Category Archives: Nutrition

Preaching Beyond the Choir

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“A lot of people have anti-racist groups. They get together and meet and have a diverse group and all they do and sit around and talk about how bad discrimination is. Then someone says ‘there’s a Klan group across town. Why don’t we invite them to come and talk to us?’ and the other person says ‘Oh no! We don’t want that guy here!’ Well, you’re doing the exact same thing they are. What’s the purpose of meeting with each other when we already agree? Find someone who disagrees and invite them to your table.”

– Daryl Davis

Joanne and I certainly have company among many practitioners across the globe who have abandoned weight-centered models of care for health-centered approaches. We congregate virtually in communities like Health at Every Size® and the Association for Size Diversity and Health. While these resources are important for building support and sharing best practices, we run the risk of only preaching to the choir if we confine our communications to people who are already on the same page as us.

Many practitioners and activists, like Ragen Chastain, Aaron Flores, Ellen Glovsky, Kerry Beake, and Linda Bacon, just to name a small handful, have been putting themselves out there, subjecting themselves to everything from ridicule to blatant hate, as they share research and perspectives that run counter to widely-held beliefs about weight and health.

As for me, while I do not consider myself part of any sort of crusade and prefer to influence change on a one-on-one basis with the patients who come to meet with me, I increasingly feel an obligation to step up to the plate when opportunities to share my perspective arise. Silence is easier, but I fear that it comes across as support for the status quo, so in essence my passivity makes me part of the problem. I need to change that.

A sales rep emailed me in August trying to get me to use his company’s product at our practice. He made some statements about weight that sounded ridiculous, but I ignored his email. In September, he emailed me a second time, and once again I did not write back. When he emailed me for a third time last week, my conscience compelled me to engage him in conversation and confront him about his statements. An email exchange ensued. Following are some excerpts.

Sales rep: “Take a moment to consider all that you can do with [product name] as your tool. You are given a list of the top 5 foods in 7 different categories that will allow an individual to reach their goals the faster than any other foods. This means losing 6 lbs a week and not 2 lbs. Or gaining 5 lbs a muscle the first month of training, instead of a mediocre 3 lbs. If your clients were able to see this amount of increased results and you were able to make more money in the process, don’t you think you would be interested?”

The underlined passage, which I underlined for emphasis, set off my BS alarm.

Me: “Thank you for your email; however, our businesses seem to be on different pages so I do not envision us working together. If you have any research to support the claims that [company name] is making I would be interested in taking a look at it.”

Sales rep: “I would be happy to provide you with literature on the claims our diet plans make if you would like. We have scraped from thousands of published articles.  Is there any specific topic that would be of interest to you?”

Honestly, at this point I was fairly certain that no such research existed, as I probably would have heard about it by now if it did, but I wanted to keep an open mind, and I also felt like this guy was George Costanza lying about a house in the Hamptons and I wanted to see how far he would go.

Me: “Thanks for your email. In your previous email, you talked about weight loss/gain results with [product name] versus without it. I’d love to take a look at that research.”

Sales rep: “Well as you know, weight loss and weight gain is majorly dependent on the amount of Calories consumer and burned over a given amount of time. What we have done is scraped many articles that claim increased weight loss or weight gain when matching a SNP to a certain macronutient profile of a food. We have also analyzed research that observed increased energy levels and increased activity levels in people who ate a majority of the food we recommend. If you’re referring to clinical trials where [product name] users and blinds are closely observed over a period time, we have not conducted a controlled study. One reason being the difficulty that diet research usually has with compliance. The second reason is we believe we can access enough data from the people using [product name] and we will be able to quantify all our results. I personally have lost over 30 lbs in the last 2 months since I started to flow a [product name] approved diet plan.”

Did you catch that? Despite the specific claims that he previously made about the weight-change results that his company’s product supposedly creates and despite his offer to provide me with the research to back up said claims, when pressed he admitted to having no such research.

Me: “Thanks, I appreciate the explanation. It is important for us to remember though that losing weight is relatively easy. Virtually any kind of restriction will create it. Data presented at last year’s Cardiometabolic Health Congress, for example, compared the results of over 20 different diets and showed that all of them resulted in the same weight loss pattern. The problem though is that all of them also resulted in the same weight regain pattern as well. Most studies that look at weight loss only look at the short term, but those that look at least five years out show that approximately 95% of people regain the lost weight and most of them end up heavier than they were at baseline. Sure, some of that is due to people not maintaining the behaviors that created the weight loss, but what I find very interesting is that many of the people who do maintain the behaviors experience weight regain as well. My clinical experience mirrors what the research indicates, as I have certainly had individuals who are so frustrated because they are working so hard to keep off lost weight, and yet it slowly creeps back on. For all of those reasons, we take the focus off of weight and instead focus on behaviors, which research shows are better predictors of health outcomes than weight anyway. Although the public is generally still hyperfocused on weight, we are seeing a slow shift in the medical community away from a weight-centered model of care to a health-centered model of care as more and more practitioners are becoming aware of the research.”

Sales rep:

That’s right, he did not write back, at least not yet. For the sake of fairness and completion, I will update this entry if and when he responds, although I am not holding my breath waiting for a reply. Most likely, he crossed me off his list when he realized he would not get any business from me and he has moved on to other sales leads without giving my latest email a second thought.

On the other hand, perhaps – even for a brief moment – I got him to rethink his stance and consider another point of view. Either way, at least I did not exacerbate the problem by staying silent.

He Said, She Said: Halloween Candy

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He Said

Halloween is when I first learned the meaning of the word “nauseous.” After returning home from trick or treating, I sat at the kitchen table eating candy until I no longer felt well. “Do you feel nauseous?” my mom asked. A loose definition formed in my childhood mind: Nauseous (adjective): Feeling completely gross from eating too much Halloween candy.

My brother, in contrast, always paced himself. While I blew through my own candy in a few days tops, he made his candy last for weeks, if not months. Eventually I realized that eating small amounts of candy at a time not only spared me from feeling nauseous, but the candy lasted longer. Preservation became fun, and at some point I started freezing candy. As springtime flowers bloomed, I would be eating last fall’s frozen Snickers.

Upon returning home from trick or treating, my brother and I dumped out our candy sacks, sorted our bounties into piles by kinds of candies, and traded with each other so we each had our favorites. In order to make our trades with each other, we each needed a foundational hierarchy of our candy likes and dislikes so we each knew which pieces we wished to keep and obtain more of and which ones we hoped to trade. In other words, we had to mindfully eat our candy in order to assess enjoyment.

Halloween and its associated candy provide opportunities for children to build their relationships with food. The healthiest relationships are built on a foundation of internal-cue recognitions and responses: having the ability to not only ask ourselves questions like “Am I hungry?” “How hungry am I?” and “What is it that I really want?” but more importantly, to be in touch with our bodies enough to be able to appropriately answer.

Building these skills involves trial and error. As I did on that Halloween so long ago, sometimes kids overeat and regret it. Sometimes they burn through their stash too quickly, not even truly enjoying a large portion of it, and wish they had conserved some for later. It is through these and similar lessons that we build the intuitive-eating skills that can serve us so well throughout our lives.

The alternative is to regulate children’s candy experience for them by forcing or coercing them to donate, trade, or throw out all or some of their candy, or by rationing the candy for them. Using external cues to regulate our eating may seem to work in the short term, but in the long run the approach almost always fails us. One particular patient comes to mind, a teenage girl who ignores her body’s hunger signals and eats according to the commands of an app. She tells me that she does not trust herself to listen to her body and that obeying the app is already “ingrained” in her. I think of the countless adults who sit across the table from me, fold their arms, lean back, and say, “Just tell me what to eat,” because for most of their lives they have been taught that they cannot trust themselves.

Well-intentioned parents want to help, but the assistance is often misplaced. Help your children to build their relationships with food by giving them the freedom to manage their Halloween candy themselves. Consider prompting your children to ask themselves how hungry they are and what do they really want before the eating begins, but not in a leading or coercive way. Give them the space to answer honestly and to follow up their candy experiences with more candid questions: “How full am I?” “How am I feeling now?” “How did I enjoy it?” and “What, if anything, would I do differently next time I have candy?” Give them the freedom to make mistakes and learn through experience, for it is partly through these lessons that we build healthy relationships with food.

 

She Said

The other day, Jonah told me about a local news story he had seen about a bunch of people who are now going to put signs on their front doors proclaiming that they are a “candy-free” house and that, as such, they will not be handing out any candy on Halloween this year. Instead, these individuals will be handing out small toys to the youngsters who come trick-or-treating to their door. Of course, the intention of these individuals is to not promote the “obesity epidemic” by handing out sugary treats to little ones.

The first thing that came to my mind about Halloween candy and kids was, “What would Ellyn Satter say?” Ellyn is a registered dietitian and eating specialist focusing primarily on children. She has written a number of pivotal books about how to feed children and how to prevent and/or help rectify problematic eating early on to promote a healthy relationship with food in years to come.

As luck would have it, Ellyn wrote an article in 2008 about the topic of Halloween candy and kids. In her opinion, she believes that Halloween candy should be treated the same way other sweets are treated and that the child needs to learn how to manage his sweets and how to “keep sweets in proportion to the other food he eats.” She cites a 2003 research study that found that girls that were “treat-deprived” (i.e., were restricted by their mothers in particular around treats and sweets) were more likely to overeat forbidden foods even if they weren’t hungry. Conversely, the study found that girls that were allowed treats on a regular basis ate them moderately and sometimes not at all.

Given the above study, Ellyn’s advice is to use Halloween candy as a “learning opportunity,” in which the child should work toward being able to manage his or her candy stash with minimal interference by the parent. What does that look like? Well, she would suggest that upon returning from trick-or-treating, the parent should let the child “lay out his booty” of Halloween candy, sort it out, and “eat as much of it as he wants.” After letting the child do this on the evening of Halloween and the next day, the child should put away the rest of the candy, and it will then be “relegated to meal- and snack-time: a couple of small pieces at meals for dessert and as much as he wants for snack time.” She goes on to say that “if [the child] can follow the rules, he gets to keep control of the stash. Otherwise [the parent does], on the assumption that as soon as the child can manage it, he gets to keep it.” Finally, she recommends offering milk with the candy to make sure the child is getting some good nutrition.

Now, when I first read the above, I found my inner skeptic coming up front and center. How could one possibly trust that his or her child could regulate his or her sweets intake? Isn’t that the parent’s job? Otherwise, wouldn’t we have a bunch of little kids gorging themselves on any sweets they could get their hands on? What’s next? Letting kids start drinking at a young age to help them learn to do so moderately as adults? It all sounded a bit too much to me.

But the more I thought about it, the more it made sense. By taking the taboo off sweets and treats, kids will be less likely to overdo it when they are faced with them. I have a colleague who regularly has a rotation of sweet treats and salty snacks in her house and does not limit her kids around this. What ends up happening, she says, is that her kids don’t see these foods as “off-limits” and therefore not so tempting. They know that if they want these foods, they can have them, but since they are always available, the forbiddenness is no longer an issue, and they eat them in moderation or sometimes not at all.

So what’s the take-home message from the above? Restricting sweets and treats can lead kids (and adults) to view these foods as “forbidden” and then when faced with them, they will find themselves overdoing it on these foods even if they aren’t hungry or in the mood for them. By incorporating these types of foods into one’s meals and snacks on a regular basis, they become less charged, and the individual will view them simply as part of their diet, not as forbidden fruit.

HAES® and Eating Disorder Workshops

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Geographical fortune afforded me opportunities to recently attend two fantastic workshops right in my backyard: the Association for Size Diversity and Health’s (ASDAH) half-day workshop on Health at Every Size® (HAES) at the Multi-Service Eating Disorders Association, and the Hynes Recovery Service’s symposium on eating disorders in adolescent and young adult patients.

These conferences offered me chances to meet and learn from some brilliant colleagues, including, but not limited to, Ellen Glovsky, Lisa Du Breuil, Marsha Hudnall, Dawn Hynes, and Kim Dennis, some of whom I have known for years and others with whom I have been connected virtually but had never before met in person.

Dr. Glovsky’s talk, in particular, was terrific. They always are. She and I first met in 2007 when she gave a talk at the Beth Israel Deaconess Medical Center, where I was a dietetic intern. As soon as she finished speaking that day, I went up to the front of the room and introduced myself. We have stayed in touch ever since.

For lack of a better term, Dr. Glovsky just gets it. Having been a dietitian for approximately 40 years, she has evolved her counseling approach away from a classical directive style to the more effective motivational interviewing model that Joanne and I learned from her and use at our practice. Although Dr. Glovsky probably does not realize it, nobody has been a greater influence on my career than her.

Over the course of these two workshops, Dr. Glovsky and the other speakers shared many interesting points and anecdotes. The nuggets that really struck me are below.

  • Research indicates that 95% of people who intentionally lose weight regain the weight within five years. Of those 95%, 60% of them will end up heavier than they were at baseline. Said differently, if 100 people attempt to lose weight, five of them will keep it off, 38 will return to baseline, and 57 will end up heavier than when they started.
  • Because outcomes are only somewhat in our control, our goals are better constructed around performance and behaviors, not outcomes. For example, instead of saying we are going to lower our cholesterol by a certain number of points, we are better off setting goals to perform certain behaviors that may lead to lowered cholesterol with the understanding that some influential factors, such as genetics, are out of our hands.
  • Parents and doctors often miss the signs of eating disorders or incorrectly explain away said signs with other conclusions. Joanne asked one of the speakers how much of a dip in the growth charts should be considered a red flag. The speaker said a drop of five (for example, a patient’s body-mass-index-for-age drops from the 50th to the 45th percentile) or more indicates that something serious, such as an eating disorder, is likely at play. That reminded me of a patient’s mother who literally laughed in my face and never brought her daughter back to see me when I expressed concern that her daughter might be suffering from a yet-to-be-diagnosed eating disorder. In addition to the other reasons for concern that I saw, over the course of the last eight months her daughter’s body-mass-index-for-age had dropped by almost 20.
  • People suffering from an eating disorder or disordered eating frequently use the elimination of certain foods (“carbs,” dairy, gluten, animal products, etc.) as a means to restrict under the guise that the choice is supposedly about health, an allergy/sensitivity, or ethics.
  • A lawyer I spoke with between sessions told me she is working on using occupational safety laws to implement regulations for models in the fashion industry. According to her, the World Health Organization defines starvation as having a body mass index below 16.0 kg/m2, while the average runway model has a body mass index of 14.0 kg/m2.
  • Websites and social media groups that encourage eating disorders and offer tips to further their destructive behaviors are prevalent and easy to find. After a quick Google search that I did myself, I was shocked and saddened by what I saw in just the first few seconds. As one of the speakers explained, individuals with these conditions often seek out like-minded people online and isolate themselves from others. Pretty soon, these online communities become their entire world.
  • For some people, the term “fat” is an insult loaded with unfair and inaccurate stereotypes. For others, the word is nothing more than a neutral adjective describing body shape or size. Practitioners need to pay close attention to the language that our patients use and the intended meanings behind their words.
  • Every once in a while, I get someone who erroneously believes that HAES is just an excuse that larger people use to justify their size. As I looked around the room at the ASDAH event, I could not help but wish that those same people were there with me to share what I was seeing: People of all sorts of shapes and sizes were there, including many slender folks.

What is weight loss really about?

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We know that the long-term success rate of weight-loss attempts is poor, yet patients often act like their reasons for wanting to lose weight are so justifiable that the odds should change just for them, as if I hold some magic solution that I keep secret and only break out when somebody gives me a really good reason to do so.

Attaining the ability to fly like a bird would sure make my life easier. No more getting stuck in traffic, spewing environmentally-harmful emissions, or spending money on gas, and perhaps I could save money on a gym membership since my physical activity would be built naturally into my daily commute. All good and valid reasons, but still the chances of me acquiring a superpower are probably not very high.

Whenever a patient tells me he or she wishes to lose weight I always ask why, but not so he or she can build a compelling case that somehow changes the dismal odds, but rather so we can find alternative paths to achieving the underlying goals.

If someone says, “I need to lose weight because I have hypertension (or high cholesterol, or high blood sugar, etc.)” I suggest we explore more effective ways of directly addressing those markers. One particular person comes to mind, a woman who had been dealing with high blood pressure and elevated cholesterol for most of her adult life, who had gone from diet to diet trying to finally achieve the long-term weight loss she had desired since her teen years. Ultimately, when she gave up that weight-centered model of care, and instead focused on improving her relationship with food and finding modes of physical activity that were enjoyable rather than punishing, both her cholesterol and blood pressure improved even as her weight actually increased.

One of my long-term patients talks about how he feels bad about himself and his appearance. He is afraid to take off his shirt at the beach for fear that he will disgust other people and himself. In my experiences, patients who link their weight to how they feel about themselves only sometimes feel better when the weight drops. Oftentimes, someone reaches his or her goal weight and then expresses a desire to lose more because the negative feelings did not dissipate with the weight lost to date.

The weight is really not the issue, but rather just the vehicle through which emotional complexities are playing out. Even for those who do feel better about themselves when the weight drops, we know that almost all weight loss is only temporary so what happens when the weight comes back? Although this particular patient does not feel ready to go yet, I have been gently encouraging him to see a therapist to work on his body image and self-esteem. For his sake, I hope that someday he learns that one need not have a certain body shape or size to feel good about oneself.

Earlier this year, a man came to me saying he wanted to lose weight in order to complete a marathon. I explained that if he chose to continue working with me, I would help him change his eating to run his best, and as a result of said eating changes he may or may not experience a change in his weight, but that I would not be directly helping him to lose weight. Skeptical, he made some condescending and rude remarks, left, and never returned. Weight and running performance are not synonymous. In fact, I ran my fastest marathon when I was at my heaviest. If someone wants to improve sports performance, then let us focus directly on that and put issues of weight aside.

Our reasons for wanting to lose weight and the importance of said reasons do not dramatically impact our ability to achieve it, but by looking deeper at our motivations to lose weight, we can move beyond focusing on weight and more effectively target the underlying goals. For example, I may never attain the ability to fly, but you know what I could do that would satisfy all of my reasons for wanting to do so? Ride my bike.

“Weight that will stay off”

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TextThe above text exchange appeared in my Facebook feed, placed there by a personal trainer (whose name I blacked out from the image) who shared it to promote his business, a testimony to his prowess and the results he can bring to his clients who are seeking to lose weight.

Let’s talk about results. Losing weight is relatively easy and numerous paths to weight loss exist. Keeping off the lost weight, well, that is a completely different story. Research shows us that about 95% of people who try to lose weight will ultimately regain it (whether or not they maintain the behaviors that created the weight loss in the first place) and of that 95%, 60% of them will end up heavier than they were at baseline.

Said differently, if 100 people intentionally lose weight, five of them will keep it off, 38 of them will return to baseline, and 57 of them will end up heavier than when they started.

These facts may not be talked about very much in our weight-loss-obsessed society, but they are no secret. At the 2013 Cardiometabolic Health Congress, data were presented showing that this pattern of weight loss and subsequent regain was virtually identical regardless of the mode somebody used to lose it. That is why some people in the healthcare field say that the best way to gain weight is to go on a diet.

So when the trainer refers to his client’s 10 pounds of lost weight as “Weight that will stay off,” on what is he basing that claim? Based on the research, if he says something like that to 20 of his clients, 19 times he will be wrong. Not only is he misleading people with false promises and expectations, but he is putting them at high risk for weight cycling and the negative consequences with which it is associated.

Chances are better than not that the client in question will eventually regain the 10 pounds he or she lost plus more. What will the text exchange between the trainer and client look like then?

The sad thing is that I think the trainer in question is actually a good trainer in terms of the mechanics of his profession. He just needs to be more careful about the lessons he is teaching his clients. Had he responded to his client’s text with a sentiment along the lines of, “Losing weight feels important to you right now, but let’s remember that being physically active is doing wonders for your health and well-being regardless of what happens with your weight,” I would not be writing this blog.

Day 197: Control

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“It’s hard to keep things fresh and not become a parody of yourself. And if you’ve ever seen that movie Spinal Tap, you’ll know how easy it is. It’s a parody of what we all do. The first time I ever saw it, I didn’t laugh. I wept. I wept because I recognized so much in so many of those scenes. I don’t think I’m alone amongst all of us here in that.”

– The Edge, U2’s Rock and Roll Hall of Fame Induction, 2005

 

To be fair, Grey’s Anatomy is probably not the worst show on television, but the overly-dramatized plots and scenes that are supposed to make me laugh but do nothing of the sort leave me wondering what so many other people see in the show. Its long run of prime-time success seems to indicate that my opinion is that of the minority.

Above my other criticisms, the aspect of the show that rubs me the wrong way is how themes in patient care just so happen to mimic whatever events are going on in the doctors’ personal lives. Every episode this occurs. My eyes roll. As if someone is telling me the same joke over and over again, I want to interrupt and plead: Stop, please, I get it already.

Then to my horror, I realize the joke is on me: They’re right. The themes running through patient care and my own life really do seem to happen with such regularity.

In the midst of a late-summer walk, the inspiration hit me to try jogging for the first time since my surgery. I broke out into a jog and slowly shuffled along before the pain in my back was so intense that I had to slow down and resume my walking. Maybe I had jogged 20 yards, roughly the equivalent of crossing a wide street. This occurred in early August. According to surgeons’ predictions, I should have been able to start running in June.

In both life and healthcare, only some factors are in our control. The rest of them? Who knows. That is why I am so careful about tying goals to specific outcomes that are only somewhat under our influence. Furthermore, it is why I am wary of predicting how my patients will fare in terms of weight, cholesterol, blood pressure, or whatever other outcomes they are attempting to influence.

One of the most influential lessons in my life happened in the span of a few seconds in the south Pacific. As I sat on the boat’s edge preparing to snorkel at the Great Barrier Reef, a wave came up and dragged me into the water. There is power, and then there is power. Mine was dwarfed by that of the ocean, which had its way with me. While I struggled to get back to the boat as the water pushed and pulled me with much greater force than I anticipated, I had an epiphany of humility: We do not have as much control over our lives as we would like to think.

Having only limited control does not mean we should throw up our hands and give up. It just means we need to keep perspective, accept our limited power as we continue our work, temper expectations, and adjust to whatever comes.

After five months of waiting, I was finally cleared to begin physical therapy in late August. With the help of my therapist, I am working hard to reclaim my conditioning and put myself in the best possible position for my desired outcome: a return to competitive running and tennis. Neither sport is a possibility right now, even though I had expected to be able to resume both activities months ago. Given that, I have refocused my efforts on outdoor cycling.

Getting on my bike again was fantastic. Riding produces no pain whatsoever. Although my cardiovascular fitness has plummeted due inactivity and I am not able to ride as far now as I used to, just going through the routine of prepping my bike, putting on my helmet, starting my bike computer, and setting off down the road is the closest to the old me I have felt in just about a year. It makes me feel, well, normal.

We only have so much control over what happens and when, but if we keep our expectations in check and adapt accordingly, we can still find ways to thrive. I’m sure there must be a Grey’s Anatomy episode about that.

 

What to Eat Before/After Exercise?

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We are always looking for suggestions for blog entry topics. This morning, a colleague messaged us on our Facebook page and asked us to write a piece on nutrition for student athletes. More specifically, she asked us to write about what a student-athlete should eat before and after a demanding workout.

Like most areas of nutrition, sports nutrition must be individualized. In other words, what works for your friend, teammate, brother, sister, etc. will not necessarily have you performing your best and vice versa, nor will the guidelines I outline below automatically work for you either. For that reason, I always suggest trying out a new eating routine on a practice day. Competition days are not for experimenting, but rather for eating the foods that you know from experience will have you performing up to the best of your capabilities.

In addition to individuality, other factors influence what and when we eat before exercise. Our main source of fuel during exercise is carbohydrates. Because of that, we want them to be the bulk of our intake before our workout. Their form, quantity, and combination with other foods depend on the intensity, duration, and mode of the upcoming workout.

Before a high-intensity bout of exercise, such as a cross-country race, we often need a greater amount of digestion time and a higher ratio of carbohydrates. For example, the student-athlete might have a plate of pasta with a small portion of grilled chicken at lunch in preparation for an afternoon race. If the athlete had the meal closer to race time, he or she may wish to ditch the chicken and have just the pasta, which will be more quickly absorbed in absence of the meat. Yogurt or toast with jam are other examples of small pre-exercise meals that work for some people. Someone who likes to fuel very closely to a high-intensity event might do better with a small amount of fruit or liquid nutrition, like Gatorade. Fruit juice is not ideal during this time; the high fructose content can cause gastrointestinal distress.

Before a low-intensity event, such as a long-distance bike ride or a game of baseball, people can often tolerate more well-rounded meals closer to exercise. Carbohydrate content should still be high, but more protein and fat can often be tolerated. Presence of the latter two macronutrients can also be helpful by slowing digestion and delaying the onset of hunger. Waffles with peanut butter, a burrito, or my previous example of pasta with chicken are examples of meals that can work well before an event of this caliber.

After exercise, our attention shifts from fueling to recovering. We have a short window of time (approximately 30-60 minutes) following exercise in which enzymatic activity is elevated and enables our bodies to be especially good at repairing muscles and replenishing glycogen stores during this time. For that reason, soon after exercise we want to consume both protein and carbohydrates. Examples include a small turkey sandwich, an apple with peanut butter, or yogurt.

Student-athletes often find themselves having to deal with a gap of time between finishing practice and when the family sits down to dinner, so having a post-practice snack that incorporates both protein and carbohydrates is going to be especially important. Taking advantage of this short window of time often necessitates bringing shelf-stable food that can tolerate being unrefrigerated from the time the student leaves home early in the morning to the afternoon after practice. Nuts, in combination with a carbohydrate source, such as fresh or dried fruit, often work well. Shelf-stable boxed milk or a product like Orgain, which is essentially protein-fortified milk, can also do the job.

Heavy sweaters and people who tend to lose a high amount of salt in their sweat (i.e. someone who leaves white streaks of salt deposits in exercise clothing) also need to focus on replenishing sodium. Gatorade Endurance or salted nuts, pretzels, popcorn, or tortilla chips are good options.

If you are a student-athlete and you would like individualized help with fueling yourself to perform your best, come see one of us or another registered dietitian who has expertise in sports nutrition.

He Said, She Said: Nutrition Facts Labels

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He Said

Those working in policy are often charged with impossible tasks. Given the differences that make us each unique, coming up with guidelines that will work for some will inevitably alienate others. My suggestion is to abandon attempts to use food labels as nutrition-education tools and instead focus on accurately conveying the contents of the food itself.

Said attempts to provide education and context frequently result in nothing but confusion. Consider the inclusion of percent-of-daily-value calculations. If people understood that these percentages refer to the needs of a fictitious, generic example, fine, but I know from experience that all too often people are misled into believing these percentages pertain to them. Consider the differences in sodium needs of an individual with hypertension versus a marathoner who leaves white streaks of dried salt on his singlet.

Along those same lines, people misunderstand the term “serving” and think they are supposed to have the specified amount. Aiming for the serving size can lead to overeating or undereating and trigger negative feelings, such as guilt. In reality, serving size is not a mandate, but rather a unit label that gives us shorthand language with which to talk about and compare foods. I would like to see the term “serving” removed and replaced with less loaded term, such as “unit,” that still serves the function of easy discussion but without the baggage.

Another one of my gripes with food labels is the rounding off that manufacturers are legally allowed to do with their numbers. For example, if a food has less than 0.5 grams of trans fat per serving, they can round down to zero. In a way, it makes sense. A piece of paper is so thin that we might call it two-dimensional. Gather a bunch of papers together into a ream, however, and suddenly the thickness is substantial. That is the problem with rounding. Joanne has a patient who was using a pump margarine that stated it was calorie-free, but she was using such a high quantity that the calories, which had legally been rounded down to zero, significantly accumulated.

Rounding also happens in a qualitative sense on the ingredient list. What exactly are “natural flavors,” for example? People should have the right to know exactly what they are consuming, and more detailed information would surely make life easier for people with food allergies.

Nutrition education is certainly needed in our society, but food labels are not the place for it.

She Said

Ah, the nutrition label. As a practitioner specializing in eating disorders (EDs), I am well aware of how the nutrition label has the potential to be used (and abused). Many of my clients could spend an hour or more in the grocery store, looking at label after label to find the healthiest food option. I had one patient tell me that she spent 30 minutes in the cereal aisle comparing labels for different types of granola, determined to find the one that had the least amount of carbohydrates and fat, while also boasting at least five grams of fiber. And, of course, the ingredient label needed to have less than 10 ingredients listed, most of the items needed to be organic, etc.

You see, for those struggling with EDs, the nutrition label is not usually their friend. Nutrition label reading is a practice in self-torture for most of them. Having that information listed on the box or bag gives the eating disordered individual the information he or she needs to make choices about his or her eating, and it often causes them to analyze and over-analyze their food choices. In some cases, my patients will refuse to look at labels altogether for fear of getting sucked down the rabbit hole of “healthiest choice.”

For most of my ED patients, I suggest that they avoid reading the nutrition labels. Why? Well, for one, to prevent the above scenario from playing out at every grocery shopping trip. Also, my goal for most of my patients is to learn to engage in Intuitive Eating (IE), and using nutrition labels to make food-based decisions (when one is struggling with an ED) is anything but intuitive; instead, it is using an external control to decide what one should eat. Ideally, I would prefer the patient choose the type of granola she enjoys eating the most, regardless of the amount of carbs, fat, or fiber grams it contains. As I have noted before, when we enjoy what we are eating, we are more likely to absorb the nutrients in that food than if we simply choke down a less yummy version of that food.

Of course, if someone has a health condition that warrants them to read labels (e.g. diabetes or celiac disease), I would suggest that they do so in order to be safe and as a health-promoting behavior. But if someone has no dietary restrictions placed upon them by their doctor, and they are struggling with an ED, avoiding the nutrition label is the way to go.

Weight Loss Specialist

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“Luck is the last dying wish of those who want to believe that winning can happen by accident. Sweat is for those who know it’s a choice.”

Suggesting that achieving our goals is up to us if only we work hard enough sounds motivating on the surface, but really it makes no sense. So, what, the 99.2% of players in the U.S. Open main draws who walked away without a title did not realize all they had to do was work hard and choose to win? Outcomes that rely on factors beyond our control breaking our way are not automatically there for the taking if only we put our mind to it.

Where that quote originally comes from is not clear to me, but I know I first heard it from a personal trainer who cites it as one of his favorite quotes. According to said trainer’s Facebook page, he now employs a certified “Weight Loss Specialist.” Awesome.

Here is the problem: If a supposed specialist is giving you the information you supposedly need to lose weight, and achieving your goal is framed as a choice that is entirely in your control and can be attained through hard work, and you do not achieve your weight-loss goal, then who is to blame?

You.

If we mislead people into believing that weight loss is entirely up to them and they do not achieve (or more likely maintain) it, they typically turn their frustration and disappointment on themselves with berating thoughts like, “I have no willpower,” “I need to be more disciplined,” “I’m such a loser,” and “I just need to work harder next time.”

Behaviors that in and of themselves were beneficial to health independent of weight loss, such as being physically active or eating fruits and vegetables, are abandoned because they did not lead to weight loss. Restriction gets taken up a notch. They pursue an even more rigid diet and/or intense exercise regimen, not realizing that these behaviors themselves can make weight increase and/or lead to health issues. A colleague of mine calls it “paradigm blindness.” In other words, many people do not realize that their presumed solution to being “overweight” actually exacerbates the condition, so they keep adding more of the supposed solution to the ever-worsening issue.

I used to help (and I use that verb loosely, as I was actually part of the problem even as I thought I was part of the solution) people with weight loss earlier in my career too, but that was before I knew better.

Well-constructed research, my clinical experience, and the experiences of many of my fellow dietitians teach us that weight loss is typically not in one’s control. Sure, our behaviors do matter, but other factors, such as genetics, environment, medical conditions, and personal history, are either partially or completely out of our hands.

The paradox is that any true “Weight Loss Specialist” would know that nobody by that title actually exists. Healthcare practitioners are supposed to help people with, you know, health, which is why Joanne and I take the focus off of weight and instead focus on behaviors that can actually make a difference.

He Said, She Said: Protein

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He Said

Most Americans get more than enough protein. Dietitians think about protein needs in terms of grams of protein per kilogram of body weight (g/kg). For the average person, 0.8 to 1.0 g/kg is perfectly adequate. For a 160-pound individual, this translates to a range of 58 to 73 grams per day of protein. Someone who is extremely active or has elevated protein needs due to a medical condition, such as recovery from surgery, may need more in the range of 1.2 to 1.5 g/kg. Those of us who suffer the misfortune of life-threatening traumas, infections, and burns need upwards of 2.0 to 3.0 g/kg as our bodies fight to survive and rebuild themselves. Under these circumstances, my example of a 160-pound person would need 146 to 219 grams per day during recovery.

So why is it then that we routinely see patients who are feeding themselves as much protein as a hospitalized third-degree burn victim? Among the multiple reasons, the most significant seems to be misinformation that spreads rapidly in our weight-centered society. Those of you who are my age or older have been around long enough to remember the low-fat fad that passed through a couple of decades ago. Just like fat phobia, today’s high-protein craze is based less on science and more on fear and a desperate feeling to grab hold of something, anything, that might be an answer to weight control. Accuracy of said answer is a distant concern.

An excessive protein intake comes at a cost. If we are consuming too much protein, only two possible scenarios exist: (1) We are consuming too few of other nutrients in order to make room for the protein, so we face the risks associated with inadequate intakes of other necessary nutrients. (2) We are still consuming adequate amounts of other nutrients, which means our overall caloric intake is excessive, and we have to deal with the ramifications of taking in more energy than our bodies need. Joanne offers additional concerns in her She Said section below.

When my patients work on building their intuitive-eating skills, oftentimes they discover that they feel better (i.e., greater energy, more regular bowel function, happier mood, etc.) when their protein intakes decrease to the recommended ranges in order to create appropriate room for healthy carbohydrates and fats.

 

She Said

In my work with those struggling with eating disorders, it seems as if protein can do no wrong. Nine times out of 10, my patients find protein to be much more benign than carbohydrate or fat. It is not unusual for a patient to report to me that all she has been eating is vegetables, some fruit, and egg whites/cottage cheese/boneless, skinless chicken breast/fish, while steering clear of bread, sweets, oils, and butter. When posed with the question about why she is avoiding the other macronutrients, the fallback answer is, “Well, protein is healthy for you, and carbs and fats will make me fat, so I don’t eat them.”

The logic behind this assumption is flawed for a few reasons. First, while it is possible to gain weight if one eats too much carbohydrate or fat, the same could be said for protein as well. Excess calories from any macronutrient will result in weight gain (to varying degrees). 500 extra calories of protein equal 500 extra calories of carbohydrate equal 500 extra calories of fat. It doesn’t matter a whole lot where those calories are coming from: If your body doesn’t need that extra fuel, it will store it.

Second, by eschewing carbohydrates and fats, one is losing out on a ton of nutrients. For example, fat-soluble vitamins A, D, E, and K are virtually impossible to absorb if they aren’t eaten in the presence of fat. This means that all of that vitamin A found in your carrots and all of that vitamin K found in your dark leafy greens will pass right through you if you don’t eat them with fat (like that found in salad dressing). Carbohydrates are also a gold mine of nutrients: Whole grains found in many breads, crackers and pastas provide fiber to keep us regular and can help manage our cholesterol levels. Carbohydrates are also the building blocks of serotonin, a neurotransmitter in the brain that is responsible for feelings of well-being and happiness. Protein can’t do any of the above by itself.

Finally, there is such a thing as too much protein. In general, it is recommended that healthy adults take in 0.8-1.0 grams of protein per kilogram of body weight. That translates to approximately 67 grams per day for an average man and 57 grams per day for an average woman. Most Americans get more than enough protein in their diets without cutting back on carbohydrates or fats. What does a typical day of protein intake look like? Well, let’s say you have two scrambled eggs for breakfast – there’s 12 grams of protein already. For lunch, you have a turkey and cheese sandwich – there’s another 32 grams of protein. Dinnertime is fish with veggies – another 25 grams of protein. That amounts to 69 grams of protein, which is more than enough. Many of my patients will confess to having double or sometimes even triple that amount, which is troubling. Excess intake of protein can take a serious toll on your kidneys, as they will work overtime to filter out the byproducts of protein breakdown. What could that mean? Kidney failure.

Protein is a valuable nutrient, to be sure. But overdoing it on any one macronutrient is not only potentially harmful to one’s body; one could be missing out on many other nutrients from other sources.