order to work together as a team, they needed each person to execute his job as he had been trained. And it really paid off!

The Pats slogan got me thinking about how eating disorder (ED) patients need a strong treatment team in place in order to recover. Each member of the treatment team needs to do his or her job to support the patient, and there needs to be a clear line of communication among all team members. In addition, each member needs to try to practice within his or her scope of expertise without taking on the others’ roles.

In ED treatment, the team can consist of a number of different players. If the patient is in an inpatient or residential program, the treatment team will likely include a doctor and/or psychiatrist, a nursing staff, a therapist, a case manager, residence counselors, and a dietitian. In an outpatient setting, the team ideally includes a physician, therapist and/or psychiatrist, and a dietitian who specializes in EDs. It could also include teachers, advisors, deans, coaches, and in some cases, the patient’s family as well. You know the saying that it takes a village to raise a child? Well, it takes a village to help a patient recover from an ED.

As much as we try not to do so, sometimes treatment team members will fumble the ball by giving advice that is outside of our scope of practice. I remember one of my patients had a therapist who was actually making changes to the meal plan I had developed for the patient without talking with me first. Although I am sure the therapist only meant to help, it gave the patient mixed messages about what roles the therapist and I would play. Similarly, there are times when my nutrition counseling sessions seem to take on a more therapeutic nature. Most people have a lot of feelings around food, eating, and weight, and sometimes it is difficult to know where the boundary lies between nutrition therapy and therapy! But I always strive to bring the conversation back to the food and then suggest the patient discuss his or her feelings more in depth with his or her therapist.

Another important aspect of treatment team work is that the team usually functions best when there is one quarterback running the show. In most cases, this individual is usually the ED physician or therapist, although sometimes it can be a case manager or even the dietitian. In reality, the patient is really the quarterback, but when he or she is really struggling with ED, a trained professional is the safest bet to step in and manage treatment.

Above all else, communication is the cornerstone of a successful treatment team. Clear communication, whether by phone, in person, or via email, can really make such a difference in a patient’s quality of care. If we are all on the same page, the patient will get a consistent message and hopefully feel more confident and secure that his or her treatment team is a cohesive unit that will help him or her eventually beat ED.

I Get Knocked Down

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The first six weeks of 2015 have been pretty rough for me. It started on January 4th. I made the fatal mistake of running down our wooden steps in just my socks. What happened, you ask? Well, I slipped and fell down the steps with such a thud that Jonah thought a piece of furniture had fallen on me! Luckily, the fall only resulted in a broken baby toe and a whopping bruise on my butt, but I was still pretty shaken up about it.

Just as I was healing from my trip down the stairs, I woke up the following Wednesday with my throat on fire and feeling feverish. My doctor told me to come in to her office so she could do a strep test on me. While the rapid strep test came up negative in her office, she took another swab and sent it to the lab. What are the chances that the second test would be positive? Well, apparently, they were pretty good – I had strep. I haven’t had strep since I was a kid, and boy, was this a bad strain. After taking a course of antibiotics, however, I started feeling better and thinking to myself that I was finally out of the woods.

How wrong I was! Just a week after recuperating from strep, I again woke up with another sore throat. This time there was no fever, and it was definitely better than the strep I had previously, but this illness along with a cough that is driving me crazy, just won’t seem to go away! Today I feel like I might finally be kicking this cold in the butt, but it has really wreaked some havoc on my mood.

All of these illnesses and injuries got me thinking – you know, I never really appreciated how wonderful it is to just be healthy until all of a sudden I wasn’t. I wish that I wouldn’t be so hard on my body when I feel like it has let me down. My body has gotten me through 36 (almost 37) years of life, most of which have been relatively healthy and safe. I should feel lucky that I can walk, swim, ride a bike or play tennis. Many people cannot do these things.

So, while the start to 2015 may not have been the best ever, I am determined not to let these past six weeks get me down. I love my body and everything it allows me to do. I will do my best to take better care of it, and that’s all I can do!

You Are Not Tom Brady

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Leading up to today’s Super Bowl, a Boston television station aired a piece examining how Tom Brady, the quarterback of the New England Patriots, eats. The segment teaches us that among other eating behaviors, Brady does not consume any added sugar or processed foods and he abstains from alcohol.

Celebrities often influence our own behaviors, which is the driving principle behind sponsorship deals. Lump me in there as well. When Andre Agassi, my all-time favorite athlete, was endorsing Nike, much of my workout apparel bore the “Just Do It” slogan. Later in Agassi’s career when he signed with Adidas, the logo on my sneakers quickly changed from a swoosh to three black stripes.

Whether consciously or subconsciously, the sentiment we tell ourselves is along the lines of, “If those sneakers [or racquet, or sports drink, or watch, etc.] are good enough for him, then they are more than good enough for me,” or perhaps, “If I use those sneakers [or racquet, or sports drink, or watch, etc.] too, then maybe I can play like him.” It is only natural that the same message may extend to our perceptions of how professional athletes eat, but if you are considering emulating Brady’s diet, think again.

With sport being the primary focus of a professional athlete’s life and so much financially riding on performance, they frequently make choices that would not necessarily be prudent for the rest of us. In a recent conversation, a physical therapist pointed out to me how professionals are quick to undergo surgery and rush through their recoveries, while an amateur with the same injury is more likely to opt for a longer, but safer, rehabilitation program rather than an operation.

In other words, the life of the professional athlete is often focused on the here and now while the long-term risks take a back seat. Look no further than how the National Football League dealt with concussions for decades – largely minimizing the significance of brain injuries and rushing concussed players back on the field with little regard for the depression, memory loss, and suicidal urges that often came with retirement – until very recent legal action inspired change.

This philosophy bleeds into nutrition as well. Following rigid food rules comes with upsides for professional athletes, but similar payoffs are unlikely to exist for amateurs. Therefore, while it may make sense for Brady and his peers to follow strict diets, the same does not hold true for the rest of us. In other words, Brady’s diet may serve him at this stage in his life, but if implemented by one of us, the same eating behaviors may be described as orthorexic.

According to the National Collegiate Athletic Association, 6.5% of high school football players will continue the sport in college, and 1.6% of college players will go on to play in a professional league. In other words, only 0.08% of high school football players will ultimately play professionally. The statistics that they report for basketball, baseball, hockey, and soccer are on par with these figures. Given the extremely high probability that student-athletes will have to make their livings in a capacity other than turning pro, they often have backup plans for their lives (well, at least hopefully they do) in the form of academic educations so they have somewhere to turn when school and their athletic careers end.

Similar benefits exist in thinking long-term about nutrition as well. With all due respect to Brady and other professional athletes who are doing what they feel they need to do in order to perform their best, all-or-nothing approaches to eating rarely serve people for too long. When an athlete retires and suddenly the incentive for restriction ends, how will he deal with previously-taboo foods? This is akin to children who grow up in rigid eating environments with strict rules regarding quantities and/or forbidden foods, and then they go off to college and binge on late-night pizza delivery and all-you-can-eat soft serve in the dining hall. Such black-and-white approaches that teach us to ignore our internal cues and rely instead on external constructs will in all likelihood ultimately backfire.

Real life exists in grays, so building healthy relationships with food means both listening to our bodies and being flexible to allow for the complexities and variables that come our way. A professional athlete may have incentive to sacrifice such a relationship and rely instead on external rules because the here-and-now upside is so great, but the rest of us are better off learning a lesson from the 99.92% of high school football players who will never play in the National Football League. In other words, think long and hard before deciding to sacrifice for the here and now, and instead focus on life’s big picture.

Psychology

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At a large family gathering over the weekend, a distant relative asked me about my work. Upon hearing that I am a dietitian, he smiled, leaned in, and asked me one of the most common initial questions that dietitians field, “So, do you practice what you preach?”

Whenever this question comes my way, I experiment with different permutations and phrasings of the same core truth in order to see which version best resonates with people. In this instance, I told him that what I “preach” might not be what he imagines, and that in reality a large chunk of what I do involves helping people to listen to and honor their internal cues regarding hunger, fullness, and food cravings.

His eyes wandered elsewhere as I spoke, and I could tell that this version of my answer was most definitely not resonating with him. When I finished, he reflected back to me, “That sounds like psychology.” He is not alone in his confusion, as other people have reacted similarly upon hearing a summary of intuitive eating. However, reconsider my answer within the framework of the following examples.

When a diabetes educator discusses the symptoms of low blood sugar with his or her patient, is that psychology?

When a physical therapist instructs a patient on how to modify an exercise in response to pain or discomfort, is that psychology?

When a primary care physician listens to his or her patient recount the side effects he or she experienced on a particular medication, is that psychology?

When a personal trainer talks with his or her client about the difference between the temporary discomfort that sometimes accompanies exertion and warning signs of injury, is that psychology?

Of course not, none of these examples are psychology; they are just examples of various discussions that take place between patients and practitioners regarding the feedback that our bodies give us in particular situations.

Yet when a dietitian engages in a similar discussion with a patient, whoa, suddenly it is seen as psychology. What does it say about how disconnected our culture teaches us to be from our internal signals regarding eating that an approach that encourages us to pay attention to said signals triggers connotations of therapy?

Dietitians are not psychologists, psychiatrists, or social workers (Well, some are, but the vast majority do not hold such a license in conjunction with their dietetic credentials.) and we know our professional boundaries. Discussions of said internal signals are not only within the realm of our work, they are critical to its success.

Just as my relative expected a more concrete and specific answer that would have put some label on my personal style of eating, new patients often expect that a similar external structure, such as a meal plan or a calorie recommendation, will drive their care. Nutrition is not that simple. In fact, long-term success often hinges on paying less attention to external cues regarding what and how much to eat and putting more focus on the internal signals that our bodies give us. Does that sound like psychology to you?

He Said, She Said: Nutrition in Schools

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He Said

Wellness class. The other freshmen and I thought the class was such a joke that if you told then-15-year-old Jonah that in a couple of decades he would wittingly choose to incorporate the word “wellness” into his business’s name, the cognitive dissonance would have rocked his adolescent world view.

Wellness class was gym without the, well, gym. The teachers were the same, but instead of leading us through units of volleyball, basketball, and badminton, they taught us about health and nutrition. The overarching culture, however, was consistent. Gym was the informal time of day, the high school version of recess. It was a time to let loose, move our bodies to one extent or another, and measure ourselves against our peers, both figuratively and, as you will read, sometimes literally. You had better believe the spirit of competition bled into the wellness classroom, too.

Even at 15, I could tell that the school’s approach to wellness was off base. We used to undergo various exercise performance tests (pull-ups, submaximal cycle ergometer, sit-and-reach) as well as anthropometric exams (weight, height, body composition). All of these evaluations happened in front of the group, so we all knew how each of our peers had fared. Gee, sounds like a great plan; what could possibly go wrong?

After the testing was over and it came time for the teachers to gather us together and offer congratulatory certificates to those of us who had what I suppose were good results in the eyes of the teachers or whatever norms against which they measured us, I crumpled up my award in my hands on the spot. Immediately, I felt guilty as if I had disrespected the teachers who had given it to me, but as time went on, I confirmed that my intuition was right.

If the teachers gave some of us certificates based on our body measurements, what kind of message did they send to all of the other students who did not receive such certificates? As a result, how do you think those students felt about themselves and their bodies? Similarly, how do you think their certificate-holding peers viewed them? The teachers indirectly started the bullying by posting their body mass indices and body composition results, thereby publicly shaming them, and other kids were more than happy to pick up the harassment where the teachers left off.

See, here’s the thing: If a teacher is conveying oversimplified and misguided lessons about how we can manipulate our bodies and our weight based on how we eat and exercise, and then they single out the kids whose bodies happen to be larger, the message they are indirectly teaching is that something is wrong with these larger students, that they are not doing enough to take care of themselves, that they are lazy and/or eat too much. And we wonder how weight stigma forms and gets perpetuated.

I still remember two of the largest kids in my class as well as their body composition results. These data should never have been my business to know. What does it say about the culture the school created that these results have stuck with me all this time? That was not wellness.

If we are going to even consider teaching nutrition in schools, we have to scrap the status quo and reexamine fundamental questions of who will do the teaching, what expertise do they hold, what environment will they create, will they reinforce stigma or break it down, and most importantly, what lessons will students actually absorb about their relationships with food, physical activity, and their bodies. If we cannot provide answers that are worthy of their own certificates of satisfaction, then we should not be teaching nutrition in schools at all.

 

She Said

As the holidays have come to a close, it’s back to reality for most of us. For some of my patients, that means back to school. Lately, it seems like I have been hearing a lot about school-based nutrition programs from my patients. Some of these programs are being run in their health classes, while others are part of their biology curriculum or other classes. It got me thinking about the subject of nutrition and school. Should nutrition be taught in elementary, middle and high schools? If so, who should be teaching it to the students? What should the nutrition course cover?

Given that the vast majority of my patients are those struggling with eating disorders, I have some mixed feelings about nutrition in school. On the one hand, I think it’s important for kids to learn about how to take care of themselves and the consequences of their lifestyle choices on their health. For instance, it makes sense to me for kids to learn about different nutrients and how they can help them grow and thrive.

But I worry that along with this helpful information, the kids might be learning a whole different lesson. From what I’ve heard, many of these nutrition programs are focused on making sure students maintain a healthy weight and actually scare them about the potential dangers of being overweight. As Jonah and I have written about extensively, health and weight are not synonymous; lifestyle behaviors are a much better predictor of health outcomes. This means that even if someone falls into the “overweight” or “obese” categories on the BMI scale, they are not necessarily doomed to poor health. Similarly, someone who falls into the “normal” weight category might not be healthy. It’s the behaviors that make the difference, not weight.

In addition, kids (and adults) come in a wide array of sizes and body types – we are not all meant to be slender. Genetics are a huge determinant of body weight. And as we have noted many times before, diets (or any program or restrictive way of eating meant to alter one’s body size) fail 95% of the time, usually ending up in weight regain. Oftentimes, I hear that school nutrition programs propagate the false idea of “calories in, calories out” in regards to weight. It’s just not that simple.

Unfortunately, the main message that most of my patients glean from these school nutrition programs is “fat = bad” and “these are the foods to avoid in order not to be fat.” In one case, one of my patients told me her biology professor had her students calculate their resting metabolic rates and then keep a food journal to log their calories to later evaluate if they were eating too much to maintain their weight. Another one of my patients told me that she actually learned about eating disorders from an educational video shown in her health class and that’s when her bulimia started. For someone who has the genetic predisposition for developing an eating disorder, these types of messages and activities can actually trigger them to start restricting.

What’s the solution to this problem? One thought I had is that schools could hire a registered dietitian as a nutrition consultant who is well versed in eating disorders and Health at Every Size®. Perhaps that dietitian could run a nutrition program for the students or train teachers to do so. Ideally, I would think the program should be focused on being weight-neutral, helping students embrace a variety of body types and sizes, and not advocating for restricting certain foods. In addition, maybe it would be a good idea to make nutrition programming an optional part of the school curricula, as some parents might not want their child to learn about nutrition in school. Perhaps the nutrition course could be offered as a voluntary program after school hours for those who are interested in it. I’m not sure what the right answers are to these questions, but I hope that as our society becomes more educated about health and weight, things will change in our schools.

Health at EVERY Size

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In response to my recent post about the calories-in-versus-calories-out myth as seen through the lens of my surgical recovery, someone posted a typo-filled response along the lines of, “You would not have posted this if you had lost weight.” He continued with pretty offensive commentary about people of a certain size not having the right to exist, but I will put that aside for now, not because I condone that nonsense, but because I want to focus on what he said in the quote.

His comment seems to be implying that I had hoped to lose weight and therefore I found a scapegoat for my supposed failure. Not true. We must remember that not everybody wants to lose weight. Some people, whether they are large, small, medium, round, slender, or any other shape, actually like their bodies the way they are. Other people may wish for a different body shape, but they understand that purposely trying to manipulate their form is unlikely to work in the long run and comes with consequences.

The commenter also seems to be assuming that I am overweight based on the fact that I shared my blog on the Health at Every Size® (HAES) Facebook page. To be clear, the name of this approach to health is not Health at Some Sizes and Failing Weight Loss Endeavors and Shame For Everybody Else. It’s Health at Every Size, and people of all shapes and sizes understand its importance in healthcare.

Consider the counterexamples we have all heard before: “He is so skinny, he can eat whatever he wants” and “She is a twig already, she doesn’t need to work out.” These weight-centered opinions have nothing to do with health. Being lean does not guarantee good health, nor does obesity guarantee poor health; behaviors do matter at every size.

Consider doctors who make assumptions about patients based on their weights. Prior to my surgery, a handful of the doctors with whom I consulted made incorrect assumptions about my lifestyle based on my size. Some doctors will decline to run routine tests on lean people based on the assumption that the patients are healthy, and some doctors will similarly decline tests for larger people, blame existing symptoms on weight, and instead recommend weight loss. None of these behaviors are about health, either.

A long time ago, shortly after my first back surgery, my neurologist asked me, “Are you exercising at all?” At the time, I was really offended. I was running, lifting weights, and playing tennis. Didn’t I look like I worked out? However, as time went on and I became more educated, I realized his question was spot on. Some muscular people never lift weights, some lean people never do cardio, and some obese people are more active than all of them but happen to exist in bigger bodies. Making assumptions about one’s lifestyle based on his or her appearance is not about health either, and to my neurologist’s credit, he knew it.

HAES is about focusing on actual health no matter what size we are, hence the name. For more information on the the HAES approach to health, check out the Association for Size Diversity and Health, of which Joanne and I are proud members.