Tag Archives: eating disorders

The End Is Near!

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

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

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

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

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

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

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

When Family and Friends Lose Weight

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

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

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

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

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

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

The Problem With Fat Shaming Professional Athletes

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

Massarotti: It’s coming.

Felger: It is coming.

Massarotti: It might already be here already.

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

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

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

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

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

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

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

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

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

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

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

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

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

Pancakes

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

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

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

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

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

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

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

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

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

So, what exactly do future dietitians learn in nutrition school?

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Our switch from holding in-person appointments to telehealth has yielded many benefits, one of which is that now nobody can see the various diplomas and certificates that are mounted on my office wall. Having these documents on display makes me somewhat uncomfortable, as it feels a bit like bragging, which is why I only put them up after some patients suggested I should. Looking at them recently, I began to wonder what these framed pieces of paper mean to the people who wanted to see them. In essence, they are just souvenirs from my education, so perhaps interest in them is really just indirect curiosity about my training. So, what exactly do future dietitians learn in nutrition school? The specifics depend on where and when they study, but if my experience is any indication, it probably looks something like this.

The Basics

As an undergrad at Tufts University double majoring in mathematics and English, I had little room in my coursework for science classes. Given that, before I could begin to directly study nutrition at the University of Massachusetts Amherst (UMass), the department required that I take some prerequisites. Therefore, my nutrition schooling started from the very beginning with the most basic biology, chemistry, and physiology courses.

Of these three disciplines, the greatest focus was on chemistry. We had two semesters of general chemistry followed by two semesters of organic chemistry and one biochemistry course, all of which had lab components. When I last studied chemistry in high school, I found it difficult to understand and I consequently struggled. With that being my history, the prospect of having to take these relatively advanced chemistry courses was so intimidating that I nearly backed out of the program on the eve of my first day of classes because I was doubtful that I could succeed. Instead, I plunged myself into the subject. Motivated by intense fear and intimidation, I did everything I could to survive. No matter how well I did, I figured failure was just around the corner, so I had better keep the pedal to the metal. In addition to regularly attending office hours, I went to the on-campus tutoring department for extra review. In my free time, I answered every question in the textbooks, including ones that were not assigned. At the peak of my anxiety, I even sat in on chemistry classes I was not enrolled in just so I could hear the material discussed again and again and again.

In the end, the university gave me a merit scholarship for being one of the top three organic chemistry students out of approximately 600. Given my history with the subject and how hard I worked, receiving this award was one of the proudest achievements in my life. However, all that knowledge has played virtually no role in my work as a dietitian. Sure, I can explain the chemical structures of sugar alcohols and omega-3 fatty acids, why some fats are solids at room temperature while others are liquids, and how a bomb calorimeter works, but these skills make me no better of a clinician than a colleague who cannot do these things. Hopefully, chemistry requirements have scaled down in the years since I was a student, as my curriculum could have easily included less chemistry without negatively affecting my abilities as a practitioner.

Food Service

If you had no idea that many dietitians end up working in food service management, then you are in good company, as I had no idea about that either before I started nutrition school. To prepare us for this possible career track, the department had us take two courses in the hotel, restaurant, and travel administration (HRTA) program and two more in the management school.

Sometimes I contrast the difference between the random bits of information that have stuck with me from a course versus what I imagine those in charge of my education hoped I would retain. From the first HRTA course, I recall learning what a physical hazard is, how baby carrots are made, and that a successful coastal New England restaurant was thriving because of their choice of oven. All I remember from my human resource management course is working my ass off to show our professor – who warned us at the beginning of the semester that she does not give out As – that, actually, she does.

My second HRTA class made more of an impression, as it was a hands-on course that had us working in a semi-mock restaurant. We prepared and served real food to real customers, but no money changed hands because free food was their reward for being our guinea pigs. Joanne could tell you that whenever we meet someone who works in a restaurant, I pepper them with earnest questions that reflect my curiosity, such as how many eggs their diner goes through in a day. Given that, I thought this course was fascinating. We devised menus, planned theme meals, and rotated between all jobs in both the front and back of the house. Never having worked in a restaurant before, this was my first time being the target of the rudeness that some customers – even those who were eating for free and knew students were running the show – inflict upon those who wait on them.

Nutrition

And finally, the nutrition coursework itself began. The most basic class, Nutrition 101, was a survey class about the profession. This is where I learned that the term “nutritionist” has no legal definition, and anybody can call themselves one. The professor told us a story about someone who took an online test and received a nutritionist certificate – for their dog. One of my classmates announced to everybody that she was studying nutrition because she wanted to become a millionaire by inventing a fad diet.

Meal management and scientific principles, otherwise known as Nutrition 210, was an interesting course in that it included a lab component. Our experiments involved making several versions of a recipe and tweaking a variable, such as an ingredient or a preparation technique, to see how the changes affected the finished products. For example, we broiled, poached, and microwaved flounder fillets and then compared the texture and flavor of the cooked fish. We counted how many chews it took to sufficiently masticate pieces of top round sirloin prepared with a variety of tenderizers. My friend and I gave a group presentation on artificial sweeteners in which we compared popular myths versus what actual scientific research had found.

Nutrition 230 was a basic nutrition course in which we discussed the chemical structures, functions, and metabolism of various nutrients. Our professor told us that one of the reasons she chose a career in nutrition is because whenever she meets people, such as at a party, they are always interested in what she does. In contrast, many of our colleagues (including myself) try to conceal what we do for work because the follow-up questions – which are almost always based on myths and incorrect assumptions about our profession – can be frustrating and exhausting to answer.

A few years ago, I emailed my former Nutrition 352 professor, who has since been promoted to an associate dean, and let her know that my greatest regret from nutrition school is having sold my textbook soon after completing her life cycle nutrition course. Despite my two part-time jobs as a personal trainer and an assistant to the university’s food service dietitian, money was tight, and I felt I could use the cash more than a leftover textbook. Besides, I did not imagine that all these years later I would still be having occasions in which I want to refer back to it, yet that has turned out to be my reality. Fortunately, the Academy of Nutrition and Dietetics’ online Nutrition Care Manual contains a section on pediatric nutrition, which has somewhat filled the void, but I still wish I had that textbook.

Nutrition 572, community nutrition, is where I began to understand that food scarcity is not some abstract notion or one that only afflicted our ancestors and people in faraway lands, but rather one that is still a reality for many of our neighbors. One of our assignments was to go to the grocery store and design a diet that would nutritionally satisfy the Dietary Approaches to Stop Hypertension (DASH) diet while also financially satisfying the Thrifty Food Plan’s allowance of $4.37 per day. Even with my math background and nutrition knowledge, I could not do it, as the closest I could come was $4.77 per day, still $0.40 over budget. This course helped me to appreciate the impacts that financial limitations and food availability can have on health. The simple truth that people can only buy what they can afford and is accessible to them sounds so obvious now, but it took studying community nutrition for me to really get it. When I rode my bicycle from Seattle to Boston that summer, I made a point to visit the grocery stores on the Native American reservations that I passed through, as I wanted to understand the options available to the residents of these relatively isolated communities. Had I not taken community nutrition, I am not so sure I would have had the same level of curiosity.

In Nutrition 577, aptly titled nutritional problems in the United States, we studied the impact of nutrition on some of this country’s most common health concerns, such as cancer, diabetes, cardiovascular disease, and osteoporosis. Our professor was excellent, perhaps the best I ever had in nutrition school. She expected a lot from us, and she held herself to the same standard. She was also fat. While I did not judge her for her size, I remember perceiving that it was awkward for her – a nutrition expert in a bigger body – to teach us about “obesity.” Whether it was her or one of the other faculty of a similar build in our department, I cannot recall, but I do remember one of them explaining how difficult it was for them to be taken seriously because of their size. Many years later, this seed grew into a conference presentation I gave entitled “‘Looking the Part’: Patients’ Size-Based Biases Towards Their Practitioners and How to Handle Them.”

Medical nutrition therapy, Nutrition 580, was where the rubber met the road. We learned how to utilize the nutrition knowledge we had thus far accumulated and apply it to treating a wide variety of medical conditions. What stands out to me though are not the disease states we learned about, but rather some key ones that were omitted, namely eating disorders. Each of us had to research a disease (Mine was chronic pancreatitis.) and present to the class about it, and if not for another student’s brief presentation on anorexia nervosa, I would have gone the entire way through nutrition school having learned literally nothing about eating disorders. Maybe I am just biased because I now specialize in treating eating disorders, but it is hard for me to fathom that such an important group of illnesses that affect so many people was barely even mentioned.

Speaking of missing curriculum, the only counseling course we had was Nutrition 585. Of course, learning about the hard science of nutrition is important, but if dietitians are unable to effectively convey their knowledge to patients, then the information is moot. Before finishing nutrition school, I was already of the opinion that students (and therefore their future patients) would be better off if the required coursework focused less on the hard sciences, particularly chemistry, and more on counseling skills. My professional experience has only strengthened this stance.

My final course in the department was Nutrition 731, nutritional assessment. During my presentation on anthropometric predictors of cardiovascular disease, I demonstrated how hydration status introduces a source of error into bioelectrical impedance device readings that estimate body fat percentage by using such a device on myself at the beginning of my talk, then putting on a bunch of extra layers of clothes and giving the bulk of my presentation while riding an exercise bike, and then using the device again after having worked up a sweat.

Outside the Department

While taking the aforementioned nutrition courses, I also took classes in other departments, such as energy metabolism in the exercise science department. One of my takeaways from this class is just how difficult it is to design research studies that yield definitive answers. For example, our professor was confident that walking a mile and running a mile require the same caloric expenditures, but he could neither confirm nor reject this hypothesis because he could not design a study that would adequately control for all the confounding variables. He was also the first person to introduce me to the “fat-but-fit” concept, which is that someone can be both healthy and live in a bigger body.

The microbiology course I took in the food science department centered on foodborne illnesses. We learned about salmonella, staph, spores that survive cooking and freezing, and other scary things that to this day continue to make me think twice about some potential eating decisions. All these years later, I am still not brave enough to roll the dice with fried rice.

My psychology course was an introduction to the field’s basics with a focus on the nervous system’s structures and physiology. One of my takeaways was how important dietary fat is for maintaining the myelin sheaths that insulate our neurons and enable rapid transmission of electric impulses.

The nutrition program required some other courses that I was able to place out of due to my previous studies. For example, my English degree got me out of their nutrition and writing course, and my math degree similarly meant that I need not bother taking statistics. The child development course I took at Tufts enabled me to skip the same class at UMass.

Although I was fairly certain that I wanted to be a dietitian, I toyed with the idea of becoming a physical therapist, so I took some additional physics and anatomy courses that were prerequisites for physical therapy programs just to cover all my bases. Learning about anatomy was interesting, not so much because of the subject matter itself, but because it taught me the importance of speaking a patient’s figurative language. With my personal training clients most comfortable with colloquial terms like “chest” and “quads,” knowing the scientific names of hundreds of body parts proved fairly useless, and the knowledge soon escaped me.

Internship

Now you know what it took to earn the nutrition degree on my wall. One of the other significant documents that hangs near it is from my dietetic internship, which is somewhat like a future doctor’s residency and must be completed before dietitians-to-be can sit for their registration and licensing exam. Because this blog is already so lengthy that pretty much everybody has stopped reading by now (Hi, mom!), I will save discussing my internship until another time.

Continuous Glucose Monitoring

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

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

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

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

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

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

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

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

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

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

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

“As long as you’re healthy . . .”

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“Health.” It’s a simple one-syllable word with a deceptively simple definition: “the state of being free from illness or injury.” What I have come to realize over the decade-plus that I have been practicing nutrition therapy as a registered dietitian is that health means many different things to different people. Health is not black or white, but a million shades of gray. But the wellness industry (diet culture’s shapeshifted cousin) would have us believe that health is not only easy to define and simple to identify, but also easy to achieve, if we just try hard enough. Well, sorry, it’s not that simple.

When I was a preteen, I remember feeling like my body was wrong, too big, taking up too much space. My mother and I would go to my pediatrician appointments, where my doctor would hem and haw about my weight. I had always trended on the 95th percentile on growth charts, and every year my pediatrician would comment on it in a concerned way. My mom would echo these concerns at home, gently reminding me that my doctor was worried for my health. When I would cry to my mom about being in a larger body than my peers, she would always come back to this statement: “You are a beautiful girl. We could make some changes to how you eat and exercise. I just want you to be healthy.”

“I just want you to be healthy.” These words ring in my ears as they have been spoken to me in different iterations throughout my life. From concerned college friends after I had gained a significant amount of weight during my freshman year (post diet, of course): “We are just worried about your health.” From my first adult PCP when I was 22 years old: “We just want to make sure you are healthy.” From my mom when I announced that I would be going on a low-carb diet at age 25: “as long as you’re healthy!”

Everyone seemed to say that my health was the most important thing and that being healthy meant being in a “healthy-looking” body. When I actively engaged in dieting, restricting, tracking every morsel, weighing myself multiple times a day, exercising even when I didn’t feel like it or was sick or injured, eschewing lunch outings with friends, losing my period – during these times, everyone marveled at how “healthy” I was. “It’s so nice to see that you are finally taking care of yourself!” my family would crow. “Keep going, get healthy!” my doctor cheered. Little did they know the personal hell I was living in. But at least I “looked” healthy. Or at least my body fit the social norm for what we collectively believe is healthy, i.e., it was no longer considered fat. But inevitably as the weight would come back on, the concerns for my health would resurface.

When I finally gave up on dieting and learned about Health at Every Size® and intuitive eating, I was ready to hear the message. At last, I didn’t need to micromanage my intake and output. I didn’t need to obsessively count and weigh and measure. I didn’t have to give lunch outings with friends a second thought. It was like a freedom I hadn’t felt since I was a child, before I was told that I had a body that was “wrong.” I began to realize that health is not one-size-fits-all and that it looks different for different people. With individuals who have chronic illnesses such as celiac disease or cystic fibrosis or those with physical disabilities such as paralysis or amputation, they would never be able to achieve a state of being “free from illness or injury.” How about the millions of people who deal with depression or anxiety? Are they unable to achieve health as well?

I feel that we need to change our beliefs and expectations around health. In my opinion, health is a multifaceted amorphous concept that is not always attainable. It is also something that changes during our lifespan for a multitude of reasons. Even if we engage in all of the “health-promoting behaviors” we have been told to do, there is no guarantee that we will be healthy. In addition, there is no moral requirement for us to engage in these behaviors. As the wise Ragen Chastain so eloquently states: “Health is not an obligation, a barometer of worthiness, completely within our control, or guaranteed.”

The wellness industry loves to prey on our fears of illness and death. It purports to give us the answers to living longer, healthier lives. All we need to do is buy their program, supplement, or detox, and we can unlock the secret to immortality. It’s a brilliant marketing scheme that swindles millions upon millions of people every year. What if we decided to care more about our mental health and wellbeing? What if we made healthcare accessible to everyone? What if we eradicated weight stigma from the medical field? What if we decided that health doesn’t look the same on every body and that this is okay? My guess is the wellness industry would lose billions of dollars. Worrying about and obsessing over our “health” is most definitely not good for us. I wonder when our society will figure this out.

Weight Stigma in Healthcare Harms Us All

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The following is a guest blog written by Deirdre, who has given us permission to use her real name.

All my life, I’ve been sick. I can remember being five years old and waking up in the morning sobbing because my eyes were swollen shut, I could not breathe, I was always tired, and had severe skin conditions and rashes all the time. I had to go on nasal sprays, steroids, oral allergy medicines, and eye drops almost year-round from that age. Around the age of 14, I started to present with vomiting up bile every single solitary morning before proceeding with my day. Despite complaining to doctors all my life about all these things, I was ALWAYS considered healthy. The number one indicator for doctors? I was thin. I always had a “healthy” BMI, and all my bloodwork looked good, so nobody ever took me seriously.

Fast forward another decade. At this point, my body was so inflamed from consuming gluten – a protein which I later found out I was severely allergic to all along – that I had gained a significant amount of weight. I was 24 years old at this point, vomiting and having diarrhea after every single meal, suffering with mental illness (depression and anxiety, some from trauma but also largely because I *never* felt well and had no choice but to press on), smoking cigarettes constantly to suppress my appetite, abusing Adderall to suppress my appetite, exercising excessively (3-5 mile runs, 10 on weekends, and 2-hour workouts daily). Doctors still would not listen to me.

When I was thin, my health complaints were ignored because I was thin. When I was big, my health complaints were ignored because I was big. This is how weight stigma harms people of all sizes. When doctors are trained to view the BMI as such a strong indicator of our health, they tend to miss out on treating the whole patient and the concerns they are actually presenting. In this way, fatphobia continues to dominate our medical fields in the most insidious ways, regardless of a patient’s size.

When I was younger, I felt like my only sustainable solution was to put restrictions on my eating. I felt like I needed to do everything in my power to just not really eat. The only thing that ever felt good to me was mint chocolate chip ice cream. It was the one food that never made me sick. I ate a pint of it nightly, then would feel guilty, throw up the next morning involuntarily, feel good about that because I was disordered in my eating habits by then, and the cycle of “weight management” continued to wreak havoc on my life and destroy my gut health, self-esteem, and brain chemistry.

At 25, I was accepted to my dream graduate school for my health degree, and thus I was always in Boston. This meant finally seeking out primary care at Fenway Health and getting a fat-positive, conscious, and compassionate doctor for the first time in my life. Dr. Karen Kelly literally saved my life, as I know I would have attempted suicide that year if I had not met her. I was at my wit’s end.

Karen’s team allowed me to face away from the scale when they took my weight. I told Karen all the symptoms I’ve always had. She referred me to an incredible gastroenterologist who finally listened to me and tested me for a bunch of autoimmune gastroenterological diseases.

Notice that only now, because I finally was seeing a fat-positive doctor, was my weight looked past in order for me to receive the care I truly needed. My current health care team, including Karen, is amazing. It is a shame that all the doctors I ever saw prior assumed that being thin meant I was healthy. That mentality destroys a doctor’s ability to see clearly, and my chronic autoimmune disease was completely missed for 25 years as a result. If my celiac disease had been caught sooner, it could have meant avoiding severe damage to my organs, and possibly even reduced my chances of long-term health implications. Now I have to live with whatever damage has been done.

More and more public health research is finally showing that fat people can be healthier than thin people. More and more people are catching on that the BMI as a marker of health is a limited, archaic, outdated, weak, inaccurate, and frankly incredibly lazy way to approach medicine. It is a way for doctors to not do their jobs. All doctors should first and foremost be researchers and scientists listening, looking, and hypothesizing with open minds. I am almost the heaviest I have ever been now, yet my cholesterol, blood pressure, oxygen, etc., are all fantastic.

The concept of weight management is a barbaric and inhumane way for any doctor to practice. One hundred years from now, we will look back at the ways we tried to force mutilation on humans through diets and bariatric surgeries and see the oppressive reality of that kind of hatred of fatness. Doctors that focus on “weight management” and miss what is really going on need to start being held accountable – sued and fired by their patients.

I think that numbers are detrimental, and so is excessive monitoring of size and shape. We came here to live in these sacks of skin as vessels for our non-physical selves, our souls, and nothing more. The BMI is bullshit and was invented by an astronomer in the 1800s who only used white Anglo-Saxon males in his sample size. BMI does not account for muscle mass, bone density, or genetics. It does not leave room for all the boobs and butts and hips our bodies create to cushion us or to grow or feed our babies.

Someday I will have chapters in a book titled “the BMI is racist,” and “the BMI is sexist.” Once I am a doctor or nurse practitioner, I will create a new tool for epidemiologists to test that will actually be inclusive of all sexes, genders, races, etc., without poisoning our minds with self-doubt and self-mutilation.

If I had unbiased doctors all my life, I may have been diagnosed with celiac disease much earlier on and could have potentially saved myself from having cancer or infertility someday. I hope to live a long life and to have children and grandchildren, and I hope to leave them in a world with less weight stigma and more active listening, especially in the field of medicine.

Outer Limits

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A little over six years ago, I wrote a blog entry in which I attempted to rebut the notion that discussing topics other than food in our sessions somehow qualifies as psychology. In reference to intuitive eating, I wrote, “What does it say about how disconnected our culture teaches us to be from our internal signals regarding eating that an approach that encourages us to pay attention to said signals triggers connotations of therapy?”

After reading the blog, a friend of mine – a clinical psychologist himself – offered something along the lines of, “Maybe the reason your work is effective is because you include some psychology.” No, I bristled. Staying within my scope of practice is important to me, and certainly anything that qualifies as psychology is beyond what a dietitian can offer, I reasoned.

Given that, I have occasionally second-guessed myself when conversations with patients have strayed into more distant orbits around food. On one hand, I have tended to listen to my instinct to prioritize what my patients want to discuss and to follow the natural flow of conversation so long as what we are talking about ultimately relates to their eating. On the other hand, when conversations become less about nutrition and more about things like body image, weight stigma, or even happenings in someone’s life that are tangential to their eating, I have worried that perhaps I have inadvertently crossed the line from where a dietitian’s work ends and that of a therapist begins.

Then along came a session at the 2021 Multi-Service Eating Disorders Association (MEDA) conference that alleviated my worry and helped me to see the matter in a different light. In their talk, entitled “Staying in Your Lane – Until You Can’t: Balancing Scope of Practice and Competent Client Care,” Anna Lutz and Sandra Wartski, a dietitian and psychologist, respectively, delved into the issue of professional bounds.

One of the most validating concepts that I took away from their talk is that there is no crisp line separating the work of the two professions, but rather there is an overlap, a gradient that bleeds from one realm of expertise into the other. In other words, some topics, such as weight stigma, are appropriate for discussion with both a dietitian and therapist, and each practitioner can bring different perspectives that hopefully complement one another.

Furthermore, scope of practice is amorphous, fluid, and depends on context, such as an individual patient’s needs at a specific moment in time and the practitioner’s own comfort level. Sometimes a patient is unable to address the work at hand, and simply having a human connection is more constructive. Anna gave an example of a time when a patient was too preoccupied with other matters to discuss food, something I have experienced with patients of mine on occasion, so they spent the entirety of their appointment talking without ever discussing the patient’s eating.

Having said all that, scopes of practice can only stretch so far. If a patient raises an issue that is beyond my ability to expertly handle, such as a disclosure of trauma that they are hoping we can process together, I am responsible for making my limitations known. Similarly, a good therapist knows better than to delve into the specifics of nutrition. Part of the reason why collaboration between treatment team members is so important is because we can let each other know when something comes up that is better handled by the other practitioner.

For me, their talk validated my intuition and reassured me that the way I approach my work is well within my professional bounds. For our patients who are reading this, I hope hearing about their session resolves any lingering questions you may carry about possibly having overshared and similarly serves as encouragement to remain open going forward.

 

The “T” Word

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“You run into that more than I do. All of my patients are already in therapy.”

That is how Joanne responded when I suggested that she write a feature about the challenge of helping resistant patients in need of therapy to agree to go. Apparently, the responsibility of writing about the topic then falls on me, and appropriately so, I suppose, for I do run into this issue quite often on my side of our practice.

Joanne rarely runs into this dilemma because she focuses exclusively on eating disorders, and by the time a patient makes their way to her, the importance of a complete treatment team – a dietitian, a physician, and yes, a therapist – has usually been explained and emphasized to them at some point already.

In contrast, while eating disorders are similarly my area of specialization, I also help people with other conditions, such as high cholesterol and hypertension. As such, I tend to attract patients who view – or want to view – their challenges as superficial food issues even if it quickly becomes apparent to me that something deeper is at play.

That brings us to a critical juncture in our work and often a difficult conversation. How do we emphasize the importance of therapy while remaining sensitive to the reality that we live in a society that stigmatizes mental health issues?

Well, we do just that. We talk about the upsides of therapy as well as the patient’s thoughts, questions, and concerns, including any hesitations they might have. Oftentimes we also talk about the stigma because I think it is important to bring out into the open the reality that a therapy referral comes with a connotation that would not arise if I were suggesting someone meet with pretty much any other kind of specialist.

Sometimes patients are hesitant to disclose their true reasons for not wanting to go to therapy, or maybe they have trouble putting their fingers on what their reasons are, but they know they do not want to go. “It is not worth the time,” “I do not hate myself,” and “I have friends I can talk to” are some of the superficial reasons patients have told me. Time, trust, and continued conversation are sometimes necessary for us to get to the point of having a candid discussion about whatever their hesitations really are.

A common sentiment I hear is, “I think I want to start with just a dietitian.” Earlier in my career, I had a peer supervision leader who refused to work with a patient with an eating disorder unless they were also in therapy, a policy that I then adopted. Eating disorders are mental health issues that play out through eating behaviors, so while they affect nutrition, they are not directly nutrition issues. The dietitian’s roles are to provide nutrition support (if applicable) and to help the patient form a new and healthier relationship with food as the disorder recedes. However, because eating disorders are mental health issues, the bulk of the recovery does not happen with a dietitian, but rather with a therapist. Without this key member of the treatment team, the patient’s chances of recovery drop so dramatically that some dietitians, including my peer supervision leader, feel it is unethical to work with someone who refuses therapy.

In the last few years, as a result of conversations I have had with other colleagues, I have reversed course. The rationale is that if I terminate my work with a patient who refuses therapy, then they are left with nobody to help them, but if I continue working with them, then at least they have me in the meantime, and, hopefully, they will become more open to the idea of therapy as time goes on.

As dietitians continue to debate this issue, my own ambivalence oscillates from one side to the other and back again, and I have no idea what my policies will be in this regard down the road. What I do know, and what dietitians who specialize in treating eating disorders agree on, is that therapy is essential for recovery.

Therapy can also be immensely helpful for some patients without eating disorders, too. One of the most interesting aspects of nutrition work – but also one of its greatest challenges – is the wide array of factors that influence the decisions we make regarding what, when, and how much to eat. Many examples, such as low self-esteem or a poor relationship with a close family member, can significantly affect eating behaviors, yet are largely beyond my expertise to treat alone. The boundary of my scope of practice bleeds into that of mental health professionals, who can effectively address these deeper issues and free people up to form healthier relationships with food.