Beginning to See the Light

Posted on November 11, 2015 by Jonah Soolman

[Preamble: After the conference I am about to discuss came to an end, I sought and received permission from the organizers to use their slides in my blog. The only stipulation was that I had to credit the authors, most of whom I disagree with strongly, and this requirement gave me pause. While I may not see eye to eye with these doctors, I respect them enough as colleagues not to publicly embarrass them by name. The internet is an unnecessarily harsh place sometimes. Everything I am about to say is in the spirit of constructive criticism, not trolling, and I can make my points without calling anybody out. When it comes down to it, all of us are on the same team. Or at least we should be.]

Last year’s Cardiometabolic Health Congress spurred a wide range of reactions, the vast majority of which were various permutations of anger or disgust. Despite such unpleasantries, I returned for the Congress’s 2015 edition late last month. Self-flaggelation is not my thing, but if we do not venture out of our own circles and challenge our biases and beliefs by listening and talking with people who hold different points of view, then we risk deluding ourselves and repeating the same messages back and forth among people who already share our stance.

During an early break between presentations, I took a walk through the exhibit hall to see which vendors were in attendance and approached one weight-loss company that advertises, “The [company name omitted] was developed by doctors and is clinically proven to be safe and effective for weight loss.” Pretty much any kind of restriction will lead to short-term weight loss, so I always find it interesting when companies act like their program is unique in this way. According to the company representative working the table, he told me the people who go through their program consume between 800 and 1,300 calories per day.

Let’s put this calorie intake in perspective. According to the Food and Agriculture Organization of the United Nations, Somalians consumed an average of just under 1,700 calories per day per person between 1999 and 2001, which made the citizens of this east African nation some of the most undernourished in the world during that time. The situation in Somalia continues to be so dire that in fiscal year 2015, the United Nations World Food Program, with help from countries including the United States, delivered 40,680 metric tons of emergency food assistance to the people of Somalia.

Think about that. American dieters who follow this “safe” weight-loss program consume a level of nutrition so inadequate that if they were eating this little and living in a different region of the world, the United Nations would be sending cargo ships full of food to help them. When is Bob Geldof going to organize a star-studded benefit concert for dieters?

The diet program’s marketing material advertises, “And once you’ve reached your goals, [company name omitted] support continues with our Healthy Living Program, where you’ll learn how to transition and maintain your new, healthier weight for the long term.” Where is the evidence to support this claim? It only took the gentlest of pushes for the rep to concede he had none.

We do, however, have plenty of evidence to the contrary, including, but not limited to, the starvation study Ancel Keys conducted in 1944. After consuming approximately 1,570 calories per day (which, just to hammer home the point, is more than people on this diet program are afforded) for an extended period of time, the subjects, according to Judith Matz and Ellen Frankel, “. . . 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.”

Data presented throughout the conference reinforced the long-term failure of diets as well. Among the slides are nine graphs showing data from various weight-loss attempts and they all depict the same pattern: sharp initial weight loss followed by slow and steady weight regain. A couple of the presenters discussed the hormonal and neurological survival mechanisms that kick in to promote weight regain after the body has experienced a period of restriction.

The discussion of these data and physiological reactions represented what I consider a noteworthy shift since last year’s conference. In 2014, very similar graphs were shown as well, but back then the weight-loss attempts were presented as successful because the end points were lower than baseline, even if the studies were short term and the trajectory of weight regain was still going up at the time of the study’s conclusion. This time, presenters were more forthcoming about the dismal results of weight-loss interventions.

Of course, that did not prevent them from hosting a vendor who sells weight-loss programs, nor did it keep some presenters from going into detail about lifestyle interventions that would supposedly lead to weight loss. The height of irony was at the end of a long day of discussing how diets do not work, the last presenter stepped to the podium and offered a how-to tutorial on dieting: measuring portions, daily weigh-ins, using apps that track calories, etc.

Not only did she recommend Weight Watchers, which in itself was as funny as it was horrifying, but she also cheerfully offered a list of “Plans that may be effective short-term (≤2 years) for weight loss,” including low-carbohydrate, low-fat calorie restricted, Mediterranean, vegan, vegetarian, and Dietary Approaches to Stop Hypertension (DASH), without any mention of what happens beyond two years. Did she think we would not notice such a glaring omission?

She also included a slide depicting a large polar bear trying to fit into a tiny igloo with the caption, “When it comes to management of obesity, one size does not fit all. Keep trying . . . and eventually you will find the perfect fit.” On what is she basing this claim? We saw no evidence presented whatsoever that any current methods of weight loss work in the long term except for a small fraction of individuals.

Presenting these behaviors and diets as the key to long-term weight loss makes no sense, not when so many other people perform the same actions without achieving similar success, as evidenced by, among other indicators, the multitude of graphs and data they just showed us. The lottery crowns new millionaires every single day, but that does not mean your financial advisor is giving you sound, ethical, evidence-based advice if he suggests you take your life savings and invest in Powerball tickets.

The “I’m an Expert” Trap

Posted on September 29, 2015 by Jonah Soolman

As my freshman year of high school neared its conclusion, my math teacher, Mr. Evers, stood at the chalkboard and drew a large square, which he said represented the entire field of mathematics. He asked us how much of that square we thought we would learn by the time we graduated from high school. After fielding a few guesses, he gave us his answer by filling in a very small corner.

That blew my mind. At the time, I was a solid math student and I wondered how there could possibly be so much more to the discipline beyond what we already had under our belts. Once I got to Tufts and decided to major in the subject, I was introduced to sections of that square I had never even heard of before: complex analysis, abstract algebra, discrete mathematics, differential equations, linear algebra, number theory, numerical analysis, etc.

By the time I finished my degree, I had stretched my mathematical abilities to their fullest extent. Subsequently, more talented classmates of mine who continued on to graduate school in the field explored areas of the square that we never touched as undergrads.

Even the boundaries of that square are expanding as the field grows. A few years ago, a publishing company contacted me and asked if they could feature me in one of their textbooks, so I reached out to a couple of my favorite math professors to let them know. In one of their replies, he included mention that his current research is focusing on how the topography of a rotating sphere, such as a planet, can be mapped based on data collected from its poles. Well, we certainly never covered that in high school.

When Mr. Evers filled in the corner of his square, I learned an important life lesson that sticks with me today and reverberates through my work as a dietitian: A little bit of knowledge can be worse than no knowledge at all if we do not understand the context and erroneously believe ourselves to be experts.

Flipping through the study guide for one of my personal training certifications, I count 15 pages on nutrition. Unfortunately, some trainers learn the material in this one chapter and incorrectly believe themselves to be nutrition experts. When I hear trainers at the gym talking with their clients about food, way more often than not the information they are offering is grossly oversimplified at best and blatantly false and/or dangerous at worst.

Reading a handful of pages on nutrition does not make one a nutrition expert, just like reading the chapter in the same study guide about interpreting electrocardiogram results does not put me on the same level as a cardiologist. Too often, the greater context goes ignored or forgotten: Guys, that one nutrition chapter is nothing more than the tiny filled-in corner of my math teacher’s square.

This is not about picking on personal trainers; all practitioners, regardless of discipline, have bounds to our professions and we are all responsible for recognizing the limitations of our expertise. One of my patients, reluctant to work with a psychotherapist, asked me, “Can’t you just handle the therapy part?” Well, no, I cannot, although I was flattered that he felt comfortable enough with me that he would ask. Even Joanne, who has a degree in psychology, recognizes and respects the vast chasm between being able to identify the need for therapy and having the expertise to provide it.

The more we continue our education, the more we realize just how much learning still remains, not just on an individual level, but on that of our field and society as a whole, too. When it comes to nutrition, realize that graduate students, professors, and other researchers are all working diligently at universities, hospitals, and research centers across the globe in search of answers to outstanding and complex questions regarding food.

Part of actually being an expert means recognizing the grays and nuances, the dearth of crisp absolutes, and that sometimes the best answer to a patient’s question is, “I don’t know, but let’s see what we can do to find out.”

He Said, She Said: Weight Loss for Athletics

Posted on September 27, 2015 by Jonah Soolman

He Said

“You’re an RD, right?” That’s what one of my patients asked me last year shortly before he got up from the table and walked out of my office, never to return. It was more of a rhetorical question, really, his polite way of telling me I don’t know how to do my job.

He and I were only in each other’s lives briefly, as that was not only his last visit, it was also his first. His new patient paperwork stated that he wanted to lose weight in order to complete a marathon. Upon reading that, I contacted him in advance of his visit and offered a heads-up that I would help him to run his best, and as a consequence of doing so, he might also lose weight; but I would not be helping him to lose weight in hopes that it would improve his running because – contrary to popular belief – that is not how things actually work.

Although I suspected he would respond by cancelling the appointment, to his credit he had an open enough mind to meet with me and discuss our different points of view. Elite marathon runners are all very skinny, he told me, so it only seemed logical to him that if he could alter his body to look more like theirs, then he would in turn become a better runner.

Way back in my sophomore year of high school, I held the same belief. When I looked at those teammates on my track team who were faster than me, I noticed that for the most part they were leaner than me. Consequently, I attempted to change my body by restricting my fat intake (Back in those days, people were scared of fats the same way people nowadays fear “carbs.”) in hopes that I would also run better.

In fact, I ran worse. My mom took me to a dietitian who educated me, dispelled some of the nutrition myths that I held, and convinced me to increase my fat intake. My times in all events dropped, and I was the fastest I had ever been in my young running career without my physique ever changing all that much.

Having a leaner, smaller, or lighter body can certainly have athletic upsides sometimes, just as having a heavier or larger body can sometimes be advantageous, and I am not arguing otherwise. However, a significant difference exists between an athlete who naturally has a given size or shape versus someone who tries to force his or her body into that mold. That is where so many people, like my 15-year-old self and the patient I mentioned earlier, get tripped up.

Anecdotally, we see many examples of athletes who perform worse after intentionally losing weight. Last month, I wrote about how CC Sabathia has struggled since cutting his carbohydrates in an effort to lose weight. He and his slender frame are in the midst of experiencing the two worst seasons of his career, both of which have come since he lost weight.

Sabathia gave an interview earlier this year in which he talked about the fatigue he now experiences. Carbohydrates are our main source of energy. Now that he follows a low-carbohydrate diet, no wonder he currently tires early in games now. Only twice in my life have I failed to complete bicycle routes that I set out to ride. The first was when I fell off my bike in Montana and fractured my back. The other was when I was briefly experimenting with a low-carbohydrate diet and did not have the fuel necessary to make it home.

This summer, I had a couple of rowers come to me hoping to lose weight so they could compete in lightweight crew. Each of them believed that if he could shed enough weight to just make the 160-pound cutoff, he would dominate. However, they were not taking into account that the processes necessary to alter their bodies (over-exercise and/or dietary restriction) were likely to leave them unable to put forth optimal performances. A well-nourished and properly-trained 159-pound athlete is probably going to row much better than his or her 159-pound teammate who maintains that weight by existing in a state of depletion.

At the same time, let us acknowledge that not every athlete is already at the weight at which they can perform his or her best. Some athletes, just like the rest of the population, are subject to behaviors, such as emotional overeating, that might be impacting weight. However, putting the horse before the cart means directly addressing issues that might be hindering performance while allowing weight change to naturally occur or not occur as a consequence. To try losing weight in hopes of becoming a better athlete though is to have the process backwards.

She Said

Some of the individuals who come to see me for nutrition counseling are student athletes who are struggling with an eating disorder (ED). These cases are particularly challenging, as one of the cruxes of being an athlete (at least at a competitive high school or college level) is making sure one is in top physical condition to succeed in one’s sport. While this desire to be in the best athletic condition might be approached in a healthy and manageable way by some individuals, for those who are predisposed to EDs, it can sometimes start, trigger, and/or worsen the individual’s ED.

In the sports where weight control is believed to be paramount to success (e.g., gymnastics, ballet, track and field, etc.), this focus and, in some cases, obsession with being “lean,” “fit,” or “cut,” can result in the athlete eating in a restrictive manner (e.g., cutting out carbohydrates, only eating vegetables and protein) and exercising excessively. Initially, these individuals seem to be doing the right thing, taking care of themselves and making the sacrifices needed to become the best at their sport. The problem arises when the obsession with weight, food, and exercise takes over the athlete’s life. Examples of this include avoiding social situations that involve eating in order to train harder at the gym, exercising even while injured or sick, and panicking when being faced with foods that are not on the “clean eating” food list.

While these scenarios are red flags in and of themselves, the physical ramifications of these behaviors are serious as well. One of the most common outcomes that results from overtraining and undereating in female athletes is the Female Athlete Triad. This syndrome is characterized by three conditions: energy deficiency with or without a diagnosed ED, menstrual disturbances or absence of period completely (amenorrhea), and loss of bone density resulting in osteopenia or osteoporosis. In a nutshell, when an athlete is not eating enough to fuel her training, this can lead to dangerous health problems.

Some health professionals believe that individuals who are dealing with the above problems can continue to participate in their sports as long as they are getting nutrition education from a registered dietitian and having regular check-ups with their primary care physician to make sure they are medically stable enough to compete. While I agree that for some individuals it is just a matter of education and monitoring, for those with EDs, allowing them to continue with their sport could greatly hinder the recovery process. An ED is a multifaceted problem that needs a full treatment team including a therapist, dietitian, and doctor who is knowledgeable about EDs. The focus should be on helping the athlete become physically healthy while dealing with the underlying psychological issues that are part of the ED.

When I am working with a student athlete who is exhibiting disordered eating and/or excessive exercise, I always defer to the physician on the treatment team to make the call about whether the patient is medically safe enough to participate in his or her sport. The work I do with the patient centers on helping them understand what their body’s needs are fuel-wise. This might include educating the patient about carbohydrates and why they are a necessary macronutrient (for athletes and non-athletes) and how to eat to improve one’s athletic performance.

If you or someone you know seems to be struggling with an ED related to being an athlete, it’s important to take action. Talk to your doctor as soon as possible to prevent the situation from becoming worse. Find a therapist and a dietitian who are adept at working with athletes who struggle with EDs. It is also important to alert the sports team’s trainer and coach to the problem, as they will be an integral part of the treatment team. When all of these pieces of the treatment team are in place, the likelihood of recovery is much higher.

“Looking the Part”: Patients’ Size-Based Biases Toward Their Practitioners and How to Handle Them

Posted on July 30, 2015 by Jonah Soolman

On July 19, 2015, I was part of a two-member panel at the Association for Size Diversity and Health (ASDAH) Conference in Boston discussing motivational interviewing. My specific task was to examine the size-based biases that patients often hold toward their practitioners and how best to respond to them using motivational interviewing techniques.

The audience was largely comprised of other clinicians, and as such I shaped my remarks in the context that I was talking with colleagues. Because this information can be helpful for others as well, I have reworked my main points in the framework of talking directly to you, our patients.

Background

In the year between finishing my nutrition degree and earning my license to practice dietetics, I interned at a Boston hospital where I did everything from work in the transplant unit to chop squash in the cafeteria kitchen. It was an interesting year, indeed.

One of my rotations was in the bariatric surgery clinic where two dietitians worked. Because I shadowed both of them closely, I know they were both excellent at their jobs, had virtually the same approach, and taught the same material, yet patients perceived them differently because of their size. Relative to each other, one of the dietitians was bigger and the other was smaller. Some patients looked at the larger one and made comments along the lines of: “Look how big she is! How can she possibly help me?” Meanwhile, other patients referenced the smaller dietitian and questioned, “Look how small she is! How can she possibly know what it is like to be me?”

As a budding dietitian just about to step out into the field, these comments made me look myself up and down and consider, well, what exactly am I supposed to look like then? That question always stuck with me and planted the seed that eventually grew into this piece you are reading now and its accompanying talk, which I nicknamed “Looking the Part”: Patients’ Size-Based Biases Toward Their Practitioners and How to Handle Them.

Practitioners are patients themselves in other contexts, too, so understand that this is not about judgment or one party versus another. For healthcare to be most effective and for us to give ourselves the best odds of attaining whatever the desired outcome might be, patients and practitioners must work together, not oppose one another. We all have incentive to break down the walls of bias.

Other Biases

First, let us give ourselves some context by realizing that patients judge practitioners for other factors that are seemingly independent of size. For example, one study looked at how physician dress affects patient trust and confidence. The researchers found that white coats elicited greater trust and confidence by far compared to scrubs, formal business attire, or casual business attire. In fact, patients indicated they were much more willing to discuss sensitive issues like their psychological, sexual, and social problems based on the presence of said coat.

In another study, white-coat-wearing doctors were also found to be the preference of parents bringing their children to the emergency room. That is, unless their children were there for surgical emergencies, in which case they preferred doctors wearing scrubs, suggesting that perhaps clothing is interpreted as a sign of experience or perhaps expertise.

Other studies have found similar biases related to factors like hairstyle and even whether or not a practitioner wears a name tag, but of course all of these factors are readily modifiable. In other words, while practitioners can restyle their hair, wear different clothing, or put on a name tag if they so choose, other sources of bias are not so easily changed.

For example, a study found that parents selecting orthodontists for their children had significant biases toward young females. Youth was seen as more up-to-date with modern techniques, while females were seen as better at communicating and expressing empathy. While this might be great news for up-and-coming women working in orthodontics, it is not such good news for their colleagues who happen to be older and/or male.

Size-Based Biases

Just like there is not a whole lot we can easily do about our age or gender, our size (contrary to popular belief) is largely out of our hands as well. Let me share with you three of the studies that looked at patients’ size-based biases.

The first study was conducted at Yale where a team of researchers sought to examine what impact, if any, physician weight has on clinician selection, trust, and willingness to follow medical advice. The subjects were split into three groups with each group receiving the same exact survey except for one difference: the physical description of the doctor, who was listed as either normal weight, overweight, or obese in the different versions.

Their results showed that patients had less trust in overweight and obese doctors, were less likely to follow their medical advice, and were more likely to change to a different provider compared to normal weight doctors. In other words, subjects were so shaken by the doctor’s weight that not only were they less likely to follow said doctor’s advice, but they were more likely to switch to another provider. These weight biases remained present regardless of the subjects’ own body weight.

Anecdotally, we see examples of this. A colleague of ours recently told me a story about an experience she had. “I had a patient who was coming to see me to figure out if she wanted to be abstinent from substances. At the second session, she was crying and couldn’t look at me. [The patient said] ‘I have to talk to you about something . . . Look at the size of you. How could you possibly help me?'”

The second study, done at Johns Hopkins, found a different result. The researchers there looked at the impact that physician body mass index (BMI) has on the trust held by overweight and obese patients. Instead of verbally describing the doctors as normal weight, overweight, or obese, as the Yale study did, these researchers used pictograms to convey the same information.

They found that while the surveyed patients generally trusted their doctors, they more strongly trusted dietary advice dispensed by overweight physicians compared to their normal-weight colleagues. The results for other forms of advice, such as exercise advice, were similar, although not statistically significant.

This finding is probably the opposite of what many of you expected. In their discussion section, the researchers suggested that perhaps a patient and his or her doctor being roughly the same size creates some sort of bond of trust, and that is behind their findings. Of course, that is just a hypothesis that would require further study.

Meanwhile, we do see examples of patients who show preferences for larger providers. A fellow dietitian told me about an experience she had where a patient refused to let her intern sit in on their session. “When I sat down to do her session, she told me she was sorry that she asked the intern to leave, but she didn’t want another skinny dietitian telling her she can’t eat more than 1,200 calories and must record everything . . . She was relieved when she saw me.”

The third study was done at the University of Gloucester in the United Kingdom where the researchers sought to determine the influence that sports dietitians’ appearance has on selection and perceived performance. They surveyed 100 competitive athletes from 17 different sports in the United Kingdom and showed them computer-generated images of the same woman that were manipulated to feature her at four different sizes designed to represent BMIs ranging from 23 to 38. The athletes were then asked to rank which of these dietitians they would most like to work with and how effective they believed the dietitians to be at their jobs.

The two images of the dietitian as smaller fared best in both questions. In other words, based on nothing more than size, the athletes were significantly more interested in working with smaller dietitians and assumed those women to be better dietitians.

When I was talking with a fellow dietitian about the topic, he had this to say about how his size impacts his work: ” . . . more than anything I’ve really noticed the looks more than the comments. I can see someone look at my stomach as I talk to them and then back at my eyes. For some people, I can see how their body language changes in a negative way when they see what I look like.”

Discussion

So, back to the question I asked myself as an intern: What am I supposed to look like? The answer, to be quite candid, seems to be: Who knows! Some research suggests that patients prefer smaller practitioners, other research indicates they want larger practitioners, and of course some patients do not care, and they understand that the practitioner’s size has nothing to do with his or her ability to provide quality care.

However, whether the majority of patients prefer me at a particular size, or whether only the minority want me at that size, honestly does not matter too much. The nature of my work is one-on-one counseling, so the only person whose feelings really matter is the individual sitting at the table with me. When I am in an appointment with someone, who knows what feelings or biases he or she might have about my size. Although I need to be cognizant of the likely existence of size-based bias, if I make assumptions about the nature of said bias, then I am being biased myself, and that helps nobody.

If I want to provide the best quality care that I can, then my job is not to try in vain to hit some ever-changing target with my appearance, but rather to create a safe space where we can neutrally and non-judgmentally explore the size-based biases that patients bring into my office. This is where motivational interviewing can be so helpful.

Motivational Interviewing

My fellow panelist, Ellen Glovsky, gave a comprehensive overview of what motivational interviewing is and how it works, while I focused on how it applies specifically in the instances of patients’ size-based biases toward their practitioners.

First, let me draw a distinction between two motivational interviewing terms: resistance and discord. Resistance is known as sustain talk, arguments for the status quo, or reasons not to change. For example, a patient talking with his or her doctor about smoking cessation might say, “Smoking is so relaxing; I’d really hate to give that up.”

Discord, on the other hand, is not an issue of changing versus staying the same, but rather an issue in the patient-practitioner relationship. Think of some of the anecdotes I mentioned. If a patient walks into his or her practitioner’s office and says something along the lines of “How can you possibly help me? Look at you!” we know that discord is present.

When I encounter discord, the first point I try to remind myself of is to remain neutral. Although it is human nature to get defensive if we feel we are being attacked, practitioners must remind themselves that in professional relationships, the focus is on helping the patient, not getting into an argument.

Instead, I use techniques common in motivational interviewing, such as open-ended questions, affirmations, reflections, and summaries, to further the conversation in an effort to learn more about where the patient is coming from. Through the course of discussion, educational opportunities often present themselves. For example, the conversation might lead to the topic of social norms that are off base, such as the notion that one need be a certain size or weight to be healthy.

During these conversations, it can be tempting for practitioners to self-disclose further information about ourselves. After all, if my body is already the topic of conversation, why not throw in more information about it? The answer is because doing so typically does more harm than good. Instead of self-disclosure resolving discord, oftentimes it widens the gap between the patient and the practitioner, which is why I say so little about myself during my sessions and save self-disclosure for my blog.

Summary

The research confirms what many of us anecdotally already knew: Patients do often judge practitioners for their size. However, the specifics of the bias are inconsistent and instead vary from person to person, so it is important that practitioners like myself continue to treat you like the individual that you are and not make assumptions about what you think about our size.

Similarly, I encourage patients to acknowledge and keep in mind two points: (1) You cannot tell anything about how your practitioner leads his or her life based on his or her size with any degree of accuracy. (2) Your practitioner’s size is independent of his or her ability to help you.

If you do have feelings about your practitioner’s size, I encourage you to say so, as keeping it inside might hinder your work. In contrast, bringing it out into the open is an opportunity to learn. The two of you can then have a neutral, open-minded, and non-judgmental discussion about your feelings and point of view and then move forward together.

Guarantees

Posted on July 14, 2015 by Jonah Soolman

Nearly two weeks ago, I checked into the hospital for what was supposed to be a relatively minor procedure to address an “extremely rare” complication related to last year’s spinal fusion.

When the surgeon got in there, he unexpectedly discovered that my body had reabsorbed the implanted bone grafts while the rods and screws were loose and moving around. This happens in 3% of cases, he said, and he has no idea why it happened to me, as I do not have any of the risk factors for poor healing. As he delivered the bad news to me upon my awakening, he expressed surprise that I was even able to walk around in that condition.

In response to the situation, he had to completely redo the fusion, making for a much longer recovery than we anticipated. One planned night in the hospital became four. One week of missed work will now likely be three. One month of taking it easy now becomes a season, at least.

Twice I fainted in the hospital, and my blood pressure and pulse dropped so low for no apparent reason that they ran tests to see if I had suffered a heart attack, but really the hardest part of the whole ordeal has been coming to grips with the reality that everything I went through last year I must now do again.

However, the situation has been made easier thanks to the help and support of friends, family, an excellent team of nurses and physical therapists at the hospital, and of course my wife, who is now picking up the slack for me in every facet of our life.

Just 12 days before the surgery, I ran the Mount Washington Road Race and we celebrated at the summit. We thought we were at the top; little did we know we were heading back to the beginning. The lesson: I will never take days like that for granted, as they are never guaranteed to come again.

Day 366

Posted on March 20, 2015 by Jonah Soolman

Today marks the one-year anniversary of my surgery. Because my spirits were so dismal in the days immediately following the operation, on day 11 I began writing a log of the small daily victories that marked my healing and recovery. While I was initially unsure how long I would keep it up, I have maintained the log to this day and have no plans to stop, not when I still have so far to go.

One year ago tomorrow, I strapped on my back brace, leaned on a walker, and shuffled slowly from my hospital room to the nurse’s station and back, flanked by my wife and a physical therapist. Due less to pain and more to my fear that the operation had not worked, I cried the whole way.

Going into the operation, I was under the impression that I would not need a brace. When I found out the surgeon was prescribing one, I angrily and defiantly informed the nurse that I refused to wear the contraption. Over time though, I became attached to it. While the brace was at first just a literal support, over time it took on a figurative role as well, sort of like my version of Wilson the volleyball. During the first two months of healing, my brace and I walked for hours and hours together, and during long walks when I was otherwise alone, unsteady on my feet, unsure of my present, and scared of an uncertain future, my brace was always there to keep me upright and give me the courage to keep moving forward.

On day 67, we walked the entire Boston Marathon route together. Shortly thereafter, my surgeon told me it was time to stop wearing the brace. Truth be told, I was sad to jettison my sidekick. Finding the brace by surprise in the house triggers a similar fondness to randomly running into an old friend in the grocery store.

My surgeon was astonished by how quickly I progressed in the first few months after the operation. “You will be back to your crazy workouts in no time,” my physical therapist told me last summer. Turned out she was way off. As I wrote on day 197, we are only somewhat in control of our destiny and life does not always unfold the way we might expect or wish for ourselves.

Setbacks have been plentiful. Activities that my surgeon said should be fine at the time, like swimming, remained intolerable until seasons after his timetable indicated. Some of the bone grafts were unusually slow to heal and for a couple of months we faced the legitimate possibility that they might never fuse. Once I got the green light to resume weight training, I hurt one shoulder, then the other, and had to leave the weight room once again while I rehabbed them. Raking leaves in the November twilight and rushing to finish before darkness, I swiftly walked into my leaf blower, broke my big toe, and ended up in a walking boot. My most recent MRI showed a bulging disk at the surgical site, a highly unusual complication, and the radiating pain down my leg has returned. What can I say, Robert Smith taught me a long time ago that life is neither fair nor unfair.

Before the surgery, I expected that my healing would plot out a linear trajectory with each week being better than the previous one, but quickly I realized that was unrealistic and a setup for disappointment. Real life has its downs, but thanks to good fortune, hard work, and help from many people, it also has its ups.

Although my ultimate goal remains to resume playing competitive tennis and I am working hard in a physical sense to make that happen, simultaneously I am doing my best to prepare myself emotionally for the possibility that it may never come to fruition. Although I remain light-years away from returning to the court, accepting the latter feels much harder – and much less likely – than ever achieving the former. Past opponents and fictitious foes have contract court time in my dreams and we battle it out several nights most weeks, and my wife does not know that I often tear up when I watch her own matches from the sidelines.

Recovery does not end once the surgical site heals. Despite all that has happened in the past twelve months, in some ways I feel like I am still at the beginning of the journey with a long and unmapped future ahead of me. One year ago, I was bawling on a hospital gurney awaiting my turn in the operating room. Today, I went for my first run outside in 18 months. It was slow, short, uncomfortable, and really, really difficult. And it was totally and completely awesome.

One Step Backward for Dietitian-Kind

Posted on March 5, 2015 by Joanne Soolman

With National Nutrition Month upon us, I have been reflecting upon the work that I and my dietetic peers are doing with our patients. Are we helping to guide our patients toward better health? Are we presenting them with the most accurate, up-to-date, and appropriate nutrition advice based on peer-reviewed, evidence-based research in the field of nutrition and health? Are we acting ethically in our profession? I would like to think that most dietitians would answer yes to the above questions. We entered this field to help people, right? Well, unfortunately, some dietitians really get it wrong. And this can damage the dietetic field as a whole.

Recently, an article came across my radar screen, which illustrates the above point to a tee. In the article, entitled “I’m a Nutritionist. Here is How I Plan to Lose 20 Pounds,” Erica Sawers, a chiropractor and registered dietitian (RD), talks about how after giving birth to two children in the past three years and “indulging in croissants and treats” during both pregnancies, she wants to lose twenty pounds to get back to her pre-pregnancy weight. She then goes on to list seven ways that she plans to achieve her goal.

For the most part, this article is plainly ridiculous. In her first bullet point, Sawers delineates that she is going to set a “realistic goal” of losing one to two pounds per week. In the very next step, however, she says that she plans to “banish the scale,” by focusing on how her clothes fit rather than focusing on a number. She then follows that sentiment with “the most I will allow myself to step on the scale is once a week, and even once a month will do.” Um, ok. I’m totally confused now. So, are you going to weigh yourself or not? Because in my lexicon, banishment means “none.” And if the number isn’t that important to you, why set twenty pounds as your goal? Am I missing something here? Seriously.

Later in the article Sawers advises, “find a diet that works for you.” She then goes on to say that she herself avoids gluten, dairy and refined sugar, but doesn’t deny herself a few squares of dark chocolate or homemade cookies on occasion. Ugh. What she is describing sounds pretty restrictive to me. Honestly, who could stick to that regimen for an extended period of time without feeling horribly deprived? It is unrealistic to think that this way of eating would be sustainable for most people. And while someone might indeed lose some weight following her regimen, I would be willing to bet that the individual would regain the lost weight and then some.

As an RD, Sawers should know better than to write an article like this. As we all have heard many times before, diets fail 95 percent of the time, meaning only 5 percent of weight-loss attempts are sustainable. In fact, most people will end up regaining the lost weight and then some when they go off the diet. Research is also starting to point at yo-yo dieting as being more dangerous than just maintaining a higher weight, as it puts more stress on the body to chronically lose and regain weight. What Sawers is presenting is a diet, pure and simple. How can she publish something like this with the knowledge that the outcome will be failure for most people who try it and could result in increased health risks?

Instead of writing an article about how to lose weight, how about writing one about how to achieve better health? As Jonah and I have written about too many times to count, weight is not an accurate indicator of health – behaviors are. The research shows time and time again that the more healthy habits an individual has (e.g. not smoking, being physically active, eating five servings of fruits and veggies daily, and drinking moderately), the better that person’s health outcomes will be. These findings are independent of weight. Let me repeat that: it’s the behaviors, not the weight!

Unfortunately, Sawers’ article is not unique. I often see these types of nonsense blogs pop up all over the internet. If this was some random person’s article about wanting to lose weight and her strategies to do so, I wouldn’t have as much of a problem with it. But, Sawers is a registered dietitian. That means that many people will take her weight-loss guide as a how-to for themselves. As dietitians, we have a responsibility to present accurate information in an ethical way. This article misses the mark.

I Get Knocked Down

Posted on February 9, 2015 by Joanne Soolman

The first six weeks of 2015 have been pretty rough for me. It started on January 4^th. I made the fatal mistake of running down our wooden steps in just my socks. What happened, you ask? Well, I slipped and fell down the steps with such a thud that Jonah thought a piece of furniture had fallen on me! Luckily, the fall only resulted in a broken baby toe and a whopping bruise on my butt, but I was still pretty shaken up about it.

Just as I was healing from my trip down the stairs, I woke up the following Wednesday with my throat on fire and feeling feverish. My doctor told me to come in to her office so she could do a strep test on me. While the rapid strep test came up negative in her office, she took another swab and sent it to the lab. What are the chances that the second test would be positive? Well, apparently, they were pretty good – I had strep. I haven’t had strep since I was a kid, and boy, was this a bad strain. After taking a course of antibiotics, however, I started feeling better and thinking to myself that I was finally out of the woods.

How wrong I was! Just a week after recuperating from strep, I again woke up with another sore throat. This time there was no fever, and it was definitely better than the strep I had previously, but this illness along with a cough that is driving me crazy, just won’t seem to go away! Today I feel like I might finally be kicking this cold in the butt, but it has really wreaked some havoc on my mood.

All of these illnesses and injuries got me thinking – you know, I never really appreciated how wonderful it is to just be healthy until all of a sudden I wasn’t. I wish that I wouldn’t be so hard on my body when I feel like it has let me down. My body has gotten me through 36 (almost 37) years of life, most of which have been relatively healthy and safe. I should feel lucky that I can walk, swim, ride a bike or play tennis. Many people cannot do these things.

So, while the start to 2015 may not have been the best ever, I am determined not to let these past six weeks get me down. I love my body and everything it allows me to do. I will do my best to take better care of it, and that’s all I can do!

Intuitive Eating

Posted on February 5, 2015 by Jonah Soolman

Thanks to a colleague’s tip, one counseling technique I sometimes implement is a one-on-one book club of sorts where a patient and I read a book together that is relevant to his or her care. Recently, I have been reading Intuitive Eating with a patient who is working hard to overcome decades of approaching eating from the vantage point of dieting and to build a new relationship with food.

He has impressed me by how open-minded he is to a new way of looking at eating and by how candidly he has shared the thoughts, questions, and concerns that have come to mind during his reading. Now about a third of the way through the book, he reports that he sees himself in many, but certainly not all, of the case studies that the authors present. However, the idea of not depriving himself feels scary. Specifically, he notes that he loves having dessert, but that he is better off skipping it because one brownie so easily turns into four. Besides, he says, health must come into the picture somewhere, so there must be a “but . . .” caveat to the notion of not depriving oneself. He is waiting for the other shoe to drop.

His concerns are common among people who are at the early stages of putting aside the dieting mentality and learning intuitive eating. He is right that we certainly consider health. After all, I am a licensed health care practitioner. Before we take into account the hard science of nutrition though, we have to address the emotions that affect eating.

Sure, physiological mechanisms exist that yield pleasure when we consume foods that are high in fat, sugar, or salt. You are alive to read this because these mechanisms gave your ancestors an evolutionary advantage and they passed them down to you. However, the reason that one brownie turns into four has less to do with physiology and more to do with the morality that gets attached to them.

When we experience guilt for eating a particular food or virtue for abstaining from it, these emotions block us from being able to truly experience and honor the internal cues that our bodies give us regarding our eating. We eat the first brownie, feel guilty for having done so, and say “screw it, today is ruined” and then reach for three more. In essence, the idea of not depriving ourselves feels scary because in our minds it translates to opening the flood gates. In other words, brownies all day, every day.

In reality, that is not how the body tends to operate. When we strip away the morality of food and see our choices on a level playing field, we discover that the appeal of previously-forbidden foods drops considerably. Some days we may want an apple for dessert, other days we may not feel like dessert at all. And what if we go through the question tree of asking ourselves are we hungry, how hungry are we, what texture/temperature/color food do we want, do we feel like something salty, savory, or bitter, and how much of that food do we really need to be satisfied, and we determine that a brownie will indeed do the trick? Then we find the best brownie we can get our hands on, eat it slowly, enjoy every bite, stop when we are feeling satisfied, and know that we can have another one whenever our bodies are asking for one.

Ideally, the hard science of nutrition comes into play after this sort of relationship with food is established. We can talk about the advantages of one kind of cereal over another, or one kind of yogurt over another, or what have you, but we have to take into account the human element. Whole wheat bread is probably a better choice for someone with high cholesterol than is white bread, for example, but if forcing down the whole wheat because it has a better nutritional profile on paper is going to trigger some sort of overeating in search of satisfaction, then he or she is probably better off just having the white bread in the first place and getting his or her soluble fiber someplace else. On the other hand, if the two breads are pretty much equally enjoyable, then sure, he or she is probably better off with the whole wheat.

Learning to eat intuitively involves taking a leap of faith that we can largely trust our bodies to tell us what and how much to eat. Reestablishing that trust involves dialing down the noise of guilt and virtue that makes our internal signals difficult to hear. If you find yourself consuming piles of brownies, or none at all, consider whether or not you are truly listening to your body.

Psychology

Posted on January 28, 2015 by Jonah Soolman

At a large family gathering over the weekend, a distant relative asked me about my work. Upon hearing that I am a dietitian, he smiled, leaned in, and asked me one of the most common initial questions that dietitians field, “So, do you practice what you preach?”

Whenever this question comes my way, I experiment with different permutations and phrasings of the same core truth in order to see which version best resonates with people. In this instance, I told him that what I “preach” might not be what he imagines, and that in reality a large chunk of what I do involves helping people to listen to and honor their internal cues regarding hunger, fullness, and food cravings.

His eyes wandered elsewhere as I spoke, and I could tell that this version of my answer was most definitely not resonating with him. When I finished, he reflected back to me, “That sounds like psychology.” He is not alone in his confusion, as other people have reacted similarly upon hearing a summary of intuitive eating. However, reconsider my answer within the framework of the following examples.

When a diabetes educator discusses the symptoms of low blood sugar with his or her patient, is that psychology?

When a physical therapist instructs a patient on how to modify an exercise in response to pain or discomfort, is that psychology?

When a primary care physician listens to his or her patient recount the side effects he or she experienced on a particular medication, is that psychology?

When a personal trainer talks with his or her client about the difference between the temporary discomfort that sometimes accompanies exertion and warning signs of injury, is that psychology?

Of course not, none of these examples are psychology; they are just examples of various discussions that take place between patients and practitioners regarding the feedback that our bodies give us in particular situations.

Yet when a dietitian engages in a similar discussion with a patient, whoa, suddenly it is seen as psychology. 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?

Dietitians are not psychologists, psychiatrists, or social workers (Well, some are, but the vast majority do not hold such a license in conjunction with their dietetic credentials.) and we know our professional boundaries. Discussions of said internal signals are not only within the realm of our work, they are critical to its success.

Just as my relative expected a more concrete and specific answer that would have put some label on my personal style of eating, new patients often expect that a similar external structure, such as a meal plan or a calorie recommendation, will drive their care. Nutrition is not that simple. In fact, long-term success often hinges on paying less attention to external cues regarding what and how much to eat and putting more focus on the internal signals that our bodies give us. Does that sound like psychology to you?

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