He Said, She Said: Whole30®

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He Said

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


She Said

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

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

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

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

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

Sh*t Tennis Ladies Say

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As some of you might know, I am an avid tennis player. After a very long hiatus (like 25 years long), I started playing competitive tennis in several different leagues three years ago. It has been so wonderful in so many ways – I love that I get to play a sport that is not only physically enjoyable, but is also a fabulous social network as well. My tennis teammates are some of my closest friends and I adore them.

That’s why sometimes it feels particularly upsetting when many of them speak in anti-fat, pro-diet, disordered ways about food, weight and body shape. All of these women are intelligent, well-spoken, kind-hearted people. All of these women are liberal, open-minded and generous. And nearly all of these women have either made negative comments about their own bodies, commented on others’ bodies, and have engaged in any number of diets/disordered eating patterns. It is truly mind-boggling. I have decided to write about a few of these comments partly as a way to vent, but I also feel like they can be valuable learning lessons for our readers.

Tennis friend: “Oh my goodness, did you see X on the tennis court today? She has lost/gained a ton of weight– doesn’t she look great/terrible?!”

Why these types of statements are problematic: 1) We have very limited control over our weight – our genetics are the key determinant of our body size. And while we can lose weight in the short-term, nearly 95% of dieters regain the weight, with many of them gaining even more weight than they had lost; 2) There could be a number of explanations for someone’s weight loss/gain – are they going through chemotherapy for cancer treatment? Did they recently have a traumatic life event that significantly changed their appetite? Are they on a medication that is causing them to bloat/lose their appetite? 3) These types of comments reinforce the idea that the most important thing about a woman is her physique. We are so much more than our bodies!

Ways that I choose to respond to comments like these:

“I really prefer not to talk about others’ weight – every body is different and unique.”

“Commenting on others bodies makes me uncomfortable – you really never know what someone is going through. She could have a medical condition we are unaware of.”

“Hey, how about we focus on her tennis game rather than her body shape/size?”

Tennis friend: “I’m so hungry.”

Me: “Oh, I have a granola bar in my bag – would you like it?”

Tennis friend: “Oh, no. I’m dieting.”

Why this is problematic: As Jonah and I have written about too many times to count, diets don’t work long term. When we restrict our intake and actively disregard our bodies’ hunger cues, our body goes into starvation mode. This results in a slowing of metabolism, decrease in energy, and heightened awareness and obsession with food. When you feel hungry, that is your body’s way of telling you it needs fuel. It is not a weakness. It is a necessity, like breathing air and drinking water. Not only that, once someone stops dieting (because the inherent nature of dieting is temporary), that person will likely overeat on high-fat/high-carb foods (which are your body’s preferred macronutrients in times of scarcity), and with their slowed metabolism, the weight will pile back on. Unfortunately, many women engage in this yo-yo dieting, which a number of studies have shown to be more damaging to one’s health than just maintaining a higher weight.

Ways I choose to respond to situations like this one:

“Being hungry is your body’s way of telling you it needs food. I guarantee you will feel so much better if you a eat something. I also bet you would have so much more energy to play tennis!”

“It sounds like you have been on quite a few diets over the past year. I know it’s hard to believe, but it is possible to eat in a non-restrictive way and be healthy.”

“Did you see Serena’s last tennis match? She was eating a snack on the changeover. I think she’s onto something!”

Tennis friend: “My knees/ankles/hips are killing me. If I could just lose these 20 lbs, I know that would fix the problem.”

Why this is problematic: As I wrote about several months ago, focusing on weight loss to cure physical ailments is not the right approach. Yes, biomechanically speaking, weighing less might help one’s knee pain resolve, but there is no guarantee of that. Not to mention, many people of all shapes and sizes have knee/ankle/hip pain (even thin people!). As we age, we tend to lose cartilage, and this often leads to joint pain. Sorry folks, but getting old is unavoidable! There are many ways to help joint pain that don’t involve weight loss (such as quad strengthening exercises for knee issues, medicine, wearable braces). And finally, even if someone were to lose weight to help their knee/ankle/hip pain, it is still highly unlikely they will be able to keep off that weight for any significant period of time.

Ways that I choose to respond to comments like these:

“You know, there are plenty of other strategies to use that could help your ankle pain. I would recommend talking with your doctor.”

“When I had knee pain, I started seeing a physical therapist who gave me a bunch of exercises to try to strengthen my quads – would you like his/her contact info?”

“While weight loss might initially help, it’s nearly impossible to keep off the weight, and it is likely that you will end up gaining more weight in the long run. Maybe you could find some other strategies to deal with the pain?”

At the end of the day, I really do understand why so many of these women make comments like the ones I shared above. And I also know that these comments are not just limited to the suburban female tennis playing community. We as a society have been brainwashed by the media, our doctors, our family and friends to think that it is right and normal to comment on other people’s bodies, to believe that what we choose to eat (or not eat) makes us virtuous or sinful, and to view weight loss as something that is easily achieved and maintained (all of these things being plainly false).  I just wish that we could change the conversation to one about things that really matter, like the state of the world, what we are passionate about, how our families are doing, etc.  Focusing on our bodies and what we put in them is terribly myopic. How much we could achieve if we just changed our focus.

Wishful Thinking

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Last December, I stumbled upon a very interesting article on the website Ravishly. The piece, entitled “Being Thin Didn’t Make Me Happy, But Being ‘Fat’ Does,” written by Joni Edelman, caught my attention for pretty obvious reasons. In it, Edelman included two pictures of herself, one with the caption “Before” and one “After.” As you might have guessed, her before picture is of her when she was at a much lower weight at the age of 35. The after picture is of her and her family, five years later when Edelman was at a much higher weight. Edelman goes on to describe the extreme measures she took to achieve her “physical hotness” displayed in the first photo, including counting calories obsessively (limiting her calories to 1000 per day), exercising excessively (running 35 miles per week), and overall living a very restrictive lifestyle.

While Edelman concedes that being at this low weight came with some “benefits” such as being able to fit into size 4 clothing and receiving positive attention from men, she says that the amount of effort, sacrifice and mental energy it took to maintain this weight significantly diminished her happiness. She found that the time and energy it took to keep her figure ended up taking away from her relationships, especially with her children, as she was preoccupied with her food and working out.

Realizing that “happiness does not require thinness” and “fatness does not presume sadness,” Edelman stopped her extreme dieting and exercise behaviors. As one would expect, she gained weight, and with medication changes to treat her bipolar depression, she gained even more weight. Despite this, Edelman wrote that she had found a “stillness, a joy, and a peace” that she had never had and that “it’s worth 10 pounds.” The article ended with Edelman telling her readers to “be fat and happy. Be unapologetically fat. Wear a bikini, and mean it. Eat pizza and ice cream and enjoy it. Drink up your life and a bottle of wine, and make no apologies.” It was a refreshing article and one that I imagine took a great deal of courage for her to write. In our fat-shaming, thin-exulting world, it’s rare to hear someone (especially a woman) talking about being both fat and happy.

A few weeks ago, one of my patients forwarded me another piece written by Edelman. Apparently, Edelman has decided to start writing a bi-weekly column entitled “Beyond Before & After,” (BB&A) where she hopes to discuss “living without dieting, fostering self-love and healthful choices made on our own terms. No scales, no calorie counting, no before, no after. Because we’re so much more than that.” Sounds promising, I initially thought to myself.

In the first installment of BB&A, Edelman talks about her blog from last December. How she received so much praise and attention for writing so bravely about something that many woman would be afraid to do – to call themselves “fat” and be okay with it. But then the article takes a turn. Edelman writes that even though she fully believed that she could be fat and happy, something started to shift. She describes instances in which her body started to fail her, such as not being able to sit on the floor without falling because she was not able to bend due to her stomach getting in the way. How she was tired of feeling breathless after walking up 13 stairs and how her weight was making it nearly impossible to heal an injured ankle. All of a sudden, Edelman writes that being fat “stopped working for [her],” and that she wanted to change this by losing weight, that “if being fat doesn’t work for you, you can change, or you can at least give it your best effort.”

Oh dear. I don’t know where to begin with this. First of all, this piece makes me sad. Here was someone who was fighting the good fight, who really seemed to get it: that weight and health and wellbeing are not inextricably linked. That there are plenty of thin people with health problems and plenty of fat people with none. Interestingly, Edelman talks about how she got her blood work done (in addition to numerous other health tests) and surprisingly enough, her labs were nearly impeccable, with a low thyroid as the sole issue that arose. Other than this (and being diagnosed with peri-menopause), Edelman was in excellent health. But, even with this positive information, Edelman is resolved to change her body.

Okay, time for some full disclosure: part of me understands where she is coming from. I am also living in a larger body and there are times that I think to myself, “you know, your knee pain and plantar fasciitis would likely improve if you lost weight.” Biomechanically, I understand that carrying more weight translates to more stress and strain on my body. But, then my rational mind kicks in and reminds me of several facts: 1) There are plenty of thin people with knee pain and plantar fasciitis (just ask nearly all of my slender tennis teammates) 2) There are numerous ways to address these health conditions without losing weight (just ask my podiatrist and my physical therapist) and, most importantly, 3) Permanent intentional weight loss is impossible for 95-98% of those who try to achieve it. So, even if losing weight did improve my issues, no one has found a way to keep the weight off. In fact, most people end up gaining even more weight than they had lost in the first place, resulting in an even higher weight.

The other issue I want to shed light on is Edelman’s admission that she has struggled with an eating disorder (ED) in the past (namely exercise bulimia). Even if she is not actively engaging in restriction and over-exercise, her weight loss goal is simply ill advised. Recovery from an eating disorder is a life-long process and it is completely at odds with purposefully losing weight. You can’t be in recovery and be actively trying to lose weight. They are incompatible. Even Edelman realizes how tricky her endeavor is going to be, admitting that she has already been weighing herself more than once a day and has been drinking copious amounts of water to help her feel full. I will not be surprised to see her get back into an ED mindset if things continue this way.

Listen, I get it. Being fat can be tough in our society, and it’s easy to blame our physical maladies on our body size. But just deciding that being fat isn’t working for you and that you are going to change your body permanently is at best wishful thinking and at worst a very dangerous endeavor. I hope that Ms. Edelman figures this out before it’s too late.

Thoughts on the 2016 Multi-Service Eating Disorders Association (MEDA) Conference

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On May 14th, I attended the 21st annual two-day conference held by the Multi-Service Eating Disorders Association (MEDA). This year’s conference theme was “Thinking Outside the Body: Empowering Yourself, Your Clients and the Community.” I was only able to go to day two of the conference, but I feel like I learned a lot during that one day of presentations and thought it would be helpful to summarize some of what I learned.

The first talk I attended was the day’s keynote address, “Gender Identity, Gender Expression, and Eating Disorders,” presented by Carly Guss, MD, Allegra Gordon, MPH, ScD, and Jerel Calzo, PhD. Obviously, the topic of gender identity has been on the forefront of many people’s minds given the latest legislation around transgender individuals being able to use public restrooms. While I am familiar with transgender issues, I have only worked with one transgender individual in my practice, so I was very interested in hearing what the presenters had to say on the matter.

While the presenters gave a helpful primer on gender identity, their main focus was on the prevalence of eating disorders (EDs) in the transgender community. According to the presenters, two recent studies found that compared to cisgender heterosexual women, transgender men and women have 4.6x odds of past-year self-reported ED, were more than twice as likely to have used diet pills and purging in the past month, had 4.8x risk of being “underweight,” and had 2.5x risk of being “obese”.  Two other studies on ED risk in the transgender community found that the majority of participants (transgender men and women) reported a history of disordered eating and that there was a “strive for thinness” to suppress unwanted secondary sex characteristics, particularly in people who were gender assigned “female” at birth but identified as males. It makes a lot of sense if you think about it – if one were to identify as a male but were born female, that person might want to prevent the development of curves and beginning of menstruation that naturally occur as a girl becomes a woman. Restriction and maintaining a very low body weight can prevent these developments from occurring.

My takeaway from this talk was that it is important for practitioners to be aware of the challenges that transgender individuals face in our society (particularly in healthcare) and their increased risks for EDs and body-image issues. It also made me examine my own practices when working with transgender clients, including how to make them feel most comfortable (e.g., using the client’s preferred pronoun[s] and having gender-inclusive language on our patient forms) and incorporating the best strategies to help them recover from their EDs.

The second talk I attended was “What You Need to Know about Trauma and PTSD: A Personal and Professional Perspective for Working with Eating Disorders.” The first presenter was Jenni Schaefer, a very well-known figure in the ED community. Ms. Schaefer is a self-described individual who has fully recovered from an ED and has written a number of books on her recovery journey. What I (and perhaps many others in the audience) was not aware of was that Ms. Schaefer is also a survivor of trauma. Her presentation was quite an eye-opener as it described how her trauma and ensuing Post Traumatic Stress Disorder (PTSD) were impacted by and complicated by her ED. This part of the presentation was especially illuminating for me, as I have a number of patients who have been victims of trauma and struggle with both PTSD and EDs. The second presenter was Luana Marques, PhD, and she discussed the different therapeutic options for patients struggling with both disorders. While the content was not exactly geared towards registered dietitians, it gave me some insight into how PTSD can affect recovery from ED and vice versa.

After an hour lunch break, I was thoroughly excited for the third talk of the day. As many of you know, Jonah and I identify as Health at Every Size® (HAES) practitioners and are supportive of the size acceptance movement. Well, we were absolutely thrilled to learn that Ragen Chastain (blogger at Dances with Fat), a world-renowned , self-described fat activist and proponent of “behavior-centered health,” was going to be presenting on both HAES and Size Acceptance in her talk entitled “The World is Messed Up, You are Fine – Helping Clients Deal with the Culture of Body Shame.”

Ragen gave an absolutely electrifying talk about how our society gives extremely damaging messages about our bodies via the medical community, the media, and even our politicians (e.g., Michelle Obama’s fight on childhood “obesity”), and how these messages can make recovery from an ED very difficult. She started the presentation by giving a quick primer on the principles of HAES and Size Acceptance, stressing the point that people of all body sizes have the right to exist and that healthy habits are more likely than body size to determine healthy outcomes.

After this introduction, Ragen displayed a number of images taken from popular magazines and websites, each showing how the media tries to manipulate celebrities’ appearances by using Photoshop. All of these manipulations aimed to make the subjects appear thinner and younger, perpetuating the idea that everyone (especially women and girls) are only beautiful if they are young and slender. A number of years ago, I never would have thought about how these images are manipulated, but now in my work with ED clients, I am super sensitive to how these images can be extremely damaging to girls and women, and I often suggest to my clients that they avoid certain magazines and publications for fear of triggering negative body image thoughts.

Ragen continued on to talk about the role of HAES in ED recovery and how important it is for ED healthcare providers to give consistent body positive messages that counteract the negative, fat-phobic messages that our patients receive every day. She gave examples of how practitioners could create a safe environment for their ED patients, such as providing a space that includes positive representations of diverse body sizes, creating “body affirming” spaces by having chairs that can accommodate people of all sizes, and being aware of our own beliefs and assumptions around weight and size.

While I was familiar with nearly everything Ragen discussed, for I am an avid reader of her blog, it was interesting to observe those in the audience who were hearing this information for the first time. There were a number of thought-provoking questions that were posed during the Q and A section at the end, and Ragen adeptly answered all of these queries with the grace and presence of someone who is confident as well as extremely knowledgeable about the topic on which she was presenting. Her talk finished with a standing ovation from the audience, something that I have rarely witnessed at any of the MEDA conference presentations I have attended. It was truly a special moment.

The presentation that followed Ragen’s was called “Taking the ‘Th’ Out of #Thinspiration – Utilizing Social Media to Encourage, Empower and Bring Hope to Those Battling or In Recovery from Eating Disorders”. The first half of the talk was presented by Donald Blackwell, a man whose own daughter had suffered from an ED and who himself became very active in ED recovery. Mr. Blackwell’s part of the presentation centered on the many different social media platforms that people use today. While I am already quite familiar with Facebook, it was helpful to learn more about the other commonly used social media vehicles, including Twitter, Tumblr, and Instagram, and how they are used in pro-ED (people who believe that EDs are “lifestyle choices”, not illnesses) as well as ED-recovery circles. I have always been aware of the numerous pro-ana (promoting anorexia nervosa [AN]) and pro-mia (promoting bulimia nervosa [BN]) websites out there, but this talk gave me an even clearer picture of the amount of harmful information that circulates on the internet.

The second part of the presentation was given by Joanna Kay Mercuri, an ED sufferer who is now in recovery. She went into even more detail about the pro-ED websites and their content as well as the pro-recovery websites and what they focus on. Ms. Mercuri also discussed her own blogging and how it helped her in her recovery, as it gave her a platform to discuss her feelings and struggles while connecting with others. The end of the talk centered on how we as a society can actually respond to the pro-ED social media and bring the pro-recovery content front and center. All in all, this talk was helpful in showing the influence and use of social media platforms regarding EDs, and it gave me a lot of insight into what my patients might be seeing online possibly every day.

The conference’s endnote address, “Overview of ARFID: Avoidant/Restrictive Food Intake Disorder,” was given by Ovidio Bermudez, MD. It was very interesting to learn about this relatively newly recognized group of disorders as it has recently been added to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). ARFID is defined by the Center for Eating Disorders as an “eating or feeding disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:

  • Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
  • Significant nutritional deficiency.
  • Dependence on enteral feeding or oral nutritional supplements.
  • Marked interference with psychosocial functioning.”

Those struggling with ARFID are not the same as those with AN or BN, as ARFID sufferers typically have no fear of weight gain and no body image distortion. Instead, individuals with ARFID are those who, due to a problem with eating, aren’t able to take in enough nutrition through their diet. Some examples of eating problems are difficulty with digestion of certain foods; strong aversions to colors, textures or smells; no appetite; or being afraid to eat as a result of a frightening episode of choking or vomiting. Sometimes individuals with ARFID can develop BN, AN, or other EDs, but not in every circumstance. I myself have worked over the past few years with several clients who have struggled with ARFID, so I found this talk most helpful in recognizing the signs and symptoms, treatment plans, and prognosis.

All in all, I found my day at the MEDA conference one filled with interesting ideas, helpful tips, and above all, support from my fellow colleagues. These types of conferences are not only a wonderful opportunity to reconnect with familiar ED treatment practitioners, but they are also a terrific time to meet the “new kids on the block.” I look forward to returning to the MEDA conference next year, for I am sure I will learn even more!

The Tipping Point

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You probably heard about Gina Kolata’s piece in the New York Times earlier this month detailing commonplace weight regain among Biggest Loser competitors, but you may have missed Dr. Sandra Aamodt’s excellent follow-up piece in which the neuroscientist shares research showing just how unlikely long-term weight loss is for any of us, not just the show’s former contestants.

While this information might be news to some of us, data showing commonplace weight regain among people who attempt to lose it has been available for quite a while, yet it has not garnered much mainstream attention despite years of efforts from researchers, advocacy groups, activists, and practitioners around the world, including myself.

Regardless of what our goals are, nobody wants to hear that they are probably unattainable, which partially explains why the myth of weight loss has survived. Unfortunately, yet understandably, people are reluctant to listen when receiving a message they do not want to hear.

The problem, however, runs deeper. The notion that we can lose weight and keep it off if only we try hard enough has taken on “everybody knows” status. We hear it in our fitness centers, around the proverbial office water cooler, up in the bleachers at Little League games, and at spring cookouts. The message is so commonplace that we do not stop to question its validity.

Doctors, dietitians, and other healthcare practitioners can inadvertently contribute to the mess. We are human and vulnerable to the same “everybody knows” paradigm too, and sometimes we take treatment guidelines at face value without looking into them for ourselves.

Lump the green version of myself in there as well. I shake my head with embarrassment and shame at some of the advice I doled out early in my career before I knew better, and I wish my profession as a whole would get up to speed.

We see the “success stories,” the people in our lives who were able to lose weight and keep it off, at least so far. The Massachusetts State Lottery website features pictures and stories of its recent million-dollar winners, but their enticing smiles do not change the reality that the most likely outcome of buying a ticket is financial loss.

Children observe their parents looking critically in the mirror, associating guilt and virtue with eating and exercise behaviors, and oscillating between rigid restriction and binges. The torch of dieting and weight obsession passes to the next generation.

If the myth of weight loss dies, so do the $60,000,000,000-per-year diet industry and the privilege enjoyed by the thin in a culture thick with fat shaming and weight stigma. They keep the fantasy alive and have plenty of incentive to make sure we continue to feel bad about ourselves.

Cognitive dissonance is a powerful force to overcome, not just for laymen, but for everyone. Given the strong headwind, I am pleased to see this information finally receiving the widespread attention it so desperately needs.

Ms. Kolata and Dr. Aamodt certainly deserve credit for their parts, but so does everybody who has ever made an effort to get the word out – practitioners and researchers who risked career suicide, activists for whom death threats are a daily way of life, and patients who have stood up and demanded evidence-based care – as they have also contributed to what I hope is finally the tipping point.

An Iatrogenic Condition

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Joanne and I were watching Shark Tank the other night and I found myself wondering if the negotiations and business analyses might be so bogus that venture capitalists and MBAs get a good chuckle out of the reality show. Maybe real estate agents, general contractors, and interior designers watch Love It or List It and shake their heads. Since these programs cover topics outside my area of expertise, their content could be spot on or largely misleading and I might not know the difference.

Yesterday, the New York Times exposed the Biggest Loser for some of the long-term harm it does to its contestants and the unrealistic expectations it sets for viewers. Most notably, weight regain is pervasive despite the ex-contestants’ best efforts to keep it at bay.

For myself and other practitioners who use a similar approach to ours, some of the minutiae may have been new to us, but generally speaking, the Times piece went right into our “Yeah, no sh-t” folders, as we have known the show to be fraudulent and problematic since its inception.

Having said that, it occurs to me that for readers whose expertise lays elsewhere, this might have actually been news. If that includes you, and you were surprised to learn about the contestants’ weight regain and struggles, I hope you do not feel gullible. How were you supposed to know?

However, any seasoned obesity or metabolism researchers who found themselves surprised by these results ought to be embarrassed. Data showing commonplace weight regain among people who attempt to lose it has been available for quite a while. Even some of the most ardent weight-loss supporters reluctantly admit that although we have several methods of inducing short-term weight loss, we have no idea how to produce long-term weight loss for more than a tiny fraction of the people who attempt to achieve it.

What we see more commonly, not just in Biggest Loser contestants, but in people across the board who attempt to intentionally lose weight, is ultimate weight regain that often exceeds their baselines.

As an example, consider the following growth chart, which is from a real patient of mine (All information that could possibly reveal her identity has been removed.) Looking at her chart, hazard a guess as to when her parents and doctor first attempted to intervene with her weight. Do you think it was at age 17, when she first came to see me?


No, it was just after age eight, when her BMI-for-age, which was in the 92nd percentile at the time, was deemed a problem. She was naturally a bigger kid, okay, but this fact’s implications have more to do with stigma than health. The focus on weight and a belief that an intervention would help to lower it created an iatrogenic condition. In other words, her weight became a problem because it was viewed as one.

Not only was the diagnosis off base, but the attempted interventions worsened the problem. The first diet produced a slimmer 10-year-old, who subsequently rebounded into a chunkier tween. Based on the research, this was to be the most likely result. As the patient’s teenage years began, subsequent attempts to lower her weight produced similar patterns of weight gain.

They took a child in the 92nd percentile and dieted her up to the 99th percentile, and in the process screwed up her relationships with food, her body, her doctor, and her family, all of which she is now working hard to untangle and fix.

None of that was the child’s fault, nor are the parents to blame, for they were just doing what they thought was right by following instructions from trusted practitioners.

And really, I do not blame the doctor either. Pediatricians and other primary care doctors are tasked with a tremendous responsibility to maintain basic knowledge about a myriad of conditions, everything from sore throats, to sexually transmitted diseases, to early signs of cancer, but this very demand limits them from being experts in any one field, including weight regulation.

The chain of education and direction has to begin somewhere. While these data on Biggest Loser contestants might have come as a surprise to laymen, the researchers who are responsible for the foundation of our healthcare policies should have seen them coming. That it took a New York Times article to wake them up is shameful, but they sure seem to be paying attention now, at least for the time being.

He Said, She Said: Exercise as Penance

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He Said

Data are only as useful as our understanding of them. Food labeling represents an opportunity for education while simultaneously illustrating the tremendous challenge of conveying complex ideas in a space only slightly larger than a postage stamp.

The nature of my work is one-on-one counseling, and as such, public health policy is not my area of expertise, but I can still recognize when those charged with such decisions are barking up the wrong tree. Such is the case with Britain’s idea to indicate the exercise load necessary to burn the calories in a given food.

First, remember that proclamations of calorie content are often flawed. Earlier in my career, I created nutrition labels for a university dining service as well as for cooking software. The labels that I produced reflected my best estimates based on other people’s estimates of generalities. Food manufacturers utilize a similar process to create their labels, and laws that allow rounding further cloud the picture. As the game of telephone teaches us, inaccuracies creep in with each step we take further away from the source.

Second, despite what activity trackers and cardio equipment dashboards would have us believe, estimations of caloric expenditure are similarly problematic. Your soda can may inform you that you need to run for 15 minutes to burn off the calories contained within, but this overgeneralization does not take into account your age, size, body composition, running mechanics, exercise intensity, course terrain, or any of the other variables that impact the energy that you as an individual will expend during a specific 15-minute bout of jogging.

Third, even if the data for calories consumed and burned were as accurate as can be, the implied calories-in-vs.-calories-out paradigm is an oversimplification of the complexities affecting weight regulation and overall health. Our eating and physical activity behaviors do matter, of course, but they are mere pieces in a puzzle mainly comprised of factors that are out of our hands.

Last, the presentation of a tradeoff between eating and physical activity reinforces a commonly held and problematic notion that food choices are worthy of punishment and exercise is our penance. As I recently told BuzzFeed and the Daily Meal, the good/bad food dichotomy, so prevalent in our society, links issues of morality, virtue, and guilt to our eating behaviors and is counterproductive. Nutrition and exercise activity have enough variables already without confounding them further with judgment.

A healthy relationship with food and physical activity means uncoupling moralization from such behaviors, not reinforcing the bond.

She Said

Earlier this month, Jonah and I were watching NECN when a news story came on that made us both cringe. Apparently, Britain is considering creating new food labels that not only tell the consumer how many calories are in the food, but how long the consumer would need to exercise to “burn off” that food. The proposed label would look like this: next to the calories that are listed for the food, there would be two stick figures of a person walking and running. Underneath those stick figures would be the number of minutes that someone would have to engage in either walking or running to negate the calories they consumed.

I find this idea to be highly problematic for several reasons. Firstly, as Jonah and I have written about before, the idea of “calories in, calories out,” is very much oversimplified. Most people believe that if an individual eats an extra 500 calories per day, that individual will have gained a pound of fat after a week. Unfortunately, it isn’t that simple. Numerous studies have shown that everyone processes calories differently, with some individuals getting more calories from the food they eat and others getting fewer calories from the same amount of food, resulting in some people gaining weight and others not gaining a pound.

One such study looked at identical twins and weight gain. Each pair of twins was fed an extra 1,000 calories per day for 100 days while under close observation (i.e., they were confined to a closed section of a university dorm). What the researchers found was that while the twins in each pair gained (or did not gain) the same amount of weight, there was a huge difference between the sets of twins. For instance, one pair of twins gained more than 29 pounds by the end of the intervention, while another pair only gained about 9 pounds. The conclusion that was reached was that some people are more efficient calorie burners, while others are more efficient at storing extra calories.

Aside from the fact that every body processes calories differently, I also take issue with the idea that one should be concerned with “burning off” what they are eating. In my work with people with eating disorders, there are quite a few individuals who engage in exercise bulimia. This means that these individuals will binge and then will try to compensate for the binge by over-exercising. It is a debilitating disease, and I believe that these labels would exacerbate symptoms for these individuals.

Finally, as I have written about before, I believe that exercise should not simply be viewed as a way to burn calories or to “right our wrongs.” Rather, as the Health at Every Size® principles suggest, physical activity should be a way for us to connect with our bodies by engaging in activities that we enjoy. Instead of torturing oneself in the gym to repent for last night’s cake, how about enjoying a walk outside in the sunshine to improve one’s mental, physical, and emotional health? Instead of calculating how many minutes one would need to log on the treadmill to “undo” a cookie, I think it is much healthier to use exercise as a way to feel more alive in our bodies rather than as a weight control tool.


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Generally speaking, Zootopia is a really nice Disney film. As Joanne and I were walking out of the theater and talking about how much we both liked it, she turned to me and said, “There was only one thing about it that bothered me, and I am guessing you know what it is.” Sure enough, I did, as the same problem had caught my eye as well.

The main reason I like the film is because it teaches some wonderful lessons about having the courage to be different, break down barriers, and acknowledge and overcome prejudice. However, the writers missed an opportunity to apply these same themes to body size and instead reinforced widely-held stereotypes about larger individuals.

Although the film does feature characters of various shapes and sizes, both protagonists are stick thin while the rounder characters are generally presented in a more negative light, such as the main character’s portly father, who in his first scene explains how he was too afraid to go after what he really wanted in life and settled for one spent as a carrot farmer.

The most glaring example is Officer Clawhauser, a large, dopey, and disorganized character often shown with food or in the act of eating. An early scene in the film portrays him as so messy and oblivious that he is unaware that he has a donut lodged in his collar.

How ironic, and unfortunate, that in a film that is largely about breaking down stereotypes, Disney glaringly reinforces one. The writers probably never even considered there might be an issue with this because the sad truth is that in a society in which we generally reject stereotypes based on race, religion, ethnicity, or sexual orientation, we inexplicably tolerate those based on body size that are no more accurate than the others, yet are just as abhorrent.

If you bring your children to see Zootopia, consider using the occasion to talk about body size and its associated prejudice. The film does a solid job of teaching that not all prey animals are cowardly, predators need not be savage, and the symbolism contained therein about the human race, but it misses an opportunity to shut down the stereotypes that heroes must be thin and larger individuals are glutinous, lazy, or unkept. This is where you, the parents, can come in and complete the lesson.

Objective / Subjective

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Numbers. Nutrition and exercise are full of them. We can tabulate calories and grams, measure portion sizes, count servings, and analyze food journals. Thanks to various electronic gadgets and apps, we can keep tabs on our steps, estimate our metabolic rate, and track other biomarkers.

As a guy who holds a degree in mathematics and used to work as a research analyst, nobody loves objective data more than I do. When I began my career transition and was moonlighting as a personal trainer, I made use of several physical tests – the Rockport walking treadmill, the sit-and-reach, the list goes on – to quantifiably track my clients’ progress over time. My career as a dietitian started off similarly, as I relied heavily upon bioimpedance analysis data, weight, and estimated macronutrient needs to guide my nutrition advice.

Imagine my surprise when, through a combination of additional education and experience, I realized how little these quantitative data actually matter. On the first day of the first nutrition course I ever took, the professor began with a brief survey of the social, cultural, personal, and financial factors that influence eating behavior. In our diet-minded society in which food is thought to be just fuel and any persuasions to the contrary are seen as weaknesses and sources of guilt, we easily forget how important this basic truth really is.

One of my patients recently told me that his wife purchased a diet book that emphasizes the glycemic index and she would like the two of them to begin eating in accordance with the author’s guidelines. Objectively, the glycemic index, which is a measure of how quickly various foods raise blood sugar relative to a standard (usually white bread), makes some sense. If a food breaks down more slowly, we stay full for longer, eat less, and consequently lose weight. At least, that is what the book’s author wants its readers to believe. Just aim for the low-number foods on the glycemic index chart and we are all set.

Right around the same time my patient told me about this book, another patient relayed to me an experience he had regarding hamburger buns. His parents typically made burgers on whole wheat slider buns that he thought were okay – not great, not awful, but okay – and he normally ate two or three burgers as the meat from the normal-sized patties jutted out beyond the rolls’ perimeter like a UFO. For reasons that remain a mystery to my patient, his mother decided to make burgers on normal white buns one evening. In contrast to their whole wheat counterparts, these white buns hit the spot. He had one burger, felt satisfied, and stopped eating. Turned out that for him, the white bread, which is sky high on the glycemic index, was actually the better choice and kept him from overeating.

The more I work with my patients, the more I am reminded of how the subjective is often of greater importance than the objective, that the qualitative usually trumps the quantitative. Numbers still have their place, for sure, but they really only play a supportive role. This, I have learned, is one of the most significant differences between nutrition on paper and nutrition in real life.

Healthcare For Some

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Yesterday I ran the Five College Realtors 10-Miler, which was my first event since last summer’s surgery and my first road race since September 2013. My time was well off my personal record for this course, which I set the last time I ran it in 2007, but I have been through quite a lot in the last nine years so expecting to pick up where I left off would have been unrealistic. Besides, it was just great to be able to race again regardless of what the clock said.

As I have written before, I owe a debt of gratitude to everybody who has helped me recover over the last two-plus years, but at the same time I think others who do not receive the same level of care from their own support systems, including their medical teams.

When I went to my primary care doctor in late 2013 complaining of back pain, I received orders for x-rays, an MRI, and a CT scan, referrals to see a physical therapist, a physiatrist, and multiple surgeons, and a collaborative discussion about the pros and cons of complementary treatments, such as acupuncture, chiropractics, massage, and neuromuscular therapy. Subsequently, I received a topical medication, oral medicines, injections, and referrals to more surgeons. Ultimately I required an operation, and then another one, more scans, and physical therapy that continues to this day.

When my “overweight” patients go to their doctors complaining of back pain, more often than not they report receiving one intervention and one intervention only, one that research shows is only achievable for a tiny fraction of the people who attempt to attain it and may not improve their condition even if they do: a directive to lose weight.

Are we not all deserving of thorough, collaborative, evidence-based healthcare, or just those of us who are thin?