He Said, She Said: MEDA Conference Takeaways

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He Said

Today’s society is talking more and more about the idea of privilege. We often hear about white privilege, male privilege, and straight privilege, but people less commonly discuss another form that directly impacts our nutrition work: thin privilege.

My thin privilege became obvious to me four years ago when I went to the doctor about back problems. In early 2016, I wrote a blog reflecting on how different my healthcare experience was than that of many of my larger patients who go to their doctors about similar woes. Not only did I receive evidence-based medicine instead of a directive to lose weight, but some of my doctors even made assumptions (incorrect assumptions, at that) about my diet based on my size. That is thin privilege.

While I was already aware of some aspects of my privilege, the most powerful talk that I attended at the Multi-Service Eating Disorders Association (MEDA) national conference helped me to understand that my thin privilege includes elements I had never before considered. Caitlin Martin-Wagar, an eating disorder clinician and doctoral student in counseling psychology, gave a presentation in which she listed several examples of thin privilege, some of which you may not have previously considered either:

  • Chairs and airplane seats fit thin bodies.
  • Thin bodies are represented in all forms of media.
  • Thin people are never the punchline in sitcoms because of their body size.
  • When thin people go to the doctor, their health concerns are generally taken more seriously.
  • Thin people can buy dolls of similar build for their children.
  • Thinness connotes good morals and positive characteristics.
  • Thin people have an easier time shopping for clothing.
  • Thin people do not have to represent all people of their size.
  • In comparison to larger individuals, thin people receive less unsolicited health/dietary advice or veiled concerns about their health.
  • Employers pay thin people more.
  • Thin people face less scrutiny while eating in public.
  • As a thin person myself, I can write this blog without receiving accusations of being self-serving.

In order to escape weight stigma and in hopes of enjoying the same privileges as thin individuals, some people embark on weight loss endeavors that are most likely to make them heavier in the long run and worsen their health. If we are serious about wanting to help people improve their health, then we have to change our society so that people of all sizes enjoy the same privileges.

Ms. Martin-Wagar offered us professionals some tips regarding how we can combat weight bias within healthcare, but she also shared some ideas for how all of us can challenge thin privilege:

  • Read and learn about the relationship – and lack of relationship – between weight and health (which you can do on our Weight Loss FAQ page).
  • Consider the barriers and challenges of living with a larger body size.
  • Learn from larger-bodied friends about their experiences.
  • Do not make comments about people’s body sizes, shapes, or weight.
  • Be aware of weight bias veiled as concern.
  • Call out injustices as you witness them.

We do not live in a zero-sum game in which treating larger people better means treating thinner people worse. Rather, we can and must work to establish a society in which thin privilege is no privilege at all, just the same rights and respect enjoyed equally by people of all sizes.

 

She Said

This year’s MEDA conference had a number of interesting and informative talks given by experts in the field of eating disorders (ED). Throughout the day, I was heartened to see that the ED treatment community is starting to embrace the principles of Health at Every Size® (HAES) and Size Acceptance. But despite this positive movement, unfortunately what stood out to me this year was that we still have a long way to go in the ED treatment community when it comes to helping those in larger bodies who are suffering from an ED.  

Ragen Chastain, the author of the blog “Dances With Fat” and renowned speaker and advocate for HAES and Size Acceptance, was the keynote speaker on the second day of the conference. Her talk centered on the idea that given the culture that we live in (i.e., one that is fatphobic, diet-minded, and generally not welcoming to people in larger bodies), those who are living in larger bodies and struggling with ED can find it nearly impossible to fully recover as everything in our society tells them that being thin is the most important thing. Ragen’s talk hit the nail on the head, and it was interesting to see many of my colleagues in the audience nodding their heads in agreement with her points. At the end, Ragen received a well-earned standing ovation, and it seemed like everyone in the room was on the same page.

Well, not everyone, it seems. During the Q&A session after her talk, Ragen received a question from one of the ED practitioners in the room. This woman started out by saying that she agreed with everything Ragen had just spoken about, but she had an anecdotal experience that made her question some of Ragen’s points. She went on to explain that her “morbidly obese” brother had struggled with his weight for years, and it had gotten to such a dire point that a number of years ago he had gastric bypass surgery. As a result of this surgery, she contended, her brother’s weight went down and all of his troubling health conditions cleared up almost instantly. She went on to say that while she knows that some gastric bypass patients regain the weight due to “cheating” on their prescribed diets, there are those who maintain their losses and “good health.”

This woman’s sentiments went over like a lead balloon, and there were audible gasps from the audience. Ever the consummate professional, Ragen adeptly navigated this uncomfortable situation. She explained that while there are always some outliers who do well with stomach amputation, there are many more who suffer from complications from the surgery, such as lifelong issues with malabsorption, deficiencies, future surgeries to correct structural problems resulting from the original surgery, and even death. In fact, Ragen went on to say that fatphobia is at the root of the weight loss surgery industry because the medical professionals who advocate for these surgeries view fat people as less valuable; that it is better to risk a fat person’s life by having them get the surgery than letting them stay fat. In other words, the weight loss surgery industry is essentially telling fat people that their lives are not as valuable as those of thin individuals and that it is better to be thin and sick or even dead rather than fat.

While I would hope that this woman was the only one at the conference who held positive beliefs around weight loss surgery, I am not foolish enough to think so. Yes, the ED treatment community is getting better about not pathologizing certain body sizes and understanding that EDs can occur in people of all body sizes. But the fact still remains that we all live in this toxic diet culture that constantly tells us that fat is undesirable and unhealthy, that the pursuit of weight loss by any means is admirable, and that thin bodies are superior to fat bodies.  When you have been marinating in this culture for your whole life, it can be hard to realize your own bias around fat people. My hope is that Ragen’s talk changed some minds that day at the MEDA conference and made people think more about how their own fatphobia contributes to diet culture and undermines recovery for patients with ED.

He Said, She Said: Good for who?

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He Said

Our society’s problematic relationship with food has many elements, one of which is that we make sweeping generalizations and place foods, ingredients, and nutrients into dichotomous groups: good vs. bad, healthy vs. unhealthy, sinful vs. virtuous. When we use language like “good for you” to describe a given food’s supposed impact on our health, who is the “you” to which statements refer? That answer makes all the difference.

Those charged with shaping nutrition policy are faced with an impossible task. They do their best to create guidelines for the general population, but their advice fails much of the group because the truth is that when it comes to nutrition, individualization is a necessity.

In contrast, I have the privilege and good fortune to be able to focus on only one person at a time: whomever is joining me at my counseling table at any given moment. Recent conversations with some of my patients reminded me of just how essential it is to customize nutrition guidance.

For example, one evening I had back-to-back patients, one of whom utilizes whole grain products to her advantage in helping her stabilize her blood sugar, while the other must temporarily avoid such high-fiber food because of his acute gastrointestinal condition. If I had made a sweeping statement about whole wheat bread being “good for you,” I would have failed at least one of them.

Another day, I had a patient who is working to increase his potassium intake for the purpose of improving his hypertension and another patient who has renal disease and is on a potassium restriction. So, is a high-potassium food like cantaloupe “good for you” or what?

A couple of weeks ago, a patient referred to Gatorade as “crap,” to which I neutrally responded by mentioning that I drink it during long marathon training runs. He continued to say that my situation is different than his, which was exactly the conclusion I hoped he would reach when I decided to disclose that a beverage with no redeeming qualities in his eyes actually works quite well for me.

My one-decade anniversary of becoming a registered dietitian is coming up this summer, and during all my years of practicing, I cannot remember two patients who ever came in with the exact same set of circumstances. In reality, our situations are always different, as each of us has a unique set of health concerns, preferences, histories, cultural norms, financial considerations, and all of the other factors that together shape one’s relationship with food.

Instead of dividing foods into dichotomous groups that reflect sweeping generalizations about what is “good for you” in reference to the general population, take a morally neutral and pragmatic approach built on individualization. Recognize that every food has a set of attributes – including taste, cost, availability, nutrient content, and preparation options, just to name a few factors in its profile – that makes it more or less advantageous depending on the circumstances. Remember, the very food that you believe is “bad for you” might be great for someone else.

 

She Said

One of the underlying themes I have found amongst nearly all of my eating disorder (ED) patients is the idea that their ED often started with the intention to become “healthier.” Whether “healthier” meant to lose weight, improve certain biomarkers, or just feel better, these individuals embarked on a restrictive food mission, omitting certain “bad” foods (mostly foods high in sugar and fat) and replacing said foods with “good” foods (mostly vegetables and protein). As harmless as these initial intentions seem at first glance, for someone with ED, they often unravel into something potentially life threatening. 

For my patients with anorexia nervosa, this fixation on “good” and “bad” foods can result in a dangerously low body weight. In addition to extremely low weight, the lack of calories literally starves every organ of the body, including the heart and the brain. Brain scans of healthy control brains versus brains of patients with anorexia show that anorexia literally shrinks the brain. As such, these individuals undergo profound brain changes that lead to decrease in cognitive functioning (due to slowed neuronal growth), depressive symptoms (due to lower levels of neurotransmitters), and a reduction in affect displayed (due to shrinkage of the frontal lobe). What is really insidious about EDs is that they start off in the brain as mental illness and eventually lead to damaging the same brain by means of malnutrition. It is a vicious cycle.

The only way to break this cycle is by refeeding (in addition to therapeutic help and perhaps medication). In this initial stage of recovery, it is imperative that the patient take in enough calories to restore his or her body weight to their healthy weight range. In fact, it is almost impossible for therapeutic measures and medications to really help these patients until their brains are at least back to functioning levels. Many of my patients with severe anorexia struggle with brain fog, have trouble formulating thoughts, and cannot communicate clearly due to brain deficits, and this makes therapy not nearly as effective as when the brain is at least functioning at baseline.

The tricky part about refeeding is that many of the “bad” foods that these patients have been avoiding are, in fact, the same foods that will help them to restore weight most easily. These high carbohydrate/high fat foods are integral to getting these patients to their healthy weight ranges, as they usually have higher concentrations of calories than low carbohydrate/low fat foods. As such, these foods pack a much bigger punch, providing more calories in a smaller amount, making it easier for patients to get what they need while lessening the gastric overload.

Many of my underweight patients who need to weight restore will ask me if they can just eat more of the “good” foods to help them gain the weight back. Aside from heart-healthy nuts, avocados, and nut butters, most of the “good” foods fall into the low carbohydrate/low fat group that provides very few calories for the same volume. In other words, these noncalorically dense foods pack less of a punch, meaning that one would need to eat a much larger volume of these foods to get the same amount of calories that are in calorically dense foods. In order for someone to regain weight, eating large amounts of vegetables and protein is not going to get them to their goal as their stomach will simply prevent them from consuming enough.

What is “healthiest” for these patients is to consume calorie-dense foods and avoid those foods that take up more volume but do not provide the necessary calories. Thus, for the sake of example, a pint of Ben & Jerry’s ice cream is a better choice than a salad for someone who needs to regain weight. We have all been taught that certain foods are always “bad” in every context (ice cream, fried foods, sweets), but the example above shows that it is not so cut and dried. Is a pint of Ben & Jerry’s the “healthiest” choice for someone with high cholesterol? Possibly not. But for someone with anorexia who needs to gain weight, it is healthier. 

In other words, “healthy” is a very subjective term when it comes to nutrition. One size does not fit all as everyone has different health goals and medical conditions. While whole wheat bread might be the better choice for someone who suffers from chronic constipation, it would wreak havoc on someone with diverticulitis and should be avoided.   The “good food/bad food” dichotomy is problematic because it does not take the individual into account. The way we talk about food in our society needs to change.

He Said, She Said: Weight Stigma

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Examples of weight stigma are prevalent and run the gamut: clothing and airline seats designed for smaller bodies, cyber bullying, verbal insults, physical attacks, and social exclusion. Even our own government has declared war on fat people. Unfortunately, weight stigma also infiltrates and inflicts harm in a space that is supposed to promote health: the doctor’s office.

Obesity is associated with a number of health woes, and, clinically, your doctor probably finds more problems in heavier patients than in thinner ones. Consequently, your doctor might recommend weight loss as a supposed path to better health. On the surface, such well-intentioned advice sounds reasonable, but it is problematic for a multitude of reasons.

Correlation does not equal causation. In other words, just because two factors tend to occur together does not mean that one necessarily causes the other. The diseases blamed on obesity could be due to other factors that tend to co-occur with increased body weight.

In other words, the causal factor might not be your weight, but rather one or a multitude of other factors associated with your weight.

Your doctor may have heard of the National Weight Control Registry, a database of “over 10,000 individuals who have lost significant amounts of weight and kept it off for long periods of time.” Some doctors believe that if their patients adopt the behaviors exhibited by people in the Registry, their patients are likely to achieve similar weight loss.

Unfortunately, presenting these behaviors as the key to long-term weight loss makes little sense when so many other people perform the same actions without achieving similar outcomes. The lottery crowns new millionaires every single day, and a quick study of the winners reveals that a behavior common to all of them is that they bought tickets, but that does not mean your financial advisor is giving you sound, ethical, evidence-based advice if he suggests you take your life savings and invest in Powerball.

Even if a causal relationship exists between body weight and your medical condition, endeavoring to lose weight is still not the answer. In light of the research showing the prevalence of weight regain that often surpasses baseline weight, we can only assume that the condition you are trying to improve by losing weight would actually worsen in the most likely scenario that you end up heavier than you are now.

For these reasons, many healthcare providers – including us – believe it is unethical to recommend weight loss to patients as a path to better health.

Weight stigma in healthcare can also negatively impact thinner individuals. For example, binge eating disorder is a condition stereotypically associated with larger people, but the reality is that it can affect people of all sizes. Doctors may dismiss or overlook red flags in individuals who do not look the part. Furthermore, just as doctors sometimes make incorrect assumptions about the behaviors of larger individuals, doctors may assume that thinner patients are leading healthier lifestyles than they really are.

On a personal note, as someone with a relatively thin body, I have certainly had my share of doctors make assumptions about my eating behaviors – without asking me a single question about my feeding habits or my relationship with food – because of my body. Typically, their assessment is along the lines of, “Clearly, your nutrition is fine,” as they glance down at me. How often do you think people labeled “overweight” or “obese” hear such a sentiment from their doctors?

In hopes of freeing themselves from weight stigma, some people resolve to change their body to a size and shape that our society deems more acceptable. While we firmly support a patient’s right to choose for themselves the approach to healthcare that feels most appropriate for them at any given time, we also believe in disclosure and informed consent so patients can make educated decisions. After knowing the facts regarding the failures of weight loss endeavors, you may still decide to travel that road. Know, however, that you have a choice. For more information regarding how to tackle weight stigma and pursue better health in a weight-neutral fashion, please see our Weight Loss FAQ.

 

She Said

Weight stigma. People living in larger bodies are often treated as less than and discriminated against in many different contexts. This goes double for those people of size who are also people of color, LGBT, and/or disabled. From being body shamed at the doctor’s office to earning less money than their thinner counterparts to being ridiculed by the media and told they are a problem that is to be solved, fat people have it tough in our society.

While it is neither unexpected nor surprising when weight stigma is exhibited in all of the above situations, it is simply mind-boggling how it is displayed in certain “woke” spaces. Take, for instance, the eating disorder (ED) treatment community. Here is a group of professionals whose job is to help individuals heal their relationships with food and their bodies. One would think that this help should be offered to ED patients in all different body sizes. Unfortunately, this is rarely the case.

I have a number of patients who clearly exhibit ED behaviors, such as restriction, bingeing and purging, or excessive exercise, yet their higher weight precludes them from meeting the criteria for an ED like anorexia nervosa or bulimia nervosa. Instead, these patients fall into the catchall category of “ED NOS” (eating disorder not otherwise specified), also known as “OSFED” (otherwise specified feeding and eating disorders). This means that even if someone is heavily restricting their intake, no longer menstruating, and severely malnourished, but their BMI falls in the “normal,” “overweight,” or “obese” categories, they are not seen as “sick” as those who are “underweight.”

Never is this more clear than in inpatient or residential treatment for EDs. While the emaciated patients are refed aggressively to help them regain weight, those in larger bodies are often fed just enough to sustain them because it is assumed that they do not need to regain any weight. In some cases, I have heard of ED facilities actually trying to help the larger ED patients lose weight, as “clearly they could stand to lose a few pounds.”

This difference in how patients are treated is not only disturbing, it is also quite damaging to ED patients who live in larger bodies. Many of my larger patients have actually become more symptomatic after being discharged from treatment because they felt they needed to be even “sicker” to receive adequate help. I specifically remember one such patient who, even though she was eating only 200 calories per day and was exercising for hours on end,would only get to stay at a program for a couple of weeks and then be discharged for outpatient care as her weight was not concerning enough.

This has got to stop. EDs are found in people with all different body types. Just because someone does not appear to be emaciated does not mean that he or she is not suffering from a debilitating ED. The ED treatment community needs to start treating ED patients who are living in larger bodies with the same care and concern as those living in smaller bodies. Hopefully, someday there will be an end to weight stigma in ED treatment as well as in other areas of our society.

Fitness Trackers

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He Said

As recently as six or seven years ago, I was still estimating the length of my running routes by driving them and reading the odometer. After my runs, I used a program on my graphing calculator that computed my pace per mile based on my time and distance covered. Archaic, I know. These days, I use a GPS watch that gives me all of these numbers and also tells me my speed in real time. The data are tremendously helpful as I train for races, and rarely do I leave the house for a run without my GPS watch.

As helpful as GPS watches and other fitness trackers can be, they also have serious drawbacks. While it is normal to be excited after a great run or disappointed after one that does not go as we had hoped, some people put a concerning level of emphasis on their exercise performance. For example, someone may push through injury or illness in order to attain a certain reading on their device when the healthier play would have been to stop earlier or take a rest day.

Issues with exercise can bleed into food. For example, someone who feels they did not run far enough or fast enough, take enough steps, or burn enough calories might punish themselves by bingeing or restricting their food intake. Someone else might overeat or allow themselves certain foods that are normally restricted after a particularly pleasing exercise session. Some people restrict either way, feeling they do not deserve to eat normally if their exercise was not up to par, while also not wanting to “undo” a good exercise performance by eating. All of these examples and other similar behaviors are red flags of an unhealthy relationship with food and physical activity exacerbated by usage of a fitness tracker.

Furthermore, we must remember that even the best fitness trackers have flaws in their technology. For example, back when Joanne wore a Fitbit (discussed below), it never registered steps she took in the supermarket if her hands were on the grocery cart. When I finished the Newport Marathon earlier this month, my GPS watch reported that I had covered 26.6 miles, which was curious since marathons are 26.2 miles long. As I discussed a couple of years ago, estimates of calories burned can also be wildly inaccurate.

Given the limitations of these devices and the trouble people can find themselves in if the numbers are carrying an unhealthy level of importance in their lives, we best candidly ask ourselves if the pros of fitness trackers really outweigh their cons.

 

She Said

Nearly everywhere you look nowadays, you will see people wearing some sort of activity tracker. Whether it’s a Fitbit, an Apple watch, or a Garmin device, it seems that lots of people are concerned with monitoring their movement from day to day. For a few years (a few years ago), even I wore a Fitbit, and I found myself becoming obsessed with the number of steps I took each day. I remember needing to meet or exceed my goal of 10,000 daily steps, regardless of how I felt physically or mentally. It became such a constant in my life that whenever I took steps without the device, I felt like those steps didn’t really count. If I forgot to wear my Fitbit before a walk or run, the steps I took were automatically negated. Throughout my day, I would often look to my Fitbit to see if I had been “good” that day, to see if I had achieved my goals. It was an obsession!

When I found Health at Every Size® (HAES), something changed for me in regards to physical activity. One of the tenets of HAES is engaging in enjoyable movement that feels good to one’s body. I like to call this “intuitive exercise” (I’m sure that someone else has coined this phrase, but I’m not sure to whom to attribute it!). In my mind, intuitive exercise is engaging in physical activities that one enjoys, i.e., not using physical activity as a way to punish one’s body. Intuitive exercise comes from an internal desire to feel good in one’s body, to participate in sport or activity that nourishes one and makes one feel alive. Intuitive exercise is not prescriptive or punitive – it’s purely for the joy of movement. 

Once I figured out what intuitive exercise was, I found that wearing my Fitbit was not really compatible with HAES. For a while, I had been letting a little wristband tell me how much I should move – pretty much the exact antithesis to intuitive exercise! In a way, I liken it to when people feel they need a diet or set of food rules to follow in order to be healthy. Time and time again, we have heard that diets fail 95% of the time, but for some reason, we are convinced that using a set of external guidelines will lead us to diet salvation. But, of course, we know that this isn’t the case, that eating intuitively and trusting our body is truly the best way to achieve a healthier relationship with food and our body.

A number of my patients struggling with eating disorders (ED) wear activity trackers, and I find this to be a particularly troubling trend. Those patients who never had issues with exercise before now are obsessed with the numbers on their Fitbits. Most of the activity trackers also track the number of calories one burns. Even though these calorie estimates are often bogus and inaccurate, people with ED can become fixated on them. Complicating matters, many of these activity trackers can also double as a “smart watch,” meaning that the wearer can use it to browse the internet and send and receive texts, emails, and phone calls. So even if someone just wanted a device to do these “smart” tasks, they would be unable to avoid the activity tracking aspect.

In general, I discourage all of my patients from using these activity monitors, even those without an ED. In my opinion, while some people may be able to use these devices as a motivating tool (i.e., encouraging them to get more physical activity into their day), the majority of people who wear them become obsessive. Those individuals struggling with ED are particularly at risk of developing (or worsening) excessive exercise behaviors, as these devices become tools for ED.  Unless one can deactivate the step counter and calorie tracker from a device, I feel these trackers can be incredibly triggering for those struggling with ED or disordered eating.  

He Said, She Said: Menu Calorie Counts

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Nutrition information has its upsides, but the data are only as useful as their interpretation. Context and framework matter; without a solid foundation, food labels and menu calorie counts can do more harm than good.

Maslow’s hierarchy of needs suggests that we, as humans, have basic needs that must be met before we can fulfill more advanced needs. Nutrition has a similar structure. At the base, someone has to have food – period. If food security is an issue, whether it is due to financial limitations, self-imposed restriction, or any other factors, then not much else matters. At the structure’s very top rests the hard science of nutrition as it relates to whatever medical conditions we may have; this is where we might talk about grams, calories, or various micronutrients. In between are issues of eating behavior that often go overlooked and yet are critical to address. Many people want to jump right to the top, but the danger in doing so is that without a solid middle, the structure is likely to fall apart.

Nutrition labels on packaged food can be helpful to someone with a healthy relationship with food and their body, but in the hands of an individual who does not have the solid middle that I previously discussed, the information can be misinterpreted, maybe reinforce a good/bad food dichotomy, and lead to or exacerbate issues like weight cycling and disordered eating.

In grocery stores, at least, we have a certain level of privacy and ambiguity that may mitigate the damage. Few shoppers probably recognize the yogurt in your cart as being higher in calories than its counterparts, and ultimately neither your fellow shoppers nor the cashier know whether that ice cream you are buying is for your kid’s birthday party or for yourself. Such uncertainties can help comfort people who fear judgment from the people around them.

Calorie counts on restaurant menus present a more complex problem. We place our orders in front of friends, family, co-workers, acquaintances, waitstaff, and fellow patrons who are primed for judgment because they – thanks to the menu – know how many calories you have elected to order for yourself.

Certainly, not everyone judges, and some of us are coated with more Teflon than others, but for many people, even the mere fear that the person across the table may be thinking “No wonder you are so fat/skinny/slow/etc.” can be enough to cause problems. The middle layer of the nutrition hierarchy involves making food decisions based on internal cues rather than external constructs. Issues of guilt, virtue, judgment, praise, and fear cloud the picture and make the establishment of this kind of relationship with food that much more difficult to attain.

Of course, restaurant nutrition information can be helpful sometimes – for example, I remember looking at the Bertucci’s website with a patient of mine in search of menu items that would mesh with his sodium restriction – but it can be provided in ways that are cognizant of potential harm. My suggestion: Post nutrition information online, as many chain restaurants already do, and have it available on site per customer request, but leave it off the menus.

 

She Said

When Jonah and I went to Bertucci’s Italian Restaurant the other night, we both realized that the menu had been redesigned (Clearly, we are regulars at Bertucci’s!). In addition to new entrees and different graphics, I was dismayed to see calorie counts prominently displayed above each and every menu item. I remember when the law was passed requiring all chain restaurants to publish their calorie information on their menus, but for some reason I had forgotten about it. (I feel like the law was passed a few years ago and just now is being implemented.) In any case, it was jarring for me to see this information, and it also made me quite concerned for my patients with eating disorders (ED).

Most, if not all, of my clients with EDs have engaged in some sort of calorie counting. Whether tallying up carbs, “macros,” or points, these patients have misused the nutrition information available to them in order to help them engage in ED behaviors. Much of my work with these individuals is around helping them to move away from the counting because it is completely antithetical to intuitive eating.

As Jonah and I have discussed before, intuitive eating is the practice of using one’s internal cues rather than depending on external factors to make food decisions. That means that someone who is an intuitive eater will (most of the time) eat when they are physically hungry and eat what they are hungry for in an amount that is satisfying. It’s about trusting your body to tell you what it needs and then honoring your body’s needs by fulfilling them.

Most of my patients with ED struggle with the idea of intuitive eating because it flies in the face of what their ED is telling them – food is to be carefully monitored and planned, certain foods are bad for you and should be off-limits, you can’t trust your hunger cues, etc. Many of these patients use calorie counting as a way to gain some control, to feel like they know exactly what they are putting in their bodies. One of my patients who is doing quite well in her ED treatment says that she still can’t shake the calorie counting habit, and she notices that this behavior ramps up when she is anxious, stressed, or overly hungry. One could say that calorie counting is a coping mechanism for many people because it helps to alleviate unpleasant feelings by giving them something concrete to focus on.

In any case, I often encourage my patients to ignore nutrition labels as it can trigger their ED. And in many cases, it is possible to (mostly) avoid this information – by purchasing unpackaged foods, buying prepared food from smaller restaurants or stores, etc. However, with this legislation, many more people will be exposed to calorie information at restaurants that they have gone to for years, and it is inescapable. I know that much of the nutrition information for chain restaurants has been available online for years and that anyone could just look up the calories on the restaurant’s website, but that at least takes a bit of effort. If someone really does not want to see this information, they will avoid it, but printing it directly on the menu makes that nearly impossible (short of never visiting the particular restaurant again).

In my opinion, I think that calorie information should be made available if the customer requests it. Everyone has the right to know what they are putting into their body. But it would be great if restaurants could also provide menus without the calorie information in order to prevent triggering individuals with ED or a history of disordered eating. It could make a number of people feel safer in these establishments, and that would make a big difference in many people’s lives.

He Said, She Said: Clean Eating

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The phrase “clean eating” never arose in nutrition school, and the only time I have seen it appear in a peer-reviewed journal article was in reference to behaviors that could be described as disordered eating. That should tell us something.

Pop culture nutrition is, after all, quite different from scientific nutrition, and “clean eating” resides squarely in the former. Given the nature of “clean eating,” let us look in that direction for its definition. “Clean eating is a deceptively simple concept,” according to Fitness Magazine. “Rather than revolving around the idea of ingesting more or less of specific things (for instance, fewer calories or more protein), the idea is more about being mindful of the food’s pathway between its origin and your plate. At its simplest, clean eating is about eating whole foods, or ‘real’ foods — those that are un- or minimally processed, refined, and handled, making them as close to their natural form as possible.”

Unsaid is the prevalent cultural implication that “minimally processed, refined, and handled” foods – “clean” foods, in other words – are healthier than foods that do not fit this description. While the concept of emphasizing foods that are less processed has some merit, the message is so oversimplified and rounded off that it is more problematic than useful.

For someone trying to keep his blood sugar steady, whole grains might be more conducive to achieving this goal than more refined grains would be because the former tend to be higher in fiber and protein compared to their white counterparts, which are stripped of these nutrients during processing (although these nutrients, and others, are sometimes added back via fortification).

In other cases though, foods that are more processed might actually be the better choice. For example, I think of one of my patients, a young woman who had lost her period for many months due to nutrient deficiency, and it was not until we increased her intake of more-refined foods – which tend to be more calorically dense – that her period returned.

What constitutes a healthy choice for someone really depends on the individual, their needs, their preferences, and other factors that are unique to them. One of the problems with the way our society talks about food is the individual gets lost. For example, we talk about foods being “good for you” or “not good for you,” but who is the “you” in question? Almost always, the phrases refer to a monolithic representation of the population that probably does not take into account the unique characteristics that separate each of us from the pack. Talking in generalities has its place (No matter who you are, drinking paint thinner is not good for you.), but way too often that kind of oversimplified talk is misleading at best and damaging at worst.

Consider the good/bad food dichotomy embedded within “clean eating.” Foods unworthy of the “clean” label are, what then, “dirty”? If you have ever dieted, remember what it was like to consume foods that were frowned upon in the context of the diet. Most likely, ingestion of a small amount of a forbidden food triggered overconsumption of said food, not because of any objective qualities inherent to the food, but rather because of the overarching subjective eating experience. We eat a little bit of “dirty” food, figure today is ruined anyway, so we might as well have some more – whether we intuitively feel like more or not – and resolve to start over “clean” tomorrow.

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

Hence, we invent a construct of “clean eating” that is based less on science and more on profound issues of humanity. Understandable as this behavior may be, I cannot say strongly enough: Our relationships with food become much less fraught when we remove issues of moralization, sin, and virtue from our food choices and eating behaviors.

 

She Said

Many of my patients with eating disorders (EDs) and/or disordered eating have engaged in “clean eating” at some point in their lives. The practice of eating only unprocessed, organic, additive-free foods that have the highest nutrient value seems to be the diet du jour for many people right now. And I get it – many of us want to live the longest and healthiest lives we can, and one of the ways we can take care of ourselves is by being aware of what food we put in our bodies. Take a look at any viral “food science” article or video online and you will hear doctors, dietitians, and other health care practitioners and researchers telling you that if you eat this one food (or don’t eat this one food), you can expect to live longer (or die sooner) – as if every food decision we make over the course of the day has the power to lengthen or shorten our lives. It makes it seem like we have so much control over our health, that if only we eat the right things, we will never have illness and will live forever. Of course, this is just not true (case in point: fitness guru Bob Harper’s recent heart attack).

Given the oversimplified and misleading fashion in which food-related information is often presented in the media, nutrition must seem like an ever-changing landscape. Sure, the field is evolving just like every other facet of health care, but not as radically or quickly as the public is led to believe. Every month, a new “super food” is unveiled and promises to improve our energy, stave off cancer, prevent heart disease, and so on and so on. Never mind that just a month earlier this food might have been on the “unhealthy” food list (I’m looking at you, coconut oil.). The point is that nutrition is always evolving, and trying to keep up with all of the foods we “should” and “shouldn’t” eat is exhausting. Yet, so many of my patients are obsessed with eating only the most nutritious, healthiest foods. They emphatically believe that some foods are inherently virtuous and clean, worthy of being ingested, while other foods are a waste of money and have no business being called food. And I believe that this is a big problem.

Food is not just fuel. Let me repeat this again. Food is not just fuel. Food is connection; it’s tradition, rituals, and how we care for ourselves and others. Food can elicit some of our most cherished memories (e.g., grandma’s famous chocolate chip cookies), and food can comfort us at times. I know that “emotional eating” has been deemed a problem by many, but really, it’s okay to eat emotionally at times. In fact, it’s completely normal! For people with EDs and disordered eating, sometimes the act of eating food can be agonizing, physically, emotionally, and mentally. I can’t count how many times I have heard some version of the following from my patients: “I wish I didn’t have to eat food, that I could just get all of my needed nutrients from an IV. It would make life so much easier.” These types of sentiments break my heart.

For individuals with EDs or disordered eating, breaking foods up into “good/bad” or “clean/unhealthy” categories is de rigueur. By having clear-cut rules about what is okay and not okay to eat, these individuals feel safer and in control (Of course, we know that really, the opposite is true – these rules control the individual.). In my work with my patients, I try to help these patients challenge their food rules. This might be having them eat a formerly loved food that they have not allowed themselves to eat due to perceived lack of nutritive value. We will also discuss the value of eating a wide variety of foods, that all foods fit, even Oreos. For most of these patients, they feel that eating less-nutrient-dense foods is a waste of time, that they are “empty calories” and have no business being eaten. I have had to justify more times than I can count why Oreos might sometimes be a better choice for a snack than an apple.

What it comes down to is this: Is eating “clean” really improving your life? Aside from perhaps improving some physical health markers, how are the other aspects of your life? Are you able to share meals with others? Are you able to partake in your child’s birthday cake? Are your food rules running your life or limiting it? These questions are what I would ask a “clean eater” to consider.

He Said, She Said: Whole30®

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He Said

Earlier in my career, I worked at a medical clinic where part of my job was to put people on a 28-day “detox” program, when ordered to do so by the doctors, for reasons ranging from digestive woes to problems with fertility. For those four weeks, the patient abstained from gluten, dairy, soy, eggs, peanuts, shellfish, corn, and other foods deemed to inflame the body. At the end of the four weeks was the possibility of reintroducing the forbidden foods in systematic fashion in hopes of determining the impact of each.

If the protocol, rationale, and reasons for use sound familiar to you, that may be because they are all strikingly similar to those of the Whole30® program. “Strip them from your diet completely,” the Whole30 program’s website says of the demonized foods. “Cut out all the psychologically unhealthy, hormone-unbalancing, gut-disrupting, inflammatory food groups for a full 30 days. Let your body heal and recover from whatever effects those foods may be causing. Push the ‘reset’ button with your metabolism, systemic inflammation, and the downstream effects of the food choices you’ve been making. Learn once and for all how the foods you’ve been eating are actually affecting your day to day life, and your long term health. The most important reason to keep reading? This will change your life.”

Oh, Whole30 might change your life all right, but perhaps not in the ways that you hope. Let’s take a closer look at the program and examine three questions that address how the claims and expectations stack up against what really happens when someone embarks on such a journey.

(1) Are the excluded foods (added sugar, alcohol, grains, legumes, dairy, carrageenan, monosodium glutamate [MSG], and sulfites) really “psychologically unhealthy, hormone-unbalancing, gut-disrupting, inflammatory food groups”?

In short, no, the connection between food and our bodies is not that simple. Taking a step back in order to gain a macroscopic view of life, we see that few of us are comfortable with murkiness and uncertainty, and this overarching theme weaves its way through our relationships with food. Our yearning for crisp delineations leads to an oversimplified good/bad food dichotomy that might make us feel at ease, but really, it is nothing more than the application of scapegoating to nutrition.

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

(2) The Whole 30 website reads, “We want you to take this seriously, and see amazing results in unexpected areas.” What about that?

One of the confounding factors, and indeed one of the greatest challenges, with elimination diets is the power of suggestion inherent to unblinded experiments. If someone wants to test if dairy is responsible for whatever symptom is ailing him, he might first cut out dairy, wait for the symptom to subside, and then add back dairy systematically to see if the symptom returns. He knows whether he is pouring himself a glass of cow’s milk or a dairy-free alternative though, and this knowledge can influence the presence or absence of the symptom in question via placebo or nocebo effects.

For example, consider the patients I wrote about a few years ago who told me how much better they felt after cutting out gluten while they – unbeknownst to them – were still consuming gluten in abundance. They expected the exclusion of gluten to produce a positive result, so the mere belief that they had done it created the desired outcome.

By scapegoating the to-be-excluded foods before the program begins, Whole30 builds expectations that their removal will yield positive results. By guiding participants to consider “results in unexpected areas,” the program throws a bunch of crap against the wall, assuming some of it will stick. You may remember that scene in Ghost in which the psychic, played by Whoopi Goldberg, offers name after name until she hits on one that her client – who fails to see through the sham – recognizes and takes as proof of a metaphysical connection to the afterlife. Similarly, the likelihood is that over the course of 30 days, at least one facet of your wellbeing will improve, even if temporarily, and Whole30 is banking on you giving credit to the program when in fact another factor could very well be responsible. 

(3) What happens beginning on day 31 and beyond?

“We cannot possibly put enough emphasis on this simple fact—the next 30 days will change your life,” the Whole30 website reads. “It will change the way you think about food, it will change your tastes, it will change your habits and your cravings. It could, quite possibly, change the emotional relationship you have with food, and with your body. It has the potential to change the way you eat for the rest of your life.”

If your expectation is that after 30 days of abstinence, you will no longer have the taste for or cravings for the foods you excluded over the past month, you will probably be quite disappointed. “A review of the literature and research on food restriction indicates that inhibiting food intake has consequences that may not have been anticipated by those attempting such restriction,” wrote Janet Polivy, a psychology professor at the University of Toronto. “Starvation and self-imposed dieting appear to result in eating binges once food is available and in psychological manifestations such as preoccupation with food and eating, increased emotional responsiveness and dysphoria, and distractibility.”

In other words, you will likely be drawn to the excluded foods more than before the program began and overconsume them. The overeating further reinforces your preconceived notion that these foods are a problem. You may even begin to believe that you have a “food addiction” and eliminate the food again, not realizing that your presumed treatment is exacerbating the supposed problem.

Back in my days of implementing the 28-day detox program, such rebound eating was commonplace, and I had many repeat patients who did the detox over and over again in the earnest belief that the latest attempt would turn out differently than all of the ones that came before it. They blamed themselves when really the program was a setup for failure.

Taking a look at the Whole30 website, I see similar red flags planted to expunge the program of responsibility while erroneously placing the blame for potential failure squarely on the shoulders of participants. “Don’t you dare tell us this is hard. Beating cancer is hard. Birthing a baby is hard. Losing a parent is hard. Drinking your coffee black. Is. Not. Hard. You’ve done harder things than this, and you have no excuse not to complete the program as written,” the site reads. “Don’t even consider the possibility of a ‘slip.’ Unless you physically tripped and your face landed in a box of doughnuts, there is no ‘slip.’ You make a choice to eat something unhealthy. It is always a choice, so do not phrase it as if you had an accident.”

See through the enticing marketing and realize that diets like Whole30 are unlikely to produce long-term positive results and are more likely to pave the way for weight cycling and an unhealthy relationship with food while making you feel responsible for their failures.

 

She Said

While the Whole30 program has been around for a few years (It was created in 2009 by two “sports nutritionists.”), it feels like I have been hearing a lot more about it recently. And since we recently rang in the New Year, there seemed to be a surge of Whole30 talk both inside and outside my office. Many of my patients have asked me about the eating plan that emphasizes eating “whole” (i.e., minimally processed) foods while avoiding dairy, soy, sugar, alcohol, grains and legumes for 30 days and then strategically reintroducing these foods one by one to see how they affect one’s health, energy and stress levels. One patient of mine is getting married this month, and her husband-to-be and many of her family members are following the Whole30 to start “shedding for the wedding.” Go on any “healthy eating” Instagram page and you will find #Whole30 all over the place, with people posting their “clean” meals and extolling the virtues of this way of eating.

As you can guess, I am not a fan of Whole30, or any fad diet for that matter. Not only is it just another way for someone to try to manipulate their food using external rules to shrink their waistline, but it also promotes the “good food/bad food” dichotomy, which can lead to a lifetime of dieting and never having a healthy relationship with food or one’s body. For someone who is predisposed to developing an eating disorder (ED), following a plan like Whole30 could be especially dangerous because diets are often the gateway to EDs. In fact, many of my patients who struggle with EDs have tried Whole30 (or similar eating plans) and have found that it worsened their ED symptoms.

The tricky thing about the Whole30 is that on the surface it sounds good – the authors talk about the health benefits one can expect to reap by following the program and how eating unprocessed foods can improve one’s health and happiness. The plan suggests that there is a “right” and “wrong” way to eat and that if one follows their food rules, they will live a longer, healthier life. In a way, it kind of smacks of orthorexia (i.e., an obsession with eating in a “perfect” manner) to me, which is tricky, as a number of people want to eat “correctly” and view food simply as fuel for our bodies that should always be of the highest nutrient value. It’s not a bad thing to want to eat healthfully and reap the benefits, but I firmly believe that flexibility is key to developing a healthy relationship with food and one’s body. Eating Oreo cookies is not a death sentence, and eating fruits and vegetables will not necessarily lead to you avoiding dying from cancer. What matters is the overall makeup of our diets, recognizing that all foods fit and that sometimes cookies are the right choice in certain situations.

Diets are seductive – they make lots of promises about how you are going to feel, how your body will change, and how your health will improve. They tell you that by following this arbitrary set of rules, you will reach true nutrition nirvana, all of your ailments will subside, and you will become the best version of yourself. Unfortunately, this is rarely the case, and most people cannot follow such strict guidelines for more than a short while, leading them to backlash by eating all of the “forbidden” foods and feeling like a failure. The very nature of diets is temporary, and any results one experiences during the “honeymoon” phase of a diet will likely dissipate once the dieter cannot follow the plan anymore.

I discourage my patients recovering from EDs from trying a plan like Whole30. In my work with these individuals, I am trying to help them eventually learn to trust their own bodies’ wisdom, that their body will tell them what, when, and how much to eat if they listen hard enough (i.e., intuitive eating). Eating in a way that is enforced by a set of external rules, like Whole30 or any other diet plan, flies directly in the face of this intuitive eating philosophy and can derail progress for many individuals dealing with ED. My advice? Skip the Whole30 and find an intuitive eating specialist who can help you rediscover what foods work for your body and promote your health (mentally, physically, and emotionally).

He Said, She Said: Sports and Nutrition

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He Said

Leading up to this month’s Newport Marathon, I solicited advice from colleagues around the world as well as fellow marathoners regarding fueling strategies that might help me to avoid the nausea that plagued me in earlier endurance events.

The suggestions I received were all over the place: Eat boiled potatoes with salt late in the race. Pack maple syrup in a fanny pack and drink it periodically along the course. Eat bananas, orange wedges, gummy bears, white bread, salt bagels, or jelly beans. Drink Gatorade, Pedialyte, flat beer, coconut water, Nuun, Skratch Labs, or mix the latter two together.

As I sifted through the various suggestions, I realized I was looking at a great example of the intersection between the hard science of nutrition and intuitive eating. During endurance events, we need to replenish fluids, carbohydrates, and electrolytes, but how we do that must be individualized based on what works for each one of us; thus we need the gamut of ideas. How we determine what works best for us is by trying various approaches based upon sound nutrition guidance and personal history, paying attention to how each trial makes us feel, and basing new iterations largely on firsthand experience.

Sometimes we, as patients, have a tendency to defer entirely to our practitioners. We see comfort in directives. “Just tell me what to eat,” a patient may say. In reality, a collaborative approach tends to be much more effective in part because determining the best path involves the patient’s input and experiences. Hydrating with a particular beverage may seem great on paper, for example, but if it disagrees with the patient’s system, then we need to form a different strategy.

Patient input is one of the most significant differences between textbook nutrition and nutrition in real life, which is why Joanne and I strive to create an atmosphere of collaboration and equality at our practice. Only our patients know how various foods make them feel, so we focus on building intuitive eating skills in part so they are able to recognize and communicate these experiences.

Leading up to the marathon, I treated every athletic endeavor as an opportunity to experiment and gather data regarding how various foods and fluids made me feel. One of the drinks I tried during a tennis practice failed to hit the spot whatsoever, but better to find that out during a casual hitting session than during an important training run or the marathon itself. Another beverage worked really well once I was actually running but made me jittery beforehand. Some foods gave me cramps and made me feel sluggish whereas others settled better than I expected. All of these outcomes, even if they were not what I had hoped, represented important data.

As a result of my experiments, I knew exactly what I was going to eat and drink come race day. Breakfast consisted of white toast with peanut butter, honey, and sliced banana with orange juice and Nuun Active. Between breakfast and the start of the race, I drank Gatorade and water until a half hour before the start, at which time I downed more Nuun Active. During the race itself, I consumed Gatorade and bananas from the aid stations as well as Nuun Energy and salted pretzels that I brought with me. Worked like a charm.

If your takeaway from this column is that you should adopt my own specific food and hydration plan during your own athletic events, then unfortunately you have missed the point: the importance of individuality. As I downed the last of my Nuun Active before the start, my friend with whom I ran the race strapped small vials of maple syrup to her waist, a fueling technique that she knew from experience would work for her. If she and I had swapped strategies, both of us would probably have felt awful. We are all different, so figuring out what works best for you is a process that involves both guidance from a professional as well as your own input based on firsthand experiences.

 

She Said

From a young age, I participated in a variety of team sports, including soccer, softball, and volleyball. While I truly loved playing these sports, my family was a tennis family, in that tennis was a sport that we all learned to play as children and enjoyed playing together. As I got older, I played tennis less and less, usually just hitting the ball around for fun with my family on vacations or with Jonah on a public court during the summer. But about 3 years ago, I decided to get back into the sport that I had enjoyed so much in my youth, so I joined several local women’s tennis teams.

While my overall experience on these teams has been overwhelmingly positive, whenever the topic of food or weight comes up, I have noticed some troubling trends. Whether it is one of my teammates or one of our opponents, a number of these women exhibit quite disordered ideas about food and weight.

When I was new to one of my teams, I remember one of my teammates asking me what I do for a living. After I told her that I work primarily with individuals struggling with eating disorders (EDs), she jokingly commented, “Oh, I so wish I had an eating disorder! I just can’t seem to lose these pesky 10 pounds!” I was very quick to correct her and explain how dangerous and life-threatening EDs are and that they are not simply something that someone can choose to engage in or not to lose a few pounds.

In addition to misunderstanding EDs and the seriousness of these disorders, many of the tennis women I encounter seem to struggle with diet mentality. A couple of years ago, I remember one of my tennis friends casually mentioning that one of the primary reasons she plays so much tennis is that it allows her to eat whatever she wants. In fact, I have heard this sentiment from other tennis peers, implying that they view tennis first and foremost as a way to burn calories.

At nearly all of my tennis matches, the home team provides food for the visitors and themselves. Depending on the time of the matches, the foods offered can range from simple snacks to pretty substantial lunches. Of course, with all of this food come a lot of shame, guilt, and judgments. I overheard one group of ladies on an opposing team debating whether they would have one of the cookies offered, with one of them declaring that she does not allow herself any “white carbs.” Other times I have seen women eating only salad or protein, as they are “trying to be good.”

Diets are a hot topic at many of my matches and practices. From Paleo to Whole 30 to Shakeology, a great number of the tennis women engage in restrictive eating in one form or another. One of my tennis friends started a cleanse not too long ago because she felt like she really needed to “detox” her liver and other organs. Another friend has been eschewing carbohydrates during the week and only indulging in them on her “cheat days.” As one might imagine, I try not to engage in any diet conversations as they can become quite charged. But when I mention what I do for a living, it seems like many of these women are only too happy to talk to me about food and nutrition.

I really don’t blame these tennis ladies for their disordered ideas about food, nutrition, and weight – they are subject to the numerous fear-mongering messages we all receive from our doctors, from the media, and from our friends and family. Talking about one’s diet or weight has become so commonplace that the idea of not talking about it seems strange somehow. But just think about all of the other things we could discuss! All of the ideas and stories we could share with each other! Wouldn’t that be more fun than talking about how to lose those pesky 10 pounds?

At the end of the day, I try to pick my battles. If someone asks me about my thoughts on dieting or certain foods, I will oblige. I try to be gentle with them around my strong anti-diet philosophy as it can be quite surprising and confusing for many people. When it comes to EDs, I do my best to educate those who ask about them. So far, many of my teammates have expressed interest in the idea of intuitive eating and the non-diet approach, so I have tried to point them in the right direction by recommending books and other resources. If I can somehow help even one of them to ditch the diets and begin to appreciate their body for what it can do (e.g., play tennis!), then I will feel like I have made a difference.

He Said, She Said: Obesity Awareness Month

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He Said

The concept of National Childhood Obesity Awareness Month is flawed in several ways, many of which Joanne covers in her She Said passage. The most glaring issue, in my opinion, is that by promoting the use of weight as a proxy for health, the government is paradoxically distracting from matters of actual health.

Human beings can be healthy at a variety of weights, which is why we cannot draw accurate conclusions about someone’s health or behaviors based solely on their size. Thin folks can have plenty of medical woes. A couple of years ago, I wrote about a slender friend of mine who was diabetic, suffered a heart attack, and ultimately died of cancer. Someone might be thin due to food insecurity, a medical condition, psychological disturbances, eating disorders or disordered eating, or overexercise, just to name a few of the health-threatening issues that might lead to lowered body weight.

With a focus on obesity, not only do we miss an opportunity to identify and assist people at risk for or suffering from these problems, but we actually push them in the direction of trouble. For example, I have recently seen an increase in pediatric patients, including males, with eating disorders or disordered eating that reportedly stemmed from a fear of getting fat brought on by discussions at school or the doctor’s office.

One of my teenage patients recently told me how his pediatrician praised him for having lost weight from one annual checkup to the next after having chastised him the year before, but what his doctor did not know was that my patient had overexercised and restricted his food intake leading up to the appointment for fear that his doctor would again be mad at him if he had not lost weight. My patient’s behaviors brought him further away from health, not towards it, and the poor communication between him and his doctor puts him at risk for improper care in the future. Furthermore, food restriction elevates his risk for binge eating disorder and, ironically, ultimate weight gain.

Trust me, children who are obese already know it. They hear about it on the playground, in gym class, on television, online, maybe in the pediatrician’s office, and from other sources that tell them something is wrong with their bodies and it is their fault. National Childhood Obesity Awareness Month calls even more attention to them and their bodies, thereby exacerbating stigmatization and bullying.

The concept of National Childhood Obesity Awareness Month may be well intentioned, but its fallout is the exact opposite of the desired effect. If we want to improve the actual health of our children, better to promote size diversity and the importance of healthy behaviors, such as fun and appropriate physical activity, for everybody.

 

She Said

According to the U.S. Department of Health and Human Services (HHS), September is National Childhood Obesity Awareness Month. Per the HHS website, “one in 3 children in the United States are overweight and obese,” putting kids at risk for developing health problems such as type 2 diabetes, hypertension, and heart disease. The website goes on to say that childhood obesity is preventable, as “communities, health professionals, and families can work together to create opportunities for kids to eat healthier and get more active.” Some of the strategies that the HHS recommends are nutrition based, such as “keeping fresh fruit within reach” and providing healthier food options at school, and other strategies are focused on activity levels, such as encouraging families to go on an after-dinner walk and incorporating daily physical activity at school.

While I actually applaud the strategies put forth by the HHS to improve kids’ health, I am saddened to see the focus be on body size. Thanks to Michelle Obama, childhood obesity is at the forefront of the American consciousness. Kids are being weighed and measured at school and then later sent home with a health report card telling them whether they are at a “healthy” body mass index (BMI) or are in the “overweight” or “obese” categories. Even though the medical community as a whole willingly acknowledges that the BMI is woefully flawed as an indicator of health status, it still condones its use in determining the health of our kids. Time and time again, studies have shown that behaviors rather than weight are a better determinant of health, but unfortunately, this is not being reflected in current policy.

My greatest concern is the effect that focusing on childhood obesity could be setting up kids to develop eating disorders (EDs). I cannot tell you how many preteens who have stepped into my office had been sent home with their BMI report card and then developed either extremely disordered eating or an actual diagnosable ED. What often happens is that the parents become alarmed at their child’s negative BMI report and will start to impose harsh diet restrictions and exercise ultimatums. I had one patient whose father promised her and her sister iPads if they both lost weight. Not only would he limit their access to “junk” food, he would make them run laps around their neighborhood after dinner every night. As a result of this, the patient developed a very disordered relationship with food and her body. This story is not unique, unfortunately. I have heard it too many times to count.

So, I have a few issues with the HHS’s focus on obesity. First of all, I don’t believe that we should have schools be weighing and measuring kids and sending them home with a BMI report card. Instead, the child’s pediatrician and parents should be the gatekeepers of the child’s health. Every child has their own unique growth charts – some trend on the higher end of weight for height, while others trend on the lower end of the chart. In other words, some kids are just meant to be in bigger bodies, while others are meant to be in smaller bodies. These body sizes do not tell us anything about the child’s health unless there are major changes in either direction. For instance, one would expect a child trending on the 85th percentile to stay at that percentile. If there was a sharp drop to the 50th percentile, that would be cause for concern. Similarly, if a child was trending on the 50th percentile and then jumped up to the 90th percentile, that should also be looked at. One body type is not inherently healthier than the other – every body is unique.

In addition, I think it is so important to not speak negatively about a child’s weight. Kids are like sponges, and they pick up on everything. Talking with one’s child about how their body works and teaching them how to take care of it is one thing, but telling a child that they are too big and need to lose weight is extremely damaging and can set the child up for years of negative body image and a life of disordered eating. Many EDs start when a well-meaning parent tries to teach their child to diet and use exercise to burn calories. In fact, there are a number of studies that show that when children are put on restricted diets, they will often end up being heavier adults.

Also, I think that if a parent has concerns about his or her child’s weight, they should talk with their child’s pediatrician separately (i.e., not with the child in the room). Instead of telling the parent that their child simply needs to lose weight, it would be wonderful if pediatricians did not just make an assumption based solely on the child’s weight that the child is engaging in unhealthy behaviors. If it is determined that the child is in fact not practicing healthy lifestyle behaviors, it would be best if the doctor just focused on helping the child develop these healthy habits (perhaps by referring them to a registered dietitian or other health care provider) and measure the child’s progress by their weight.

Given that, I don’t think that National Childhood Obesity Awareness Month is helpful at all in helping our kids lead healthier lives. By teaching them that weight is synonymous with health, we are doing them a major disservice. Perhaps September could instead be called National Healthy Habits Awareness Month? Just a thought.

He Said, She Said: My Big Fat Fabulous Life

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In a recent episode, of My Big Fat Fabulous Life, the protagonist visits her alma mater where she gives a talk about body positivity and then fields questions from students. Who knows what really went on in that auditorium, but if we take the video at face value, she did a fine job of responding, especially for a layman who was put on the spot. With time and expertise on our side, we took our own stabs at answering two of the questions that arose.

 

He Said

“The medical community actually agrees that obesity can lead to a shorter life span. Do you think that your No BS [No Body Shame] campaign, which emphasizes feeling confident and beautiful at any size, do you think that that can coexist along with the very real facts that they do cause legitimate health concerns?”

The premise of this question is faulty in a few different ways.

No, the medical community does not agree that obesity can lead to a shorter life span.

Research actually suggests that other factors have a greater impact on mortality than does body size. For example, a 2012 study by Matheson et al. looked at the impacts of consuming five or more fruits and vegetables daily, exercising regularly, consuming alcohol in moderation, and not smoking and found that mortality was virtually identical across all studied body mass index groups when subjects had all four healthy habits. In other words, when it comes to our risk of dying early, behaviors are a better predictor than is body size.

In his 2010 study, Fogelholm found that physically active obese individuals had better cardiovascular and all-cause mortality risk than sedentary “normal weight” people, again suggesting that when it comes to matters of life span, behavior is a more important factor than is body size.

The entire body of research is bigger than just two articles, and of course, not every study reaches the same conclusion, which reinforces how much we still have to learn and underscores how inaccurate claims of universal agreement within the medical community are regarding this complex topic.

Size acceptance and health are two separate issues.

“The mission of the No Body Shame campaign,” according to its website, “is to help every individual overcome the debilitating effects of societal-induced shame. Supporters of No Body Shame have named weight, height, skin color, sexual orientation, gender, different abilities, and specific physical attributes as causes of shame. Whitney believes that when we commit ourselves to living our best lives now, accepting ourselves as we are even if others do not accept us, real changes in confidence and quality of life are not only possible, but imminent.”

Note that nowhere in the mission statement does health appear. No BS is part of the size acceptance movement, which is related to, but not synonymous with, initiatives like Health at Every Size (HAES®) that promote a paradigm shift within the medical community to focus on actual health instead of weight.

In explaining size acceptance, Ragen Chastain writes, “Everybody deserves basic human respect and civil rights and that should never be up to show of hands or vote of any kind. Fat people have a right to exist, there are no other valid opinions about that. Our rights to life, liberty and the pursuit of happiness are not someone else’s to give, they are inalienable. SA [Size Acceptance] activism is not about asking someone to confer rights upon us but rather demanding that they stop trying to keep them from us through an inappropriate use of power.

HAES, on the other hand, can be succinctly encapsulated as a weight-neutral approach to health. The Association for Size Diversity and Health (ASDAH) elaborates by saying, “The framing for a HAES approach comes out of discussions among healthcare workers, consumers, and activists who reject both the use of weight, size, or BMI as proxies for health, and the myth that weight is a choice. The HAES model is an approach to both policy and individual decision-making. It addresses broad forces that support health, such as safe and affordable access. It also helps people find sustainable practices that support individual and community well-being.

While size acceptance and HAES are different concepts, clearly they relate. The situation is more complex than I am about to make it seem, but for the sake of brevity, consider how weight stigma pushes people into weight-loss pursuits that are most likely to worsen their health. If we as a society are more accepting of people of all sizes, we free each other up to instead focus on our actual health.

The implication that feeling unconfident or unbeautiful at certain sizes inspires better health is the exact opposite of what tends to actually happen.

Tomiyama and Mann conducted a study in which they posed two sets of questions to different subject groups. One set of questions was designed to make the subjects aware of weight stigma while the control questions asked about ecofriendly behaviors.

After subjects answered their questions, researchers presented them with a variety of foods and gave them permission to eat whatever and however much they would like. The people who had just responded to questions about weight stigma consumed significantly higher amounts of sugar and calories than those who answered neutral questions.

Their findings mirror our clinical observations and experiences. People often believe that self-dissatisfaction will somehow inspire better health, when in reality the individuals who love and accept themselves as they are tend to be the ones motivated to take better care of themselves.

Correlation is not synonymous with causation.

The questioner ended her inquiry with, “the very real facts that they do cause legitimate health concerns.” The context suggests that she misspoke when she used the word “they” and was actually referring to obesity.

If that presumption is indeed correct, then she is confusing correlation and causation. Earlier this month, I watched a fireworks display one evening and then a parade the next morning. Did the fireworks cause the parade, or did these events occur in close proximity to each other due to another factor, say, Independence Day?

Similarly, when we consider the diseases linked to obesity, we must remember that correlation does not equal causation. The link, in other words, might not be a causal relationship, but rather an association due to other factors. Many examples exist, but for the sake of brevity, consider just one: stress. Cardiovascular disease, which is often blamed on obesity, is also associated with life stress.

If you are not obese yourself, do your best to put yourself in those shoes for a moment: You live in a society where the government has declared war on your body size; where fat hate and bullying are prevalent online and in real life; where you might fear going to the doctor because you are more likely to receive a judgmental directive to lose weight rather than an actual evidence-based medical intervention; where commercials, memes, advertisements, talk at the gym, the grocery store, and over the dinner table hammer at you repeatedly throughout the day, every single day, that something is wrong with you and it is your fault. Tell me, how is your stress level?

 

She Said

“My father passed away this past April. He was severely overweight, he was diabetic, and he was an avoider, right. Do you think there is an ethical concern in folks who view you as a health and fitness expert or at least a public figure and use that body positivity message as an excuse to avoid actually addressing their real health concerns?”

While the second sentence of this audience member’s question is not a question at all, I think it needs to be addressed. Although he didn’t specifically say so, this statement reads as though the questioner believes that his father’s weight was to blame for the development of his type 2 diabetes (T2D). As we have discussed numerous times before, weight and health are two very different things and that while being “overweight” or “obese” might be correlated with certain health conditions, such as diabetes, there is no evidence that being “overweight” or “obese” causes these conditions.

In a 2012 interview for the Health at Every Size blog, author Linda Bacon explains, “while it’s true that the majority of people with T2D are in the BMI categories of ‘overweight’ or ‘obese,’ that’s at least in part because the insulin resistance that underlies most cases of T2D often causes people to gain weight. In fact, weight gain may actually be an early symptom—rather than a primary cause—of the path toward diabetes.” In addition, Bacon cites a “review of controlled weight-loss studies involving people with T2D” which showed that while “overweight” or “obese” individuals with T2D had initial improvements in their blood sugar levels with weight loss, those levels eventually returned to baseline within 6 to 18 months, even for those few individuals who had managed to keep the weight off.

I also think it is important to look at the way that the questioner described his dad: as an “avoider.” That tells me that this man believes that his father did not take care of himself to the extent he could have in order to have prevented his untimely death; that if his father had not “avoided” his health issues by presumably eating better and losing weight, he might still be here today. That seems like a very serious assumption. Sometimes even when people take all the right steps in dealing with their health condition, they will still pass away. We all like to think that if we eat perfectly, don’t smoke, don’t drink, and do all the “right things” (i.e., healthy life behaviors), we will live forever. Unfortunately, none of us is immortal.

Now to address the actual question that was asked. I find this question problematic for a couple of reasons. First, I don’t think that Whitney (the protagonist of MBFFL) has ever tried to portray herself as a “health and fitness expert.” Over the first 3 seasons, she has consulted with a registered dietitian who practices Health at Every Size® (HAES®), has seen a cardiologist, and has been working with a personal trainer in addition to other health professionals. She herself admits that she struggles with the health and fitness part of her life, particularly in that she battled an eating disorder for much of her teens and twenties. She has never presented herself as an expert in nutrition, fitness, or medicine.

The second reason I find the question problematic is that the questioner assumes that the message of body positivity is being used as an excuse for people of size to avoid dealing with their health issues. This is simply untrue. Body positivity is about seeing all bodies as “good” bodies, that no one body type is the “ideal,” regardless of what our society (particularly the media) likes to tell us. In other words, the body positivity movement says “there is no wrong way to have a body.” It also recognizes that “good health” is not a requirement to have a body and that sometimes (due to circumstances outside of one’s control) our bodies might not be healthy. This does not mean, however, that these bodies are any less good.

At the end of the day, I think the best way to think about this question is through the lens of the “Underpants Rule,” coined by the brilliant blogger Ragen Chastain of Dances with Fat. Ragen defines the rule as such: “everyone is the boss of their own underpants so you get to choose for you and other people get to choose from them and it’s not your job to tell other people what to do.” This means that others do not have a right to tell you how you should take care of your body and vice versa. Whitney has never told her viewers (at least to my knowledge) how they should be treating their health conditions – she is only focusing on her own body and health issues.

Body positivity does not assume that everyone is actively trying to be living their healthiest life. It is more about helping people realize that skinny bodies are not the only bodies that are worthy or beautiful. Yes, some individuals might show love for their bodies by trying to take care of them by eating a varied, nutritious diet, being physically active in an enjoyable way, getting enough sleep, and managing stress. But not everyone is able to engage in all of these behaviors. The body positivity movement says that even if one is not in the best of health, their body is still valuable.