He Said
Our society’s problematic relationship with food has many elements, one of which is that we make sweeping generalizations and place foods, ingredients, and nutrients into dichotomous groups: good vs. bad, healthy vs. unhealthy, sinful vs. virtuous. When we use language like “good for you” to describe a given food’s supposed impact on our health, who is the “you” to which statements refer? That answer makes all the difference.
Those charged with shaping nutrition policy are faced with an impossible task. They do their best to create guidelines for the general population, but their advice fails much of the group because the truth is that when it comes to nutrition, individualization is a necessity.
In contrast, I have the privilege and good fortune to be able to focus on only one person at a time: whomever is joining me at my counseling table at any given moment. Recent conversations with some of my patients reminded me of just how essential it is to customize nutrition guidance.
For example, one evening I had back-to-back patients, one of whom utilizes whole grain products to her advantage in helping her stabilize her blood sugar, while the other must temporarily avoid such high-fiber food because of his acute gastrointestinal condition. If I had made a sweeping statement about whole wheat bread being “good for you,” I would have failed at least one of them.
Another day, I had a patient who is working to increase his potassium intake for the purpose of improving his hypertension and another patient who has renal disease and is on a potassium restriction. So, is a high-potassium food like cantaloupe “good for you” or what?
A couple of weeks ago, a patient referred to Gatorade as “crap,” to which I neutrally responded by mentioning that I drink it during long marathon training runs. He continued to say that my situation is different than his, which was exactly the conclusion I hoped he would reach when I decided to disclose that a beverage with no redeeming qualities in his eyes actually works quite well for me.
My one-decade anniversary of becoming a registered dietitian is coming up this summer, and during all my years of practicing, I cannot remember two patients who ever came in with the exact same set of circumstances. In reality, our situations are always different, as each of us has a unique set of health concerns, preferences, histories, cultural norms, financial considerations, and all of the other factors that together shape one’s relationship with food.
Instead of dividing foods into dichotomous groups that reflect sweeping generalizations about what is “good for you” in reference to the general population, take a morally neutral and pragmatic approach built on individualization. Recognize that every food has a set of attributes – including taste, cost, availability, nutrient content, and preparation options, just to name a few factors in its profile – that makes it more or less advantageous depending on the circumstances. Remember, the very food that you believe is “bad for you” might be great for someone else.
She Said
One of the underlying themes I have found amongst nearly all of my eating disorder (ED) patients is the idea that their ED often started with the intention to become “healthier.” Whether “healthier” meant to lose weight, improve certain biomarkers, or just feel better, these individuals embarked on a restrictive food mission, omitting certain “bad” foods (mostly foods high in sugar and fat) and replacing said foods with “good” foods (mostly vegetables and protein). As harmless as these initial intentions seem at first glance, for someone with ED, they often unravel into something potentially life threatening.
For my patients with anorexia nervosa, this fixation on “good” and “bad” foods can result in a dangerously low body weight. In addition to extremely low weight, the lack of calories literally starves every organ of the body, including the heart and the brain. Brain scans of healthy control brains versus brains of patients with anorexia show that anorexia literally shrinks the brain. As such, these individuals undergo profound brain changes that lead to decrease in cognitive functioning (due to slowed neuronal growth), depressive symptoms (due to lower levels of neurotransmitters), and a reduction in affect displayed (due to shrinkage of the frontal lobe). What is really insidious about EDs is that they start off in the brain as mental illness and eventually lead to damaging the same brain by means of malnutrition. It is a vicious cycle.
The only way to break this cycle is by refeeding (in addition to therapeutic help and perhaps medication). In this initial stage of recovery, it is imperative that the patient take in enough calories to restore his or her body weight to their healthy weight range. In fact, it is almost impossible for therapeutic measures and medications to really help these patients until their brains are at least back to functioning levels. Many of my patients with severe anorexia struggle with brain fog, have trouble formulating thoughts, and cannot communicate clearly due to brain deficits, and this makes therapy not nearly as effective as when the brain is at least functioning at baseline.
The tricky part about refeeding is that many of the “bad” foods that these patients have been avoiding are, in fact, the same foods that will help them to restore weight most easily. These high carbohydrate/high fat foods are integral to getting these patients to their healthy weight ranges, as they usually have higher concentrations of calories than low carbohydrate/low fat foods. As such, these foods pack a much bigger punch, providing more calories in a smaller amount, making it easier for patients to get what they need while lessening the gastric overload.
Many of my underweight patients who need to weight restore will ask me if they can just eat more of the “good” foods to help them gain the weight back. Aside from heart-healthy nuts, avocados, and nut butters, most of the “good” foods fall into the low carbohydrate/low fat group that provides very few calories for the same volume. In other words, these noncalorically dense foods pack less of a punch, meaning that one would need to eat a much larger volume of these foods to get the same amount of calories that are in calorically dense foods. In order for someone to regain weight, eating large amounts of vegetables and protein is not going to get them to their goal as their stomach will simply prevent them from consuming enough.
What is “healthiest” for these patients is to consume calorie-dense foods and avoid those foods that take up more volume but do not provide the necessary calories. Thus, for the sake of example, a pint of Ben & Jerry’s ice cream is a better choice than a salad for someone who needs to regain weight. We have all been taught that certain foods are always “bad” in every context (ice cream, fried foods, sweets), but the example above shows that it is not so cut and dried. Is a pint of Ben & Jerry’s the “healthiest” choice for someone with high cholesterol? Possibly not. But for someone with anorexia who needs to gain weight, it is healthier.
In other words, “healthy” is a very subjective term when it comes to nutrition. One size does not fit all as everyone has different health goals and medical conditions. While whole wheat bread might be the better choice for someone who suffers from chronic constipation, it would wreak havoc on someone with diverticulitis and should be avoided. The “good food/bad food” dichotomy is problematic because it does not take the individual into account. The way we talk about food in our society needs to change.
