Tag Archives: health at every size

Obesity Cuts Life Expectancy, Santa Is Responsible for Your Christmas Presents, and Other Misleading Statements

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My interest in writing a blog right now is pretty much nil, but I cannot let today’s misleading boston.com article entitled “Obesity Cuts Life Expectancy by Up to 14 Years, Study Shows” go by without reacting, for I know the damage that pieces like this do to people, including some of my patients.

Long story short: The researchers who authored the primary source article did not adequately control for behaviors. They screened out potential participants who had ever smoked and/or had a history of certain diseases, but the lifestyle behavior information they collected from participants was limited to alcohol use and physical activity level. Researchers collected no information about other lifestyle factors, like stress management and eating and sleeping habits, all of which can impact health. The behavioral data they did collect was self reported, which introduces all sorts of error. Other research has shown that when behaviors are controlled for, body weight does not seem to matter, but the study design that these authors used prohibited any opportunity from being able to confirm or refute those findings.

The boston.com piece discusses a second article as well that examined the relationship between obesity and exercise. In reference to this latter article, the boston.com piece’s subheading concludes with, “And it’s under-exercise, not overeating, that’s causing America’s [obesity] epidemic.” That eye-catching text will certainly garner many clicks, which is unfortunate because it is not true. The actual research piece reads, “The research highlights the correlation between obesity and sedentary lifestyles, but because it is an observational study, it does not address the possible causal link between inactivity and weight gain.”

I cannot stress it enough: Correlation is not causation. They are entirely different. I know, I know, we each know somebody who has put on weight after they stopped working out. Sure, that does happen sometimes, but on the macroscopic level that is the population, the picture is much more complex than that with many other factors in play.

The boston.com article’s final paragraph begins with, “Losing weight is proven to significantly reverse the health effects of obesity.” Wrong. When we adapt healthier lifestyle behaviors, our body weight might change as well, but if we credit the weight change instead of the behavior change then we have it backwards.

The harm in all of this is that it reinforces a weight-centered model of eating and physical activity that ultimately fails nearly everybody who uses it. If we take a weight-centered approach and do not maintain the weight we want, we risk losing motivation and reverting to old behaviors because the goal was unattainable.

There is a better way. In the health-centered model that we advocate, the behaviors in and of themselves matter independent of weight. Whether weight goes up, down, or stays the same is irrelevant because the behaviors themselves are what count. Better-designed research seems to support this model: When we control for behaviors, health and weight look to be independent.

Health-Focused Weight Management

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“So I was just reading the Huffington Post article that you guys posted on Facebook. Serious question, is it possible that the pride in your body movement has gone too far? I understand the evils of anorexia, bulimia, and other eating disorders, but being fat, especially as fat as the woman in that article, is bad, right? If I eat unhealthily and stop exercising, I gain weight (see, e.g., the 4 months after [my son] was born). So fat [name omitted] is more unhealthy than skinnier [name omitted] (to a degree, of course). And the people who I know that are overweight clearly have the worst eating habits and some of them have ended up with diabetes, high blood pressure, and cardiovascular problems.

“So why this big movement of pride in your body no matter how fat you are? I feel like it’s teaching a dangerous message. That lady in the bikini needs to lose weight by changing her diet and exercising more, doesn’t she? Being thinner will inevitably be better for her health and decrease the risk of her getting weight-related health problems. So why are we celebrating her being proud of how fat she is and then broadcasting to the world that she should be proud of her body no matter what?”

One of my best friends sent me the preceding email in response to me posting the Huffington Post article he mentioned on our Facebook page. We have been friends for decades and I know he asks these questions with honest, open-minded curiosity. Here are the points I wrote back to him.

1) Obesity is associated with health problems, but to my knowledge the legitimate research has never established a causal relationship despite attempts to do so. In fact, what the research has shown is that behaviors (smoking, physical activity, fruit and vegetable intake, proper sleep, limited alcohol consumption, etc.) are the real predictors of morbidity and mortality. When we control for these sorts of lifestyle choices, health outcomes are basically the same regardless of body weight.

2) Even if being obese was in and of itself a legitimate health problem, we really do not know how to help people lose weight and keep it off for the long run. The research shows that about 95% of the attempts people make to intentionally lose weight fail in the long run, and the majority of these people end up heavier in the end than they were at baseline. Weight regain can be due to behavior change, but it can occur even when the behaviors that yielded the weight loss are maintained. From an evolutionary perspective, consider that we are designed to keep on weight, not lose it, for the sake of survival. I have a patient who lost about 40 pounds, her motivation to keep it off is sky high, and she is very strict about maintaining the behaviors that got her weight down. Yet the weight is starting to creep back on slowly but surely. We can only do so much to fight biology.

3) When somebody tries to lose weight and it does not go as planned, the endeavor is not necessarily harmless. In other words, they do not automatically just return to baseline as if nothing happened. Weight cycling can cause everything from depression to metabolic issues like high blood pressure and high cholesterol. Given that 19 out of 20 weight-loss attempts fail, we need to really consider these risks.

4) The social stigma about being overweight pushes people into weight loss attempts, which we know are likely to fail them. We have a “war on obesity” in this country, which is ridiculous considering there are people everywhere making all sorts of behavior choices that could legitimately be considered unhealthy, but they do not face the same ridicule. Where is the outrage against people who do not get enough sleep? Why don’t we bitch about inadequate sleepers raising health care costs for the rest of us? Why don’t people who yawn in public seem to face the same bullying and looks of disgust that many obese people deal with on a regular basis? Our culture is so unaccepting of people who we deem overweight that we push them into weight-loss attempts that will likely leave them less healthy in the long run.

5) Because they are trying so hard to lose weight, Americans spend upwards of $60 billion annually on weight-loss programs and products. That’s insane. Imagine if we took those same resources and put them towards things that would actually help with health: cooking lessons, sports equipment, fruits and vegetables, walking shoes, gym memberships, comfortable mattresses, etc.

It is true that when somebody adapts unhealthy lifestyle choices, he or she might gain weight. If we have a baby and no longer have time for physical activity or proper sleep, for example, our weight might increase. The weight gain itself is just a symptom of the problem though, as opposed to actually being the problem. The real issues at hand are the lifestyle changes that happened to result in weight gain.

At the same time, we cannot conclude that somebody who is heavier automatically has an unhealthy lifestyle. Too many factors, including genetics, are in play. If we look at a heavier person and make any assumptions about how he or she leads his or her life, we are showing a prejudice that is as abhorrent and as any other stereotype.

The approach I take with my patients is to focus on behaviors, establish healthy lifestyle choices, and let the weight settle wherever it naturally belongs. Because our weight may or may not end up where we, our moms, our partners, society as a whole, etc. would like it to be, I encourage people to love and accept themselves no matter what they look like or weigh. That is why the Huffington Post piece and similar posts that confront weight stigma and call for size and weight acceptance are so important.

Looking the Part

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Wow, I am hard pressed to remember an instance when something I read made me as angry as Juliann Schaeffer’s article in Today’s Dietitian entitled “Dietitians and Their Weight Struggles.”

In summary, the article contains quotes from dietitians who offer their opinions as to whether or not a dietitian’s weight and appearance should matter. Although the piece improves at the end when some sanity and rationality is injected into it, the beginning quotes from one of my fellow dietitians are so shamefully off base that I feel deeply embarrassed to be associated with her.

“If someone has a weight issue, then in my opinion, they should choose a specialty that does not conflict with being overweight.”

“If you can’t make it work for you, how can you make the case for someone else?”

“. . . the reality is that health care is a business, and people do judge you by appearance. Is it right or wrong? That doesn’t make a difference. It’s a business, and it is what it is whether we like it or not.”

“I wouldn’t think much of advice from a cardiologist if I knew he had had a heart attack.”

So wait, are we dietitians supposed to list our BMIs on our resumes and websites now, or how does this work?

It is one thing for some personal trainers, chiropractors, life coaches, “nutritionists,” therapists, doctors, and other dietitian wannabes to go outside the scope of their expertise and give harmful dietary guidance, but when an actual dietitian represents the profession the way she has there is just no excuse for it. This is our wheelhouse. We should be better than that.

When I was an intern, I had a rotation in a bariatric surgery clinic where two dietitians worked. One was heavier, one was leaner. Some patients did not want to work with the heavier one because they questioned, “Look how heavy she is; how can she possibly help me?” Yet other patients did not want to work with the leaner dietitian because they worried, “Look how skinny she is; how can she possibly relate to what it is like to be fat?”

Last year, a new patient told me she almost cancelled her appointment because she was intimidated by what a “great athlete” I was. Just a few months ago, another new patient came to me all impressed that I had “beaten cancer.” Well, no, I did no such thing. She had misunderstood my online autobiography. When I told her that, she deflated like a balloon.

Let’s get real for a moment. The whole notion that a practitioner has to look or behave a certain way in order to help patients is incorrect. Out of all the questions I asked the surgeons I met with before my most recent back surgery, I never thought to ask who among them has back problems. But I should have because if a surgeon has back problems then it is logical to conclude he or she cannot help me with my issues, right? Or wait, I want a surgeon with back problems because he or she can relate to my experience, is that how it goes?

How about just finding the surgeon whose approach, experience, and demeanor made me feel most comfortable and confident? I know, crazy me and my outlandish notions.

During my first year as a personal trainer, few members were interested in my services. Although I had good relationships with many of them and they routinely asked me questions about exercise, few were willing to cross the line of actually hiring me. However, after I took two months off to ride my bike across the country, suddenly members were booking sessions with me left and right and my boss began to refer new clients my way, too. Other trainers treated me and my opinions with more respect. The gym even gave me a raise without me asking for it.

Come on.

Sure, more money and clients were great, but the driving force behind the upturn in business was so ridiculous that I felt insulted. It took riding my bicycle 4,000 miles, up and down mountain ranges, through all sorts of weather, for my expertise to be recognized and taken seriously? The ride did not make me a better trainer. If anything, I was a worse trainer after my trip because I was rusty from not having worked in two months. But hey, perception is all that matters to some people.

Right now, I have a patient who wants to be a CrossFit coach and feels she needs to lose 15-25 pounds in order to be taken seriously by potential clients. Sure, she has room for changes in her lifestyle, just like we all do, but she generally eats well and takes great care of herself. As disappointing as it is for her to hear, it seems her body just naturally belongs 15-25 pounds heavier than she would like it to be. Do I push her further down the path she feels obligated to follow, risking perhaps disordered eating or an eating disorder, as she sacrifices health for a number and a look, or do I guide her towards the reality that she can be a great trainer no matter her weight and appearance?

Due to my surgery, it has been seven weeks since I lifted weights and did any physical activity in earnest. Muscle atrophy is setting in. My shoulders and chest are smaller. My six pack is gone.

Am I a worse dietitian now than I was two months ago?

What if you did not know that major surgery had affected my fitness and you came in here and saw a scrawny dietitian without any context? Would you have less confidence in me than if you knew about my operation?

What if I had not undergone surgery and I just decided to take two months off from working out?

What if I had a healthy relationship with both physical activity and food, but my body just happened to be thinner, less muscular, or heavier than society feels its dietitians should look? Would you go elsewhere?

I have blogged about my athletic accomplishments, such as my mountain running, on a small handful of occasions because it can enhance patient care for them to understand that I am a human being with a life outside of this office and I face challenges just like everybody else. Perhaps patients garner some inspiration from those postings, but if anybody reads one and then comes to see me with the mindset, “Jonah is thin and Jonah is an athlete; therefore, he can help me,” God, that would just make me want to take all of the posts down. I just cannot be part of that act.

The purpose of self-disclosure is to enhance patient care, not to serve as an advertisement, not to capitalize on misconstrued ideas, and certainly not for a practitioner to defend or justify his or her behaviors or body shape.

I disagree with the notion that health care is a business. The first priority should be patient care, not money. If the dietitian I quoted earlier had her priorities in order, she would be helping to reeducate her patients and change a culture of misunderstanding rather than playing into it for profit. Giving people what they want and expect for the sake of financial reward does not justify providing poor care and perpetuating a myth.

Or maybe I should just play along and take up steroids, lest patients go elsewhere because I no longer look the part, right?

Come on.

Body Image and Self-Acceptance

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Between the blogs Joanne and I have written, as well entries by others that we have shared, we have posted quite a bit lately about body image and self-acceptance. While the link between these topics and nutrition is likely obvious to some readers, it occurs to me that it might not be so apparent to others and an explanation is probably in order.

The driving force behind our food choices is multifaceted. When I gave a talk to the FDA last month, the participants and I brainstormed a list of factors that influence our eating: perceived nutritional value, health concerns, availability, cultural norms, emotions, ethics, allergies, culinary expertise, previous experiences, finances, taste, time, and personal goals, just to name a few.

Within personal goals often lies a desire to look different. Consider the following examples: A model severely restricts his or her eating, becoming anorexic in the process, in order to gain a certain look. A naturally-slender man, convinced that his lean frame is responsible for him still being single, forces himself to overeat in hopes of gaining weight and finding a partner. A husband tells his wife that she is “not ready for that dress yet” and so she diets, convinced that he will not be attracted to her until she loses four more pounds. A young lifeguard, self-conscious about being in a bathing suit all day, becomes bulimic.

Those are all real people who we know, either through our work or our personal lives, and they are all examples of individuals adapting unhealthy eating behaviors because of how they feel about their appearances. Therein lies the problem: More often than not, dissatisfaction with how we look leads not to healthier lifestyles, but to harmful behaviors.

Oftentimes, a deep issue is being displaced and playing itself out through one’s food choices. Therefore, in addition to working together with us on their eating, we encourage our patients, when appropriate, to work with a qualified therapist on severing any link they may have between their appearance or weight and their self-worth, and to love and accept themselves the way they are regardless of their size or shape.

As these issues fade away, space is created for a healthier, simpler, and more satisfying relationship with food.

What Not to Say to Someone With an Eating Disorder

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It’s National Eating Disorder Awareness Week, so to stay with that theme, I thought it might be worthwhile to write about one of the most common questions I get from parents of my eating disorder (ED) patients: “What should I not say to my daughter/son who has an active ED?” Working with hundreds of ED patients and their families, I have compiled a list of “what not to say to or around your loved one who is struggling with an ED.” Here are three comments that could be triggering to your loved one.

1) “You look so healthy! How could you possibly have an ED?”

On the surface, this seems to be an innocuous and even positive comment. But, all the ED patient hears is: “You don’t look emaciated enough to have an ED. So therefore, you are fat.” Clearly, this is not what the speaker intended, but someone with an ED has a very distorted view of themselves and how others perceive him or her. It’s important to remember that people with EDs come in all shapes and sizes and it really isn’t possible to determine the severity of someone’s ED just by looking at him or her.

2) “I can’t believe how fat I’ve gotten! That’s it, no more carbs ‘til Christmas!”

I can’t tell you how many times my patients tell me that one of their parents has uttered the above. A parent might think that since the comment is about himself or herself, it shouldn’t be triggering to the child. This is incorrect. Kids learn by example and if they hear you talk badly about yourself and be critical of your body, they will think it’s okay for them to talk badly about themselves and criticize their bodies. This just fuels the ED even more.

3) “I know she needs to gain weight to be healthy. But we don’t want her to gain too much weight, right?”

Yes, I have heard these words from a number of parents and in front of their kid, no less. Weight gain is often a requirement in the recovery for anorexia nervosa. But weight isn’t the only factor that needs to be measured. Vital signs such as heart rate and blood pressure both lying down and standing up are very important indicators of health. Other measures of health include blood tests to look at nutrition status, whether or not a menstruating female has lost their period, and bone density. EDs take a toll on the entire body, not just weight. By keeping the focus on weight, we are fueling the idea that weight is the end all and be all. This is just not true.

Obviously, none of the above comments are meant to be malicious – we all want the best for our loved ones. But, it’s important to think about how your comment might be perceived by your son/daughter/sister/friend. We can’t edit ourselves every minute of every day, but by being aware of your words, you could spare your loved one (and yourself) a lot of unnecessary grief.

Balance

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A couple of people sent me the link to this article about identical twin brothers who performed a nutrition experiment on themselves.  One of them adopted a diet very low in fat while the other followed a diet extremely low in carbohydrates.

By the end, neither one of them felt well.  One brother concluded, “We should not vilify a single nutrient.  It is too easy to demonize fat or sugar, but that enables you to let yourself off the hook in other ways.  The enemy is right in front of us in the shape of processed foods.”

While I agree with the first part of what he said, his last sentence undermines his initial point.  Just as it makes no sense to scapegoat a particular nutrient that exists in the larger context of one’s eating pattern, it is similarly ridiculous to blame a particular form of food (in this case, processed food) that exists in the vast expanse that is one’s overall lifestyle.  To do so is to badly oversimplify what is a very complex picture.  Exclusion, oversimplification, and blame rarely lead to good nutrition.

The people I have seen who have been able to attain and maintain good health are the people who find balance: balance in their eating, and balance in their lifestyles.  Every food has its pros and cons and therefore no food is “the enemy.”  Even processed foods have their upsides: enjoyment, convenience, shelf life, price, etc.  Otherwise, nobody would ever eat them.

While eating processed foods all the time clearly has ramifications, so does never eating them.  Decreased enjoyment, social isolation, weight gain (yes, gain), preoccupation with food, and eating disorders can all result from this kind of restriction.  Misled by a culture of dieting and nutritional scapegoating, many well-intentioned individuals struggle with these issues.  Joanne and I regularly work with such patients at our practice, where we help them to find a healthier relationship with food and ultimately better health overall.

The time to leave exclusion and scapegoating behind is now.  Instead, understand that every food can have its place in a healthy lifestyle.  Pursue balance.  We are here to help.

Is the Risk of Foodborne Illness Worth It?

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Almost immediately after posting a Wall Street Journal article entitled “Does Rinsing Fruit Make a Difference?” on our Facebook page yesterday, I got an email from a family member talking about pre-washed salad mixes in the past tense (“What a convenience they were.”) and asking me if I will change my own eating habits because of this article.

When it comes to foodborne illness, risk always exists.  One can take every known precaution and still contract a foodborne illness, or one can grotesquely forgo all food safety guidelines yet not get sick.  The question is not one of risk’s presence, but rather one of risk’s relative magnitude.

Each one of us has to decide for ourselves how much risk we are comfortable taking.  The article talks about the health of one’s immune system as being an element of consideration, but other factors are in play, too: What does one like to eat?  What can one afford?  How much time does one have for food preparation?  What are the realistic alternatives if one forgoes a given food?  Pros and cons exist for eating and not eating a given food, and these must all be considered before reaching a conclusion. 

The answer to my family member’s question is no, I will not be changing my own eating based on this article.  Generally speaking, I do not care for vegetables.  I know, I know, a dietitian who does not like vegetables.  As it turns out, dietitians are people too and we have our own challenges with food just like everybody else.  The modes in which I enjoy vegetables are slim: carrots and peppers dipped in humus, spinach in lasagna, and broccoli and mushrooms on pizza.  In terms of true enjoyment, that’s about it.

Raw salad greens topped with fresh fruit and nuts are moderately enjoyable, but the tipping point is such that convenience is a major factor for me.  Take away pre-washed salad mixes and the likelihood that I will buy whole greens and prepare a similar mixture on my own is very slim.  Therefore, when I weigh their benefits against the risk of foodborne illness, continuing to consume pre-washed salad mixes makes sense for me.

Somebody else might reach a different conclusion for his or her own life and that is perfectly fine.  My case is nothing more than an example; I am not suggesting that others should or should not reach the same conclusion for themselves that I have reached for myself.  Everybody has different needs, priorities, goals, and constraints, which is why Joanne and I feel so strongly about providing individualized nutrition counseling that is customized for each one of our patients.

He Said, She Said: New Year’s Resolutions

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You already know that New Year’s resolutions do not typically last, but you have not yet heard our opinions as to why and what you can do about it.

He Said

A few weeks is not yet enough time for most New Year’s resolutions to have fallen apart, but if past statistics are any indication, by the end of the year only 8% of us will have been successful in achieving our resolutions.  The poor rate of conversion from resolution to reality is partly due to the goals themselves, as Joanne will discuss below, but being honest with ourselves about how ready we are for change is of utmost importance, too.

According to the Transtheoretical Model describing behavior change, individuals can fall into any one of five stages.  The preceding link gives detailed explanations of each stage, which I will concisely summarize below.

  • Precontemplation: The person does not see a problem and therefore has no intention of changing.
  • Contemplation: The person recognizes that a problem may exist but feels ambivalent about what to do.
  • Preparation: The person has decided to make changes and is formulating a plan.
  • Action: The person is implementing changes but has not yet maintained them for six months.
  • Maintenance: The person has maintained the given changes for six months or longer.  (Note: Some versions of the Transtheoretical Model also throw in an additional stage, Termination, but often this stage is considered part of the Maintenance stage.)

Classically, the idea is that a person moves from one stage to the next in the sequence in which I listed them, but in reality someone can jump from any one stage to another at any point in time.  The Model is not perfect, but it expresses an invaluable truth: Not everybody is ready to change.

This truth, by the way, is perfectly fine.  Change is a process, as the Model indicates.  When Joanne describes our counseling approach to people unfamiliar with how we work, she often tells them, “We meet our patients where they are.”  She does not mean that literally as if we make home visits; rather, she is referring to their stage of change.  Recognition of said stage is critical to successful counseling.

What do you think would happen if I counseled a patient on the changes he can make to his eating (thereby treating him as if he is in the Preparation stage) while he does not even see a problem with his diet and came to my office only because his doctor insisted he see a dietitian (which suggests he is in the Precontemplation stage)?  He would not feel heard, the session would be unproductive, in all likelihood he would not return for another session, and whatever health condition he is dealing with would remain a problem.

Conversely, if I listen to him without judgment as he shares his emotions and opinions, acknowledge the validity of his feelings and point of view, and discuss his doctor’s concerns with him, he may transition to the Contemplation stage and move closer to ultimately making and sustaining behavior changes that will improve his health.

Alternatively, perhaps after learning more about his condition and the potential consequences, he decides that he will maintain his current lifestyle anyway, at least for now.  It is his life, he can do what he wants with it, and I respect his choice without judgment.  At least he will have had an opportunity to weigh his options and make an informed decision.

Similarly, we each have to meet ourselves where we are at, too.  In other words, when we make New Year’s resolutions, we have to be honest with ourselves about how ready we are to make the given change happen.  The calendar’s flip from December to January does not automatically transition us to the Action stage.  In all likelihood, if we were truly in the Action stage, we would have implemented the change before New Year’s rather than wait for the holiday.  Willpower can only force change for so long.  Whatever was holding us back before New Year’s will remain and ultimately catch up to us after the holiday and bring an end to the resolution.

Instead of setting yourself up for failure by setting a goal that is unfit for your readiness to change, use the New Year as an opportunity to be honest with yourself about your health and how you feel about it.  In other words, meet yourself where you are instead of forcing yourself to take an action before you are truly ready for it.  Reach out for whatever information or support you need.  Consider the following examples:

  • A husband in the Precontemplation stage might give in to his wife’s urging to finally make an appointment with a dermatologist to have his strange-looking mole examined if for no other reason than to appease her.
  • Perhaps a diabetic in the Contemplation stage might decide to schedule an appointment with his doctor to discuss his ambivalence regarding monitoring his blood sugar at home.
  • An individual in the Preparation stage might meet with me to plan specific and achievable changes to his eating that will improve his cholesterol, then go home and discuss the upcoming changes with his family.
  • An osteoporosis patient in the Action stage might continue to use the package of personal training sessions she bought so she can continue learning how to lift weights safely and preserve her bone structure.

Most important, remember that New Year’s is just an arbitrary point, and one need not wait for a new calendar year to start the process of making change.  Said differently, we do not need an exterior cue to trigger internal change.  When we are truly ready, we will make the change happen no matter what date it is.  One of my favorite quotes is from Andre Agassi’s Hall of Fame induction: “ . . . every journey is epic, every journey is important, every journey begins today.”

 

She Said

Mid-January through the beginning of February is a tricky time for many of my patients.  Their motivation for keeping all of their nutrition resolutions is starting to dwindle, and many people feel like they have failed in one way or another.  What I often find is that many of my patients had set the bar too high in terms of nutrition goals.  They expect too much from themselves and have no other option than to not meet their goals.  Most of these goals are so overly ambitious that it would be very difficult for almost anyone to follow through with them.

So what’s a person to do?

When my patients ask me for help setting nutrition goals, I tell them to think S.M.A.R.T., as in goals that are Specific, Measurable, Attainable, Relevant, and Time-bound. No, I didn’t invent this clever mnemonic; it has been attributed to George T. Doran who wrote a paper called There’s a S.MA.R.T. way to write management’s goals and objectives in the November 1981 issue of Management Review.  But I really like the simplicity of this handy acronym.

Specific goals are those that are clear-cut and unambiguous.  Examples of specific goals could be “I will make a kale smoothie for breakfast…,” or “I will prepare a new salmon recipe…”  Measurable means that the goal must be quantifiable in some way so that you can clearly assess your progress.  This can be accomplished by adding to the above goals; for example, “I will make a kale smoothie for breakfast 2 times….” and “I will prepare a new salmon recipe one night….”

Attainable goals are those that are ones that realistic for you.  If, for instance, you know that making a kale smoothie for breakfast 5 mornings per week isn’t likely to happen (e.g., you often sleep late and don’t have time, you have difficulty going to the grocery store to get the ingredients, etc.), then shoot for something you absolutely know you can do.  In other words, it’s much better to start with smaller goals and then build on them than to start with goals that are too ambitious for you.

Relevant goals are ones that are worthwhile and applicable to you.  If upping your omega-3 intake isn’t that important to you, then don’t set a goal to eat more salmon.  By the same token, if you are already succeeding at one area of your nutrition (say, getting your leafy greens), then maybe it’s time to focus on something else, like increasing your nut intake.

Finally, it’s important that your goals are time-bound, that there is a particular time frame for achieving them.  You could add on to the examples given above: “I will make a kale smoothie for breakfast 2 times this week,” and “I will prepare a new salmon dish one night per week for two months.”  By giving yourself a deadline, you will be more likely to achieve your goal on or before that deadline.

If the above seems a bit much, the one piece of advice I give all of my patients is to keep it simple.  When goals are overly complicated and ambitious, it can be overwhelming.  And be kind to yourself – you are human, after all!

The Real You Is Sexy

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Aerie, the lingerie branch of American Eagle, is going with a “The Real You Is Sexy” campaign for their spring line.  My understanding is that the ads are not retouched in any way and show the models just as they were when the photographers took their pictures.  Aerie deserves credit for this move, but this change alone does not fix the underlying problem.  The greater problem is with us, not the fashion industry.

Reality is more complex than I am about to make it seem, but the basic premise is that we compare ourselves to models, feel pressure to look like them, feel bad about ourselves for not looking like them, and adopt certain behaviors – healthy or not – in an effort to match them.  Other advertisement campaigns that do retouch photos can dramatically alter a model’s appearance making him or her seem flawless.  When such a picture is held up as the ideal, we are comparing ourselves to someone who does not even exist.  As such, who can possibly live up to that standard?  Aerie deserves credit for at least removing this as a factor from the equation.

The larger problem though is that we compare our bodies to others in the first place, and that is not going to go away even if the fashion industry completely does away with retouching.  For example, I work with a patient who watches women leaner than herself pass by in town and feels bad about herself as a result.  No retouching there; she is comparing herself to people she sees with her own eyes.

We do not know what somebody does to look a certain way.  I do not know any of the Aerie models and I have no idea what they do to maintain their looks, but chances are neither do you.  They might look the way they do because they are genetically predisposed to have that figure and on top of it take excellent care of themselves.  On the other hand, they could also look that way due to eating disorders, overexercise, or other unhealthy behaviors.  One of my patients, a former model who is working to overcome anorexia, tells me of the pressure in the industry to gain a certain look at any costs, healthy or not.  If a model gets his or her frame through an eating disorder, are we really to look up to that image as an ideal just because there is no retouching involved?  In that sense, we still should not be using models – retouched or not – for a point of comparison.   

To further the point, we should not be comparing our bodies to anybody else either.  I discussed with my patient, the one who compared herself to other women in town, that we have no idea what those women do to maintain their looks.  Some of them are probably perfectly healthy, while others might struggle with eating disorders or other unhealthy behaviors.  Some of them are deeply unhappy and live rigid lives in isolation so they can do exactly what they need to do in order to maintain their physiques.  Some of them would laugh if they knew other people look up to them because no matter how great somebody else says they look, they still hate their bodies themselves.  I know all of this because I just described patients of mine.  These problems are much more prevalent than one might think.

It is time to stop comparing our bodies to others.  Weight, waist-to-hip ratio, and other anthropometric measurements do not define us and should not determine our self-worth.  Love and accept yourself the way you are now, not X pounds from now, and focus on leading a healthy lifestyle built on a foundation of balance.

The Lottery

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Ralph Francois, of Quincy, won $1,000,000 playing Mega Millions. Marjorie Teixeira, Frank DiMascio, and Christine Cummings, of Melrose, Watertown, and Dedham, respectively, all won lottery prizes on the same December day. Stanley Goryl of Smithfield, Francis McPherson of Somerville, Marque Scott of Fall River, Patricia Cannata of Attleboro, and Linh Dang of Dorchester are just a few of the 15 locals who won at least $1,000,000 through the lottery last month. Their pictures, smiling and holding up enlarged replicas of their winning tickets and prize checks, are both evidence of their victories as well as enticements to the rest of us suggesting that we can be winners too.

Despite these testimonials that fill us with hope, most people do not walk away a winner.  Massachusetts lottery players, on average, will only win back $0.72 for every $1.00 they spend on lottery tickets. According to a study by Bloomberg, state lotteries “have the worst odds of any form of legal gambling” in the country. To put things in perspective, one reportedly is 1,400 times more likely to die in an asteroid apocalypse than he or she is to win Powerball. As if the odds themselves were not concerning enough, playing the lottery can sometimes spiral out of control. A link on the Massachusetts State Lottery’s website directs people to where they can get help for compulsive gambling.

Some people enjoy gambling, including the lottery, and as one of my friends said to me recently, “You can’t win if you don’t play.” Going about it with a sporting attitude for the sake of entertainment and excitement is one thing, but nobody actually believes that playing the lottery will really net a profit, right? Wrong. According to a couple of 2005 surveys put out by the Consumer Federation of America and the Financial Planning Association, 21% of the surveyed Americans believe that winning the lottery represents the most practical way for them to accumulate several hundred thousand dollars. I imagine one would be hard pressed to find a legitimate financial adviser who would suggest that playing the lottery is a sound investment strategy.

Given the time of year with people around me making all sorts of resolutions, the clear parallel between playing the lottery and resolving to lose weight has been on my mind. Joanne and I have written extensively about the chronic failures of weight-centered dietary approaches. Although the exact outcome depends on the specific parameters of the given study in question, research across the board shows that the chances of keeping off lost weight are poor. According to one group of researchers, “Less than 20% of individuals that have attempted to lose weight are able to achieve and maintain a 10% reduction over a year. Over one-third of lost weight tends to return within the first year, and the majority is gained back within three to five years.”

Joanne and I advocate focusing on health rather than weight. In that sense, weight outcomes are only somewhat interesting to us. However, for programs and approaches that revolve around weight, shouldn’t the results at least be better than this?

However, just like people who play the lottery despite the terrible odds of making a profit, we get sucked in by glamorous testimonials, peer pressure, advertisements, and the like, all encouraging us to lose weight. We enter the weight-loss game with the expectation, whether by delusion, misunderstanding, or overconfidence, that we will be the rare exception who comes out on top. “You can’t win if you don’t play,” right?

The difference is that we are not playing a game; we are playing with our health. At best, the weight-loss-weight-regain cycle postpones behavior change that will actually improve our health. More likely, the cycle itself can leave us in a less healthy state, either physiologically, psychologically, or both. Furthermore, just as the lottery can lead to a gambling addiction, weight loss pursuits can lead to serious eating disorders which add a whole new layer of complexity to one’s health problems.

Instead of entering a game that you are likely to lose, leave weight-centered approaches behind and focus on making healthier choices. No, lifestyle change is neither sexy nor rapid. Lifestyle change does not make for good reality television. What it can do though is increase your chances of getting healthy and staying that way.