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.

Praising Adele’s Weight Loss Is Fatphobic

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The following is a guest blog written by “Sarah,” a nurse practitioner in the Boston area, who strongly believes in utilizing Health at Every Size (HAES) and anti-diet approaches in both her personal and professional lives. She has been Joanne’s patient for about six years and is in recovery from an eating disorder.

It is no secret that our current society is obsessed with physical appearance. The perceived attractiveness of a person very much determines how they are valued, respected, and treated. This is especially true in regard to women, and to an even further extent, celebrity women. 

At this point, I am sure most of you have come across recent media stories of renowned singer Adele’s dramatic weight loss. After an Instagram post from Adele of herself in a form-fitting dress, with a caption giving a mention of her birthday and a shout-out to the first responders in the midst of the COVID-19 pandemic, comments swarmed in that had nothing to do with what she actually wrote. Now there were some comments that highlighted the fact that we should be praising Adele for her immense talent and not her appearance. Five or ten years ago, some of these comments would probably not have existed, and therefore that does highlight the progress we have made in rejecting diet culture and in the public knowledge of this movement. However, the majority of the comments praised her new, thinner, more “acceptable” body. 

Now I want to make it clear that I know absolutely nothing about Adele as a human, including her diet or exercise regimen. It is truly none of my or anyone else’s business what Adele decides to do or not to do in regard to her body. Even as someone who fully believes in HAES and is very anti-diet, if Adele did intentionally seek a smaller body, I can’t say that I blame her. Our world is a hostile place for those of us living in marginalized bodies. If you are fat, disabled, trans, poor, non-white, or any iteration of these, you are subjected to discrimination and othering. Therefore, it is no wonder why one would want to attempt to fit into a more socially respected body. 

I would normally say that it is unfair to assume anything about Adele’s means of attaining this new look, but in recent articles, she does discuss a particular diet of a VERY scary low number of calories (*trigger warning) and a rigidly structured exercise plan. Again, it is no one’s business how Adele decides to treat her body, but by the DSM standard, there is no question that she would be diagnosed with an eating disorder. I recognize that this is more of a systems issue, and those who mean well by praising her new body are operating under a fat-phobic structure. While eating disorder behaviors are considered concerning when the individual is thin, these same behaviors are encouraged for those who are in larger bodies. It is what we are taught and how we operate as a culture; it is no wonder that full recovery from eating disorders is so challenging (and oftentimes unachievable).

Now let’s get down to the real issue and meaning behind Adele’s weight loss (which really has not much to do with her at all). Body autonomy is part of the HAES movement, and I fully stand behind this for Adele or anyone else. It is the mere fact that a single picture can prompt so many comments (positive or negative) about one’s body that is the core issue here. 

The focus by others on a changing body, in a positive or negative way, often keeps people from recovering fully. If we lived in a world where a body was just a body regardless of how large or small it became, this would not even be a topic of conversation. Although it is an inevitable fact that bodies fluctuate for various reasons throughout the lifespan, we cannot seem to accept this as a society. Naomi Wolf stated: “A culture fixated on female thinness is not an obsession about female beauty, but an obsession about female obedience. Dieting is the most potent political sedative in women’s history; a quietly mad population is a tractable one.” Diet culture and fatphobia are the prime examples of this. We are taught that our worth depends on other people’s evaluation of us and that how our body looks to others matters more than how it feels to us. Especially as women, we are taught that making others happy is more important than making ourselves happy and that the most important thing is that others will like and approve of us, and therefore it is no wonder that we constantly rely on external validation to prove our worth.

Being fat and/or gaining weight is seen as the ultimate failure, and there is countless evidence of this belief expressed throughout history. We see and hear examples of this in our everyday lives, whether we recognize it or not. It is more common knowledge these days that “diets don’t work,” but we have yet to make significant progress in the idea that one’s body does not determine their worth. That is not to discredit all of the amazing progress that the HAES community has made, and as someone in a straight-size body, I cannot speak to the true experience of someone living in a larger, marginalized body. However, as a woman living in constant recovery from an eating disorder, I can say that the fear of weight gain has held me back in so many ways throughout this journey. Fatphobia truly affects everybody (whether they realize it or not) but is much more pervasive for women. 

I now know that these are reactive thoughts stemming from decades of diet culture brainwashing and the instinctual need to belong as a human. These messages have become even louder throughout the COVID-19 pandemic. Not only are we separated from many of our in-person support systems, dealing with real threats to our health and vitality, but we are relatively stuck at home with our thoughts. Although I do truly believe sitting and ruminating in these thoughts and fears can lead to growth in so many ways, it is also extremely triggering. We have less access physically and maybe financially to certain foods, and this can be triggering in itself.

To add to this, those who suffer from eating disorders and also live in larger bodies are especially vulnerable given the extreme fatphobia that knows no boundaries. There have been countless news articles claiming that people living in larger bodies are more susceptible to COVID-19. Not only is this untrue, but it is incredible healthism and just another example of diet culture profiting from our fears. Attempting to change one’s body size in the hopes of health and immortality has never worked in the past and scientifically never will. It is disappointing that these messages of blame and shame are being touted instead of compassion, inclusivity, and actual scientific facts, especially during this time. 

So how do we begin to change as a culture? By recognizing that beliefs and facts are not the same. By rejecting diet culture and recognizing that our body size or health status has nothing to do with our worth as humans and by treating others with respect and dignity just because they exist. As the wise Ragen Chastain said best: “Health is not an obligation, barometer of worthiness, or entirely within our control,” and this could not be more relevant in our current climate.

“Sometimes I want to binge so bad.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Kids Are Alright

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Weight Watchers, I won’t call you by your new convenient moniker “WW” designed to try to fool the public that you aren’t all about the weight. You might try to kid yourself into thinking that you are just about “wellness” and that the goal of weight loss is just a byproduct of a “healthy lifestyle change.” Nope. It’s just the same crap in a slightly different package. Any way you slice it, the only thing you care about is your bottom line, not helping your customers get healthy. If you really understood health, you would realize that a lifetime of weight cycling, weight stigma, and self-loathing are far more damaging than just staying fat. 

Weight Watchers continues to spread the lie that intentional weight loss is attainable if you just try hard enough. And if you fail at maintaining your weight loss, you, not the diet, are to blame. Bull. If your program worked, you’d be out of business. Even your former financial director Richard Samber stated as much in an interview, explaining that repeat customers are “where your business comes from.”

Where is the evidence that Weight Watchers “works” anyways? The company is famously close-lipped around their long-term success rates. In fact, they cannot demonstrate that anyone, save for a measly tiny percentage of dieters, can keep off the weight they lose for more than five years. And those who do manage to keep the weight off often use disordered eating and exercise behaviors to do so.

Intentional weight loss endeavors, whether they are through Weight Watchers or any other diet or “lifestyle change,” fail 90-95% of the time. Yet our medical community continues to push weight loss on fat patients, telling them that they are at risk of death if they don’t lose the weight. For myself and many other fat people, going to the doctor can be an anxiety-inducing experience, as we are often met with weight stigma and advice to stop eating so much (even if that’s not what’s going on). Many fat people I know just avoid going to the doctor altogether to avoid this weight shaming. Is that health-promoting behavior? I don’t think so.

The notion that weight loss is achievable and maintainable is one of those common beliefs that is put forth by diet culture. Diet culture tells us that being fat is inherently unhealthy and unappealing, that those of us who cannot lose weight are lazy, inept, unintelligent individuals who just aren’t trying hard enough. Diet culture glosses over all of the research that shows how and why our bodies fight like hell against losing weight. Diet culture ignores the facts that repeated dieting and yo-yoing is actually much more physically harmful than just maintaining a higher weight and that shaming fat individuals is not helping anyone but is taking a toll on all of our health and well-being.

Weight Watchers’ latest endeavor, launching an app that targets children aged 8-17, makes my blood boil. In the iconic words of John McEnroe, you cannot be serious, Weight Watchers. Never mind all of the eating disorders that this app will help to create and/or encourage; this app contributes to the weight stigma that plagues our society. It reinforces the idea that being fat is a bad thing and that it must be avoided at all costs. It fosters a feeling of shame in heavier kids, a feeling of being “less than.” 

As a chubby (not fat) child, I was repeatedly told by my pediatrician and my family that my body was wrong. These messages and the messages I got from diet culture led me to develop disordered beliefs around food, exercise, and my body. It wasn’t until I found Health at Every Size that I finally figured out that my body is not to blame. My body doesn’t need to change. Our weight-shaming culture needs to change. And I am honestly scared for the legions of kids and teenagers who are exposed to this toxic culture.

Weight Watchers’ app will teach kids that they cannot trust their own bodies, that their own bodies are damaged or ill-equipped to tell them what and how much they need to eat. This app will create lifelong struggles for these kids, who likely will have a disordered relationship with food and their bodies for the rest of their lives. I cannot even wrap my mind around the amount of psychological and physical damage this program will cause. 

I don’t know if it’s the fact that I have a daughter myself now that this is striking such a chord with me. I fear for her. I don’t ever want her to feel like she needs to make herself smaller to be loved, accepted, or healthy. I don’t want her to spend her life trying to change her body and fear its appetites. I want her to be confident in her body, to trust that it will tell her what it needs, and that her weight is not the measure of her worth. 

So, Weight Watchers, I hope this program fails and you disappear into the ether sooner than later. 

Macy’s

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This month, Macy’s found themselves in hot water for selling plates, made by Pourtions, that many people criticized for encouraging eating disorders and fat shaming.

One of the plates, for example, features three concentric circles, the smallest of which is labeled “skinny jeans,” while the middle one reads “favorite jeans,” and on the largest of the three circles is emblazoned “mom jeans,” insinuating that the bigger the portion, the larger the pants size.

According to Huffington Post, Mary Cassidy, Pourtions’ president, explained, “Pourtions is intended to support healthy eating and drinking. Everyone who has appreciated Pourtions knows that it can be tough sometimes to be as mindful and moderate in our eating and drinking as we’d like, but that a gentle reminder can make a big difference. That was all we ever meant to encourage.”

Her company’s intentions do matter, for if they had purposely intended harm, then this would be a very different matter, but the impact remains the same whether their actions were malicious or an attempt at humor that missed the mark.

“These expectations can actually kill someone, and I know someone it has,” read a tweet from one responder, who elaborated that the plates spread a “toxic message, promoting even greater women beauty standards and dangerous health habits.”

Eating disorders are serious business. They can wreak havoc on one’s health, family, career, and life in general. And yes, they can be fatal. Additionally, they are more common than many people realize.

“As we all know, pressure to be thin leads to dieting, which can lead to a variety of problems, including eating disorders,” I wrote in the April 2016 issue of Boston Baseball. “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,” which is a large section in the bleachers behind the Red Sox bullpen.

One does not even have to have a diagnosed eating disorder to be suffering the effects of diet culture and weight stigma. We see plenty of disordered eating which can be comprised of a constellation of symptoms, such as a strong good/bad food dichotomy or feelings of guilt and virtue associated with eating behaviors, that does not meet the diagnostic criteria for a specific eating disorder but can be just as disruptive and dangerous.

When we work with people recovering from eating disorders and disordered eating, we help them to uncouple judgment from their eating behaviors, and part of this work entails exploring where they learned such judgment in the first place.

The judgments implied by the Pourtions plates are so blatant that they are self-explanatory, but sometimes the message is more subtle. For example, Trader Joe’s has a line of “reduced guilt” products, such as their low-fat mac and cheese, which implies increased guilt for its full-fat counterpart. One might argue that the “reduced guilt” tag is a tongue-in-cheek marketing gimmick and is not to be taken to heart. Perhaps, but messages like these – whether in your face or toned down – are so commonplace that they are insidious.

Honoring internal eating cues is difficult to do in a society with pervasive messages that our bodies are not to be trusted. We have 100-calorie snack packs, for example, that people often utilize in an attempt to limit their consumption via an external control – in this case, the pre-portioned quantity – but the implication is that 100 calories is the correct amount to consume, that it should be enough food. In some cases, it will be, but 100 calories is an arbitrary amount of energy, and chances are low that it will just so happen to match up with someone’s hunger/fullness cues. If someone gets to the bottom of the bag and yet they are still hungry, the dissonance between their body saying, “Hey, I need more food,” and society saying, “Hey, you have already eaten enough,” is confusing and stressful.

The small print on food labels reads, “Percent Daily Values are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs,” but time and time again, I have patients who believe they should be consuming 2,000 daily calories because food labels imply that this is the standard amount for an adult human. They then have difficulty making sense of their bodies asking for more food than that and feel tempted to restrict in an effort to match the label.

While I am not advocating for the abolition of food labels or snack packs, we have to consider the gap between impact and intent and realize that these tools might not actually be as helpful in reality as they seemed in their creators’ imaginations.

To Macy’s credit, they took the feedback they received to heart; seemingly realized that despite the humorous intent of the Pourtions products, the reality is that the plates are offensive and send harmful and dangerous messages; and consequently stopped selling them.

The Natural Purple Pill?

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At this year’s Cardiometabolic Health Congress, a cardiologist I will call “Dr. Q” began his nutrition presentation with a factoid: 90% of cardiologists reported zero or minimal nutrition education, yet 95% of them felt it was their personal responsibility to discuss it. Meanwhile, 61% of the public thinks that doctors are “very credible” sources of nutrition information.

In other words, we have doctors who do not know what they are talking about talking about it anyway, and patients are listening and trusting them because they are doctors.

He called blueberries “the natural purple pill” and cited research showing that 93,600 women who were studied over 18 years and who consumed three servings of blueberries per week throughout the study had a 34% reduced risk of a myocardial infarction. He then flashed a slide listing the dozens of known chemical compounds in blueberries, asked how we know which nutrient or combination of nutrients is responsible for the benefits, and answered his own question with, “I don’t think any of that really matters,” intimating that the bottom line is that blueberries offer health benefits.

But the underlying mechanism absolutely does matter. He assumed a causal relationship between at least one of the chemical compounds and reduced risk of heart attack, but the relationship between blueberry intake and heart attack risk could also be correlation. For example, the real factor at play might not be some minute compound, but rather money.

Relative to other fruits, blueberries are incredibly expensive. According to data I obtained from Peapod.com, blueberries cost $0.44-$0.64/oz. (depending on the size of the container purchased), which exceeds apples, grapes, melons, strawberries, and all other fruits I examined except for pomegranate seeds ($0.63/oz.) and raspberries ($0.56/oz.)

Could it be that the women in the study who could afford to eat blueberries three times a week also had other financial advantages that enabled them to take better care of themselves, such as the ability to absorb higher insurance costs for office visits and testing, health club memberships, time off from work or no work at all, massages, and psychotherapy?

On the flip side, you know who is probably not splurging on blueberries or able to engage so extensively in taking care of their health? Those working multiple jobs just to get by, those living paycheck to paycheck, those suffering from food scarcity, those relying upon the Thrifty Food Plan, and those who need to make $3.33 stretch enough to buy multiple items to feed their entire family instead of blowing it on a small container of “purple pills.”

“Whether measured by income, formal education, or job status, there is a socioeconomic gradient to health,” Bacon and Aphramor write in Body Respect. “And the greater the inequality in society, the steeper the gradient. The United States has the greatest inequality of all wealthy nations – and the greatest health disparities.”

This is what I was getting at last year when I wrote about nutrition and politics. We talk about the concept of intersectionality and how various layers of oppression aggregate. The further one’s identity lies from that of the pinnacle of privilege – a thin, white, heterosexual, educated, wealthy, American-born, Christian male – the more the individual is subject to oppression.

It might not just be that one’s economic situation makes regularly consuming blueberries unrealistic and limits their access to health care, but that in addition to fretting about cash flow, that person might also have to worry about suffering a hate crime or having their rights stripped away. Even if someone does not fall victim to such misfortune, remember that stress itself is associated with cardiovascular disease, so the very threat itself is problematic.

Assuming that the reduced risk of heart attack was due to a few weekly handfuls of berries without considering the greater context is ridiculous and exemplifies the problems inherent in viewing nutrition solely as a hard science. Anybody who has extensively studied the field should know to consider social, cultural, and other factors, which makes me wonder: When Dr. Q told us that 90% of cardiologists reported zero or minimal nutrition education and yet 95% of them felt it was their personal responsibility to discuss it, was he describing himself?

He Said, She Said: MEDA Conference Takeaways

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He Said

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

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

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

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

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

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

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

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

 

She Said

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

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

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

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

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

He Said, She Said: Good for who?

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He Said

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

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

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

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

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

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

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

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

 

She Said

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

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

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

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

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

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

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