The Buffet: An Intuitive Eater’s Playground

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Out of all the situations that my patients find challenging, the buffet is the one they most commonly mention. No wonder that they do, as buffets are laden with many of the dynamics that can be tricky for budding intuitive eaters. Another way of looking at the matter is to think of buffets not as tests or proving grounds, but rather as playgrounds: a place to practice, have fun, and figure out which elements of intuitive eating might benefit from further work.

Consider the following factors and how you can use buffets to examine the role that they might be playing in your eating.

Quantity: As far as I can recall, every buffet I have gone to has been of the all-you-can-eat format without any external constraints to limit how much I ate. For people who are used to leaning on outside forces to put a cap on their quantity consumed – such as a restaurant’s serving size, the mound that mom puts on their plate, or a 100-calorie snack pack – buffets can leave them feeling lost and unsure when to stop. Some patients shy away from buffets for this reason, but I suggest instead running straight for them, as they present fantastic opportunities to practice recognizing and honoring our fullness cues. After all, without any external cues telling us when to stop, we have no choice but to look inward at our body’s cues to make the decision.

Cost: If you are a fan of the Phantom Gourmet, you have likely seen The Nordic Lodge featured several times over the years. Joanne and I went once several years ago to see what the fuss was about, and it certainly was an interesting experience. The adult admission price was lower than the current $125.00-per-person fee when we went, but it was certainly still expensive, and I found myself feeling anxious about making sure I got my money’s worth. Then I reminded myself that the entry fee was a sunk cost whether I stopped when I was comfortably full, made myself sick, or anywhere in between. Eating to the point of feeling physically gross was not going to somehow enhance the experience or make me feel differently about the money we spent. That is just me though, and I am not suggesting that there is a right or wrong answer here, as some people might indeed feel more positive about their overall experience if they leave a buffet feeling like they ate their money’s worth; but it is interesting to examine in real time how cost might be influencing your eating behavior.

Rarities: If you have attended The Langham Hotel’s chocolate buffet, you know that they do not allow doggy bags. Although our waiter did once discreetly slip me some extra napkins so I could wrap up a piece of pastry to take home, their official stance is you either eat the food there or you do not eat it at all. Feeling a pull to take advantage of a now-or-never, or at least a now-or-wait-a-long-time-for-another-opportunity, situation to eat something can be an example of beckoning. Even though some patients feel that eating in response to beckoning is a negative behavior, I disagree and feel it is a morally neutral action that is neither good nor bad. As I discussed in a previous blog, simply having an awareness of whether we are eating in response to humming or beckoning has its upsides, and there may be no better place to ask ourselves this question than at a buffet you rarely attend or may never go to again.

Scarcity: My college dining hall was an all-you-can-eat buffet format, but they nevertheless still ran out of the most popular foods sometimes. Although I cannot recall any specific examples, I know there were certain desserts that would run out quickly relative to the others. Whenever they were on the day’s menu, the race was on to get some before the other students finished it all. Looking back, I am certain there were days that I chose something not because I genuinely wanted it, but because I felt a competitive drive to get it before it was gone. Next time you are at a buffet and you spy an item that is running low, consider how your selection may or may not differ if the quantity were bountiful.

Dichotomies: One of my patients told me that when they were young and attended buffets with their parents, they sometimes tried to sneak extra quantities of “bad” food when their parents could not see them, such as taking some and eating it before they got back to the table. Some people feel compelled to balance out their intake of “bad” food by forcing themselves to take some “good” food too whether they really feel like having the latter or not. In reality, the dichotomies that people believe regarding food – whether they are good/bad, healthy/unhealthy, clean/unclean, etc. – have much less to do with science and more to do with the way we impose principles of spirituality on our eating. Buffets can be a great place to examine the role that such a dichotomy may be playing in your food choices.

Comparisons: Going back to our Nordic Lodge experience, I clearly remember looking around at other diners and their plates because I was curious to see how others were approaching the buffet. Some people take things a step farther by comparing their own eating to others. Such comparisons might be the basis for someone to feel virtuous or guilty about their own food choices. Beyond that, sometimes we might use the behavior of others as a determinant of the permission we give ourselves. For example, maybe we are considering going back for a third plate of food, but we do not give ourselves the green light until someone else in the party does it first, and if they never do, then we deny ourselves.

While buffets can feel triggering, they can be great playgrounds for practicing and developing our intuitive eating skills. Instead of shying away from the challenge, lean into it and have fun!

No Nutritional Value?

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People sometimes use the phrase “no nutritional value” to demean certain foods or to flagellate themselves or someone else for having consumed one of them. Whenever someone speaks these words, I curiously wonder: Do they mean the phrase literally or figuratively? Either way is problematic, unfortunately, and is indicative of room for growth in their relationship with food.

If someone perceives that a food literally has no nutritional value, chances are high that they are factually incorrect. Anything we eat that contains at least one macronutrient (carbohydrate, fat, protein, water, or alcohol) or micronutrient (vitamin or mineral) has – by definition – nutritional value. Check out a food’s nutrition label, and if you see any numbers other than zeros, you know it has nutritional value. Even if you see zeros across the board, unlisted nutrients are still likely present, or perhaps the quantities are low enough that labeling laws allow for rounding down to zero. Sitting here now, I am hard-pressed to think of even a single example of an edible entity that has literally no nutritional value.

Besides, criticizing a food for having little or none of a particular nutrient implies that other foods with higher concentrations of it are somehow superior, but this is not necessarily true. Some nutrients have a tolerable upper limit, which is the “maximum daily intake unlikely to cause adverse health effects.” For example, consuming too much zinc can cause a copper deficiency, as the two minerals compete for absorption. People have died from drinking so much water that their blood’s sodium concentration became perilously low. Vitamin A toxicity, which can also be fatal, can arise from eating just a single serving of polar bear liver.

Even if we consider smaller quantities, ones not large enough to seriously risk our health, consuming too much can prove useless. Purchase a supplement with a high concentration of B vitamins and note how your urine turns neon yellow, which results from our bodies expelling the excess vitamins it cannot use. (Insert here your own joke about flushing your money down the toilet.) Taking in a large amount of calcium at once does little good for our bones, as our bodies are limited in how much they can absorb at a time. The bottom line is that more does not always imply better or healthier.

Having said that, I know that most people who say “no nutritional value” do not mean it literally, but rather as an expression of how they deduce foods, ingredients, and nutrients into moral hierarchies. For example, someone may tell me pasta has no nutritional value because they see carbohydrates as inferior to protein. Another person may claim that butter has no nutritional value because they look down upon its high fat concentration. Yet another patient may say that juice has no nutritional value because their demonization of sugar blinds them from appreciating the vitamins, minerals, phytochemicals, and other nutrients swimming around in the beverage.

People are often hard on themselves or feel anxious for eating foods that they perceive as having no nutritional value, which hinders their ability to eat intuitively. Recognizing our body’s signals can sometimes be challenging enough even without guilt and stress complicating matters and clouding the picture. One of my patients described the situation to me with a simile, saying it is like playing a sport and straining to focus on what the coach is saying while other people on the sidelines loudly yell conflicting advice. Similarly, if we feel virtuous for eating a food that we perceive to have nutritional value, we might be at risk for blocking out signals from our body that the food is not actually hitting the spot.

See if this common scenario feels familiar. You are in the midst of eating a food that you perceive to have “no nutritional value.” Even though you can tell you are getting full, you decide to keep eating it because you figure today is ruined anyway, so you might as well finish it all so it is no longer in the house, and you can start fresh tomorrow. Here is another situation that might ring true. You are craving a specific food, but since you feel it has “no nutritional value,” you try to satisfy the craving with an alternative version that you believe has a better nutrition profile. Since the latter does not quite hit the spot though, you consume more of it in an attempt to make up for lack of pleasure with quantity. Still not satisfied, you try other foods. Your grazing may eventually encompass eating the food that you craved in the first place. Now you feel stuffed and maybe guilty, whereas if you had allowed yourself to consume the object of your desire in the first place, you could have had a more enjoyable and peaceful eating experience and then gotten on with your day.

When I was in nutrition school, I used to modify my cookie recipes in an attempt to make them “healthier.” It took me a long time to understand why I tended to eat so many of these modified creations in one sitting, but eventually I realized it was because these cookies – which were more akin to high-fiber pancakes than actual cookies – were not hitting the spot. That is not a knock against pancakes, which are of course fine, but they do not fill a cookie-shaped hole as well as the real thing. Once I came to understand what was happening, I abandoned those modified recipes and returned to the original. Instead of having a whole pile of the “healthier” but less satisfying versions, I would have a couple of real cookies, feel satisfied, and be done.

If any of what you have read here resonates with your own thought patterns or experiences, ask yourself this: How might my own eating change if I abandon the flawed notion that some foods have “no nutritional value”?

Matching

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Figuring out what to eat can sometimes be a challenge. We stare at the contents of our open refrigerator, knowing we are hungry but unsure of what to choose, before we close the door only to immediately open it again and resume the search. We ask the waiter to come back in a few minutes and then return our attention to the menu. Our uncertainty can lead to frustration, confusion, and wasted time, but we have a remedy: matching.

Matching is an intuitive eating tool that can help us to make food selection decisions based upon our body’s internal cues. Diet culture tells us not to listen to our bodies, that its cues are untrustworthy and therefore to be ignored in favor of external systems, such as points systems or lists of foods to eat and those to avoid, in order to make choices.

However, our bodies are actually quite good at letting us know which food is going to hit the spot at any given time. As examples, consider how much better water tastes when we are thirsty compared to when we are already well hydrated, or how some people with anemia feel naturally attracted to high-iron foods. The latter might not know that beef has a high concentration of heme iron, but they do know that right about now, they could really go for a burger. Our bodies give us signals; we just have to be tuned in enough to notice what they are saying and trust them.

Following is an outline for how to put the matching process into practice.

  1. Before opening the refrigerator, pantry, or restaurant menu, ask yourself these questions to help guide your decision based upon your body’s intuitive eating cues.
    1. “What temperature food do I feel like having?” Example answers include hot, lukewarm, room temperature, cool, or frozen.
    2. “What texture food do I feel like having?” Example answers include crunchy, smooth, liquid, or a combination.
    3. “What color food do I feel like having?” Example answers include multicolored or monotone in a specific color.
    4. “What flavor food do I feel like having?” Example answers include sweet, salty, spicy, or bitter.
  2. With your answers in mind, survey your available food options to see which ones match – hence the term “matching” – your criteria.
  3. Imagine yourself eating each of the options you identified and choose the one you feel is most likely to hit the spot.
  4. Eat the food you selected, then ask yourself how the eating experience compared to your expectations. If your choice hit the spot as you anticipated, great! If not, no worries, just consider it data for the future.

You probably will not be able to answer all of the questions regarding temperature, color, texture, and flavor, but being able to answer even one can be enough to point you in a direction. Also, these are not leading questions, and you are not trying to talk yourself into wanting – or not wanting – a particular food.

Lastly, keep in mind that the matching process is a tool, not a rule that can be violated. For example, if you go through the process and determine that you want crackers and cheese, but then you remember that you have yogurt that is about to expire and you opt to use it up instead, you are not doing anything wrong, nor are you bad at intuitive eating. We all live in the real world where a multitude of factors influence our eating, and it would be unrealistic to expect someone to always base their eating decisions solely on matching. Use this tool to the extent that you want to and find it helpful.

“You have permission to not eat.”

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Some of my patients who are relearning how to eat intuitively find it helpful to utilize a mantra, a phrase they can say to themselves to help them through a challenging situation. Because we often discuss the concept of unconditional permission, “You have permission to eat” is a refrain that my patients commonly use. One of my patients though flipped it on its head and began to use “You have permission to not eat.” At first, I was a bit perplexed, but the more I listened to her and reflected on these words, the more I realized their power.

Having the freedom to allow ourselves to eat whatever we want, whenever we want, and however much we want – otherwise known as unconditional permission – is central to intuitive eating. Without this foundation, everything else we study can easily warp into dieting tools. Given that, I initially bristled at “You have permission to not eat” because I thought it might be a veiled attempt at restriction, but that is not the case at all. Rather, the power in these words comes from acknowledging the times when we feel obligated to eat even when our bodies are saying no and freeing ourselves from the burden of feeling powerless.

As a first example, consider the scenario that my patient told me about when she was explaining the power of her mantra. She was at dinner with her extended family, and all of the latter were leaning towards ordering dessert. While my patient did not feel like having dessert, she also felt a social obligation to order it since others were. Then she reminded herself, “You have permission to not eat,” which reaffirmed that whether or not to order dessert was her prerogative, and she could act in her own best interests regardless of how the rest of her family went about their eating.

Thinking about other possible applications, I realized how helpful this mantra can be for people who feel pressure to not “waste” food. We are familiar with guilt-inducing refrains to clean our plate, such as “There are starving children in the world,” as if whether or not we finish the food in front of us has any impact whatsoever on the global politics of food insecurity. In these moments, “You have permission to not eat” reminds us that we do not have to be human garbage disposals for the sake of some theoretical benefit to others.

My thoughts then went to how this phrase could be useful for people working through compulsive overeating. Recovery is, of course, more complex than simply reciting a mantra, but just as the concept of unconditional permission is essential for diet survivors who are building healthy relationships with food, “You have permission to not eat” reminds compulsive overeaters that they have the freedom to move away from the urges to overconsume that have felt so irresistible.

Lastly, I considered how “You have permission to not eat” can aid those who overconsume due to habit or tradition. Maybe we eat to the point of physical discomfort every Thanksgiving because we have come to accept that this is the norm on the holiday, or maybe we buy popcorn every time we go to the theater regardless of whether or not we are hungry or feel like popcorn just because eating the snack feels like an intertwined and essential component of movie watching. “You have permission to not eat” reminds us that even if we have long engaged in certain eating behaviors, we have the freedom to move away from them if we feel that they no longer serve us.

You may discover other applications in which “You have permission to not eat” is a helpful mantra, but guard against the temptation to use it as a tool to restrict because that would likely backfire and be counterproductive. If you feel yourself tempted to go down that road, remind yourself of the phrase from which this mantra came: “You have permission to eat.”

An Open Letter to Daycares, Preschools, Nursery Schools, and Elementary Schools

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We so appreciate the care you take of our little ones. In fact, I am sure that most parents would agree being able to send our kiddos to daycare, preschool, and/or elementary school is a huge factor in maintaining our sanity. The way that you help our children learn, grow, and adapt is amazing, and we are grateful for you. Having said all this, we need to talk about the policing of our kids’ food in school.

Lately, I have begun hearing more and more from parents whose kids are being sent back home with notes about their packed lunch. One parent received a phone call from a daycare saying that they were not going to give her daughter the 10 M&Ms that she had packed in her daughter’s lunchbox because they were “unhealthy.” Keep in mind, this mom had the forethought to pack in her daughter’s lunch The Feeding Doctor’s lunch box card stating that she did not want the staff to interfere with her daughter’s eating of lunch and that her daughter is allowed to eat any or all (or none) of the foods packed in the lunch in any order she wants. The staff overruled these directions and said that candy is “frowned upon” in their program.

Listen, I get it. In our fatphobic, diet culture world, we’ve been taught that sugar is the enemy. That if we give it to our kids, they will turn into sweets-addicted, hyperactive lunatics who will be out of control, that their bodies will balloon up like Violet Beauregarde in Willy Wonka’s Chocolate Factory, and that their teeth will fall out due to cavities. As a registered dietitian who has a Master of Science in Nutrition and Health Promotion with over a decade of experience in the dietetic field, I’m here to tell you that all of this is false.

Kids are naturally born intuitive eaters. Newborn babies cry when they are hungry and drink breastmilk (or formula) provided by their caregivers until they are satiated. They are perfectly in tune with their bodies’ cues and eat in response to them.  As babies grow and they start eating solids, they continue to eat intuitively. If you’ve ever tried to get a baby to eat anything they don’t want to eat (I’m looking at you, strained peas.), you know they just won’t have it. As kids reach toddlerhood, often their eating habits become erratic. Some days, it seems like my daughter barely eats anything, but on other days, she appears to eat more than a grown adult. Despite this seeming chaos, our kids’ bodies know what they are doing. While meals might seem hit-or-miss during one day, it’s best to look at our kids’ eating over a period of days as things will usually average out.   

Kids usually remain intuitive eaters until the adults in their lives start interfering with their food. Whether it be pressuring kids to take “one more bite” at dinner even if they are no longer hungry, limiting their access to sweets and other highly palatable foods because they are “unhealthy”, or expressing concern about their eating “too much,” parents and other adults can really throw a monkey wrench into their kids’ relationship with food.  Many parents worry about their kids gravitating towards foods that are high in fat, sugar, and/or salt because they themselves have a complicated relationship with those foods. In reality, if we relax around these foods and include them regularly with more “nutrient-dense” foods, we can neutralize them and take the “shine” off of them as well. In my work with kids and families, it’s the kids who are the most restricted around highly palatable foods that end up bingeing on them when they get the chance, sneak eating them in their room, or being hyperfixated on them at their friends’ houses. If we teach our kids that food has no moral value (i.e., eating vegetables doesn’t make you a “good” person and cookies aren’t the devil’s food), they will be able to make choices about what and how much to eat based on their internal hunger and fullness cues.

In addition to being natural-born intuitive eaters, young kids have very binary thinking. That is, when we present them with the idea that there are “good” foods and “bad” foods, they take this information quite literally and are unable to see the gray. So many children feel guilt or shame for enjoying “bad” foods because they feel like they are bad for eating them. This is setting our kids up to have a very charged emotional experience around these foods which can continue on into adulthood for many of them.  If we teach kids that all foods fit and that the most important thing is getting a good variety of all sorts of foods, we can help foster their relationship with food and their bodies.

Another thing to consider is the concept of helping our kids become “competent eaters.” Coined by child feeding therapist and dietitian Ellyn Satter, competent eaters are those who eat in accordance with their hunger and fullness cues while taking into consideration their bodies’ needs and preferences. Parents’ (and caregivers’) role in this process is to be in charge of certain aspects of meals and snacks. Satter’s Division of Responsibility further clarifies that parents are in charge of what food is being served, when and where this food is offered. Meanwhile, kids are responsible for whether they choose to eat the food provided and how much they want to eat of said food. Ideally, parents offer their kids a variety of foods, including both highly palatable foods and foods that are more nutrient dense, and then let their kids eat in accordance with their bodies. This model posits that interfering with kids’ eating by cajoling them to eat more vegetables, discouraging them from eating other foods, or even praising them for eating more nutrient-dense foods will lead to power struggles at the dinner table.

So what can we adults do to help our kids develop a healthy relationship with food and their bodies? Here are some strategies:

  1. Avoid categorizing some foods as “junk” or “bad” and others as “good” or “healthy.” Food is just food and does not have moral value. Food is only “bad” if you are allergic to it or it is rotten or spoiled.
  2. Parents need to provide a wide variety of foods to their kids, including regular access to highly palatable foods in order to take these foods off the pedestal and make them morally equivalent to more nutrient-dense foods.
  3. Caregivers at school should refrain from pressuring kids to eat certain parts of their lunch before letting them eat other parts (e.g., “You need to finish your sandwich before you can have your cookies.”) If a child wants to eat their cookies first, please let them.
  4. Caregivers at school should also avoid confiscating food from kids’ lunchboxes unless those foods are an allergy or choking risk. If the parents packed the lunch, please respect that they know how to feed their kids.  
  5. Finally, school caregivers, please be mindful about sharing your own food anxiety with kids. Kids should not be hearing about your latest diet or how you don’t allow yourself to eat X, Y, or Z. Children are like sponges and absorb all of this information.

Again, thank you for everything you do for our little ones. We are so grateful to have you in our kids’ lives. Let’s help our children develop a healthy relationship with food and their bodies by setting a good example and not letting diet culture into the classroom.  

Praising Adele’s Weight Loss Is Fatphobic

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

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

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

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

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

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

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

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

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

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

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

Decision Time

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Shortly after midnight on Saturday, April 14, 2018, I had a dream in which I was at the staging area for that morning’s Newport marathon, but I had not yet checked in for the race or stored my belongings even though it was 7:13 AM, just 17 minute shy of race time. Frantic, I was trying to figure out how I was going to take care of these logistical to-do items and get to the starting line on schedule. Then I woke up.

Approximately seven hours later, I was at the staging area down in Newport for the actual marathon. The truck containing the mobile locker I had rented in advance was mysteriously not there yet. Confused and anxious, I wondered what I was going to do with all of the gear I had planned on locking up, including my wallet, keys, phone, clothes, and post-race snacks. Standing there feeling somewhat paralyzed by uncertainty, I took out my phone and checked the time. It was 7:15 AM. (Premonitions allow for a two-minute margin of error, no?)

Midnight clairvoyance and the subsequent inauspicious sunrise set the tone for the rest of my day. Eventually, I got in line for gear check, an unsecured area for runners to leave their belongings, for I could no longer wait for the mobile lockers to arrive. Good thing I did not hold out for them either, as I found out later that the driver overslept and did not arrive with the lockers until well after my race began.

As I was standing in a long line comprised mainly of runners competing in the 5K and half marathon events that were commencing later in the morning, I heard the national anthem and then saw my fellow marathoners starting down the road. After several minutes, I got the attention of a volunteer and stammered, “I don’t know what I’m doing and my race just started without me.” He told me to drop my bag, that he would take care of it, and from there I hurried to the course and crossed the starting line well after the rest of the field.

While I prepare meticulously for race-day logistics, my pre-race plans went out the window due to the chaos that ensued from the mobile lockers’ absence. About a mile down the road, I realized I had accidentally left two of my three anti-nausea medicines in the bag I checked with the volunteer. Such a mistake was quite concerning, as nausea tends to be my limiting factor in marathons, even more than muscle soreness or general fatigue.

Not having my medication only compounded problems that began with a poor training cycle due to a herniated disc in my lower back, an abdominal hernia for which surgery was scheduled six days after the marathon, and a couple of other medical hindrances. Things were not looking good already, and yet they got worse.

Quickly, my fellow runners and I discovered that hydration was going to be a problem. Unlike most marathons that offer both water and sports drinks regularly along the course, most of the beverage stations on this course featured only water. Moreover, the cups were maybe a quarter full. Subtract from that the fluid that splashed out during the drinking process, and the net amount that made it down my throat was not nearly enough to keep me hydrated. The stations that did offer a beverage other than water had a low-calorie electrolyte drink, woefully insufficient to replenish the carbohydrates expended during such an endeavor.

Despite these challenges, I was inexplicably on pace for my all-time best marathon through mile 18, but by then things were getting ridiculous. We had not had a beverage station since mile 13, no electrolyte drink since probably mile 11, and the course was in the midst of a miles-long uphill stretch that felt more challenging to me than Boston’s Heartbreak Hill ever has.

The nausea, which had been building slowly, was pronounced enough where I felt like the time was right to use the one anti-nausea medication that I remembered to bring out on the course with me. In keeping with the theme of the day, the pills promptly fell out of my Ziploc bag onto the road. The quiet tick of the medication hitting the pavement was likely inaudible to anybody else, but to me it was the thunder of my last hope for a great marathon finish crashing down.

Limited by nausea and dehydration-induced muscle cramping, my pace slowed significantly over the final miles. Around mile 25, a blister that I did not know I had burst on the bottom of my right foot, altering my gait and slowing me even further. Hobbled, I kept running and crossed the finish line limping.

Somehow, out of the day’s nonsense sprang my fastest marathon time in 15 years, but this is less a story of resolve and more a tale of someone struggling in real time to weigh the pros and cons of disregarding or honoring his body’s signals, which in this case were clearly telling me to drop out of the race.

The course was essentially a figure eight with the start, midpoint, and finish all at the center. If I was going to call it a day early, hitting the eject button at the midpoint made the most sense, so I took stock of the situation as I neared the 13.1-mile mark. Inadequate fluids, dehydration and cramping that were already setting in, insufficient medication, and memories of my 2004 Boston marathon – which ended with an ambulance ride to the emergency room – all suggested that dropping out was the sensible and safest play.

On the other hand, my speed was inexplicably fast up to that point and I did not want to take for granted that I would ever have a shot at a marathon personal best again. While I reserve the right to change my mind, I went into this race figuring it was probably my last marathon. While I enjoy the training and racing, impending parenthood had me looking at the situation from a different perspective. Long training runs take a lot out of me, so much so that I am pretty much useless the rest of the day, and I do not think it is fair to put our daughter in a position where daddy cannot play, or go to the playground, or go for a walk, or do pretty much anything at all because he ran far and needs to rest.

Even if I do decide to train for another marathon someday, who knows, I could wake up sick on race day, or sprain my ankle on a Baby Einstein guitar while heading out the door to the starting line, or suffer any item on a tremendously long list of inflictions or mishaps beyond my control that could throw the whole endeavor out the window at any point in my training cycle or at the very last instant.

As I neared the half, I was cognizant of the reality that being 13 miles into a marathon with a chance for a personal best might never happen again. For as much had gone wrong, a lot had also gone right to allow me to be in such a position. Having weighed the pros and cons, I decided to continue on with the race despite all of the reasons to stop.

Disregarding my body’s cues eventually caught up with me. A few minutes after I crossed the finish line, the nausea worsened, I was shivering (a symptom of dehydration) despite the warm temperatures, and my breathing was abnormally rapid. Laying face up in the sun while wearing a hooded sweatshirt and winter jacket did not help. With my condition deteriorating, I made my way to the medical tent.

The paramedics took my blood pressure, which was sky high compared to my norm, and I was having trouble answering their questions. While I have a history of occasionally feeling miserable after long runs, this was worse than my norm. The scariest part to me was that I was aware of my incoherence, yet I could not do anything about it. They asked me what medications I take, but I could not put together an articulate response. In my mind, I was like, “Come on, dude, you know what meds you take, just tell them,” but I was incapable of getting the words out.

The paramedics wrapped me in blankets, put me in the back of an ambulance, and cranked the heat to warm me. They gave me oxygen and placed leads to monitor my pulse, heart rhythm, and oxygen saturation. After two hours of laying on the gurney getting rehydrated and warmed, we agreed that I was well enough – but albeit still far from 100% – to leave the ambulance and make my way back to my car.

Stepping out of the ambulance, I was startled to discover that the finish area was virtually deserted, as the spectators, volunteers, race organizers, and my fellow runners had pretty much all gone home. Watching the few remaining workers disassemble the food tent and the final handful of artifacts from a post-race party that had presumably been so happy and festive just a short time earlier, I felt an eerie and unsettling sensation: loneliness.

Later that evening, Joanne commented over dinner that I looked sad. She was right. Ending up in an ambulance with a health scare is no way to conclude an event. Finishing a marathon normally yields a significant sense of accomplishment, but this time I felt conflicted and somewhat hollow. Even though completing the course was a triumph of sorts, I had mixed feelings for having put myself in unnecessary jeopardy.

Like I tell my patients who are working on listening to and honoring their internal cues: assessing hunger and fullness levels, sorting through matching criteria, checking for humming and beckoning, and utilizing other intuitive eating tools are never meant to be leading questions, and there are no such things as absolute right answers. Decisions made regarding what, when, and how much to eat matter much less than having utilized a thoughtful process to reach them.

Similarly, having considered all of the pros and cons of the options available to me at the moment I had to make a choice, I feel like continuing to run was the best course of action for me despite my body’s cues suggesting that I stop. Ultimately, I am glad I finished the race even if I did pay a price for my decision.

Just after crossing the finish line. Am I having fun or what?

Intuitive Eating: An Introduction

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This article originally appeared as a guest piece in the Progress Wellness newsletter.

What the heck is intuitive eating? We often hear the term, but what does it mean, how can it help us, what are its common misconceptions, and how can we begin to put it into practice?

First, some context: In our society, we are often taught that we cannot trust our bodies and that we need something external from ourselves to guide our eating. Hence, we have calorie counting, tracking apps, points systems, lists of foods to eat and those to avoid, meal plans, and other tools that tell us what, when, and how much to eat.

Intuitive eating, on the other hand, is a system based on the reality that contrary to popular belief, we can actually trust our bodies to guide our eating decisions. Internal signals give us information regarding our hunger and fullness, what foods will hit the spot at any given eating occasion, and how much of those foods we need to feel satisfied. Think of how much better water tastes when we are thirsty versus when we are already well hydrated, for example. Someone with anemia might not know that red meat is high in iron; they just know that a hamburger sounds mighty fine.

In contrast to external tools, intuitive eating tends to be a more peaceful and satisfying way of making decisions regarding what, when, and how much to eat. Not only that, but clinical trials have also found that intuitive eating is associated with improvements in physiological measures (blood pressure, blood lipids), health behaviors (eating and physical activity habits, dietary quality), and psychosocial outcomes (body image, self-esteem).

Whereas diet culture has rules and judgment, intuitive eating offers guidelines and flexibility, and it encourages neutral curiosity when events do not transpire as one would hope. Some people turn intuitive eating into the “hunger and fullness diet” by believing that they must eat when they reach a certain level of hunger and must stop when a certain level of fullness is attained, but such action is an oversimplification and misuse of the skills. If someone practicing intuitive eating ends up overly full, rather than beating themselves up for it and judging themselves as bad or undisciplined, they will just explore what happened to see if perhaps next time they might want to make a different decision.

Some people use intuitive eating as a weight loss tool, but doing so is a mistake. While some individuals will lose weight when they eat intuitively, many will not. By focusing on weight loss, people are likely going to end up disappointed and also stunt their development as intuitive eaters.

We are born intuitive eaters, and internal eating cues still reside in virtually all of us. Even if we fear our signals are gone, more likely they are simply buried by years of disuse, and we can uncover them and put them to use once again.

As a first step, when you are considering eating, take a moment to ask yourself, “How hungry am I right now?” You can imagine hunger and fullness existing on a linear continuum with extreme hunger at one end and extreme fullness at the opposite end. Ask yourself where on that continuum you are. Keep in mind that this is never to be a leading question, and your answer has nothing to do with permission to eat. You are simply gathering data and trying to notice the signals that your body gives you.

As a second step, if you have decided you are going to eat, rather than jumping to immediately see what your options are, take a moment to first look inward. Ask yourself if a particular flavor (sweet, salty, spicy, etc.) would hit the spot. Similarly, consider temperature (hot, frozen, chilled, room temperature, etc.), texture (crunchy, smooth, liquid, etc.), and even color. You might not have answers for all of these questions, but even knowing one of them (Temperature tends to be easiest for most people to discern.) can give you some direction. With your answer(s) in mind, now survey your choices, whether on a restaurant menu or in your own pantry or refrigerator, and try choosing the food that most matches your identified criteria.

Most people who are looking to become intuitive eaters need more help than can be found in a blog. Consider seeking the help of a registered dietitian who specializes in intuitive eating, and remember to be patient, as it can often take six months to a year, or even longer, of work and practice before your intuitive eating skills once again take their natural place as your default decision-making tools.

Macy’s

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

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

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

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

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

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

“As we all know, pressure to be thin leads to dieting, which can lead to a variety of problems, including eating disorders,” I wrote in the April 2016 issue of Boston Baseball. “These life-threatening illnesses are so common in Massachusetts that if the crowd at a sold-out Fenway Park represented a random sample of the state’s population, those in attendance with a diagnosed eating disorder would fill section 41,” which is a large section in the bleachers behind the Red Sox bullpen.

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

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

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

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

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

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

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

A Reader’s Intuitive Eating Question

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“The concept of intuitive eating is hard for me to grasp. The way I understand it is that I need to listen to my body so I will recognize when I’m hungry, and eat until my body tells me I’m not hungry anymore. If that’s basically correct, my problem is that I’m rarely ever hungry because I only recently ate, and always continue to eat until external clues tell me to stop (e.g. I ran out of time or food, or my eating partner has finished). How can I begin to listen to my body so I know when I’ve become hungry enough so that it’s okay to eat, and when I should stop eating?”

A reader emailed us the question above in response to an invitation in a previous newsletter to suggest future topics. It sounds as if the writer is still working to fully understand the concept of intuitive eating and how to incorporate it into his life, and I hope I can help.

Some of the language that the writer uses caught my eye: need, enough, okay, should. Diets have rules and directives that are clear and crisp. Even though diets typically fail in the end, part of the reason they are enticing is that they tell us what to do, which simplifies things by taking some of the decision-making out of our hands while paradoxically making us feel like we have more control over the situation.

People who are coming to intuitive eating from a history of dieting commonly and understandably assume that intuitive eating is just a different house built from the same framework of dieting, hence absolute language that implies a set of rules. In reality, intuitive eating has no rules, but rather guidelines and ideas for consideration. The difference is more than semantics, as people who attempt to pound intuitive eating into a rules-based framework end up warping it into the hunger-and-fullness diet, which both misses the point of the approach and makes incorporation more difficult.

With that in mind, I might suggest tweaking the writer’s question in order to remove the implication that his hunger has to reach a certain threshold for him to gain permission to eat and that he must stop when his fullness hits a particular level. He – and everybody else who follows an intuitive eating approach – always has unconditional permission to eat. Tearing down constructs that tell us when we can and cannot eat oftentimes feels scary, but it is essential in order to create the space necessary for us to make multifaceted eating decisions that are in our own best interests.

Instead of the question being how can the writer listen to his body so he can adhere to rules regarding when he can and cannot eat, perhaps a more helpful set of questions would include: How can he listen to his body so he can notice what different levels of hunger and fullness feel like and how different foods make him physically feel? How can he listen to his body in order to be more adept at distinguishing between times when he is eating for physical hunger versus some other factor, such as emotional or social reasons?

In that sense, I actually think the writer is more ahead of the game than he realizes, for he listed some of the external factors – time, quantity of food available, his partner’s own eating behaviors – that are hindering him from making food decisions from an internal standpoint. The next step on this front might be to explore the pros and cons of maintaining the status quo versus implementing change in order to determine the extent to which he wants to and is ready to create change.

Another avenue to explore is the writer’s statement that as a consequence of his eating behaviors, he rarely experiences hunger cues. If we are not hungry as we head into an eating experience, detecting subtle signs of fullness as they set in can be more difficult due to a lack of contrast. In other words, we cannot notice hunger signals subsiding if they were never there to begin with. If we grow accustomed to an absence of hunger cues, we might lose the ability to recognize the more subtle stages of hunger. Therefore, the writer might benefit from performing some experiments to intentionally let himself get hungry, to really notice what that feels like, and then consciously eat in response to it and see how the experience contrasts to when he eats in response to external cues.

Becoming an intuitive eater is a process. The journey never looks exactly the same for two people, as we are all so different and unique, but one commonality is that the road traveled is rarely direct. We discuss ideas, experiment, gather data that suggests areas of opportunity for further growth, and repeat the cycle until someone finds peace with food.