Tag Archives: needham dietitian

What We Can Learn From Eating While Sick

Posted on by
Reply

We managed to avoid it for over three years, but COVID finally got us. Joanne and I developed strange sensations in our throats virtually simultaneously and then tested positive a couple of days later. Whether due to the disease itself or as a side effect of Paxlovid, we developed terrible tastes in our mouths. Joanne described it as tasting like gasoline, while to me it seemed more a combination of cheese, bad breath, and metal. Additionally, I experienced waves of queasiness and a drastically reduced appetite.

Some of my patients talk about how much easier it is for them to eat intuitively when they are sick versus when they are fully healthy, and my experiences were somewhat similar to their own. When our appetites are diminished and food seems off-putting, our range of tolerable eating options shrinks considerably, which ironically makes food selection easier because foods we are willing and able to eat stand out in greater contrast to the rest.

Sometimes my patients, when they are ill, have an easier time practicing unconditional permission for a couple of reasons. First, because their array of appealing foods is so small, their only realistic option is to go with these foods. Second, because they are sick, they feel they are more deserving of self-care than when they are healthy, so they worry less about their perceived nutritional quality of food or about what they “should” be eating.

Being sick is so unpleasant and disruptive that at least making food choices can be easier for the aforementioned reasons, yet we can learn lessons from eating while sick that we can apply when we are healthy.

Choosing from a vast sea of eating options can be difficult and overwhelming, which is why deciding what to order from the Cheesecake Factory’s massive menu can be challenging. It is why, when our daughter demands “Choices!” when I ask her what she wants for a given meal, I offer her a small selection of different foods. We do advocate for having a wide variety of foods on hand at home so we have a reasonable shot at being able to satisfy whatever criteria our intuitive eating questions lead us to, but selection can nevertheless be hard if every option feels appealing. As when we are sick, having a smaller range of options that sounds good can make the process easier, but we can accomplish the same objective without being ill by eating before the magnitude of our hunger grows to unwieldy levels.

Only some of my patients utilize a hunger/fullness continuum, as it can sometimes be counterproductive if misused, but those who do know that we define a “3” as a comfortable hunger where we are ready for a meal and we are able to discern which foods sound like they will best hit the spot. In contrast, we define a “2” as a hunger that has grown uncomfortable, where we may feel irritable and stressed, and choosing what to eat can be especially challenging because our bodies are essentially telling us, “I don’t care what you feed me, just give me food!”

By eating before we get to a “2,” we give ourselves an opportunity to separate the most appealing foods more easily from the rest of our options. The practicalities of real life sometimes preclude us from being able to have our meals and snacks exactly when our body’s hunger cues suggest we are best off eating, but through experience, we can learn how to incorporate well-timed snacks that have us arriving at mealtime comfortably hungry rather than ravenous.

In terms of unconditional permission and the relative ease with which we can practice it when we are sick, remember that we are always deserving of self-care – including having the freedom to eat what, when, and how much we want without justification – regardless of our state of health. Think of self-care as something to be practiced not just when we are ill and need to get better, but also when we are already well and hope to stay that way. Personally, I can remember many times over the last few decades when I put self-care to the side, disregarded what my body was asking for, and ended up in a state of illness that was arguably avoidable if I had taken better care of myself.

Next time you are sick, consider the lessons about your eating that you can take with you as you leave the illness behind.

When Family and Friends Lose Weight

Posted on by
3

It’s the beginning of summer, and one theme in particular has been popping up a lot lately in my appointments with patients. It seems like everyone’s mother/uncle/friend from college/cousin has gone on a “weight loss journey” since the winter. As you might expect, witnessing your loved ones and/or friends and acquaintances engage in intentional weight loss can stir up a lot of feelings in those of us who are trying to embrace the bodies that we have. Research on intentional weight loss has found “almost complete relapse” after three to five years. Other data are more specific and suggest 90% to 95% of dieters regain all or most of the weight within five years, while other research has found that between one third and two thirds of people end up heavier than they were at baseline. It can be hard to watch others receive the praise and acceptance that often comes along with these “weight loss journeys.” It’s difficult to watch these folks gain more and more privilege while we remain in bodies that often put us at a disadvantage in our fatphobic society. So what are we supposed to do with all of these feelings?

First off, I try to remind my patients that their mother’s/uncle’s/friend’s/cousin’s bodies are not our business. I firmly believe in body autonomy, or as Ragen Chastain calls it, “The Underpants Rule.” In essence, what someone chooses to do with their body is up to them (as long as it is not harming others). Our family and friends will often make choices that we don’t agree with. And those of us who are trying to fight the near-constant onslaught of fatphobia we are fed on a daily basis feel strongly that these friends/family members are doing harm to themselves and perpetuating diet culture. But at the end of the day, we aren’t in charge of others’ bodies. Just like we wouldn’t want someone telling us how to live in our own bodies, we can’t police others.

That being said, I think there is nothing wrong with protecting oneself and setting boundaries around diet and weight loss talk. If you are active on social media and the friend/family member is an active poster of weight loss updates, befores and afters, or touting their new “healthy lifestyle,” it might be time to either snooze them for a short while or hide them from your timeline indefinitely. This can be done by clicking the “unfollow” button on someone’s Facebook profile or clicking the “mute” button on Instagram. By doing this, you are removing the element of surprise from seeing these things popping up on your timeline. It’s hard to look away or unsee some of these posts, so preventing them from appearing on your social media from the start can be helpful.

Another way that you can set a boundary is by being up front with the friend/family member about how their diet/weight loss talk is affecting you. Sometimes I will help my patients role play what they would like to say to the friend/family member who brings up their diet/weight loss. In these types of situations, I encourage patients to try to give their friend/family member the benefit of the doubt. That is, it is very unlikely that they are intentionally causing you harm or distress; they just are unaware of how this kind of talk can be triggering. Here’s an example of how these conversations can be broached: “Hey, I know that you aren’t intending to, but when you talk about your diet/lifestyle/weight loss journey with me, it makes me feel uncomfortable. I am happy that you are happy with what you are doing, but hearing about it is unhelpful for me as I’m working on accepting my body and letting go of diet culture.” If you are struggling with an eating disorder (and this person knows about it), it could be helpful to also say, “Part of my eating disorder recovery is not engaging in diet/weight loss talk as it can make my symptoms worse.”

If after these tactics, the message is still not getting through, it is within your right to limit your exposure to these individuals. This might mean doing shorter meet-ups rather than long, drawn-out hangouts, limiting your time spent at family gatherings, or getting together less often. If this is not an option, you can take space when you need to at these events, excusing yourself from the room or going for a walk by yourself, for example. I also highly recommend cultivating your own “anti-diet” community either online or in person if you are able to. There are many fat-positive folks all over the world, and it can feel less lonely when you are around those who “get it.” Instagram and Facebook can be helpful in finding these people and connecting with them.

At the end of the day, I hope that the one thing you will remember is that just because your
friend/family member is actively engaging in diet culture, you do not have to go that route. You deserve to embrace and live in the body you have, and you do not have to change it. Your body has never been the problem – our fatphobic culture is.

The Problem With Fat Shaming Professional Athletes

Posted on by
Reply

Felger: If we ever get to the point where we can’t fat shame athletes, I quit.

Massarotti: It’s coming.

Felger: It is coming.

Massarotti: It might already be here already.

Felger: It’s not. We’re not talking about a teenage girl. We’re talking about professional athletes whose job it is is to be in shape. We are allowed to call them fat and tease them for being fat. If that becomes off limits, I’m done.

The aforementioned exchange, which took place in the context of discussing Kyle Lowry of the Miami Heat, occurred between co-hosts Michael Felger and Tony Massarotti near the end of their Felger & Mazz sports talk show on May 17, 2023. Much like the fat shaming directed at Pablo Sandoval seven years ago, this problematic dialogue misses the mark and causes harm.

Felger asserted that part of a professional athlete’s job is to be in shape, but what constitutes “in shape” should not be defined by anthropometrics, such as weight or body fat percentage, but rather by an athlete’s readiness to perform their given sport at the level their employers expect of them. If an athlete lacks the strength, endurance, or flexibility to perform, the deficiency in their fitness is the real issue regardless of how their body is built; otherwise, teams would just fill their rosters with bodybuilders and models and call it a day.

“In shape” is also context dependent, as the physical abilities necessary to perform at a high level vary from sport to sport. A gymnast who lifts weights and runs but never stretches, a shot putter who stretches and runs but never lifts, and a marathoner who stretches and lifts but never runs would all have serious issues with their performance regardless of how their bodies look.

Besides, Kyle Lowry is actually quite a good basketball player. Lowry is in the midst of finishing his 17th season in the NBA, he earned spots in six straight All-Star games from 2015 to 2020, he started all 65 regular season and 24 playoff games that his team played on their way to winning the 2019 championship, and he was a member of the USA Olympic team that won the gold medal in 2016. Sure, his statistics dropped off a bit this season, but blaming the dip on his physique – which looks to be the same now as it did four years ago – is a bit of a head-scratcher considering the 37-year-old is the seventh oldest player (out of approximately 450) in a league where the average player is 26.01 years old. According to basketball-reference.com, Lowry’s career performance arc is thus far most similar to those of Terry Porter, Vince Carter, and Allen Iverson, the latter of whom is already enshrined in the Hall of Fame, and another – Carter – will likely get in too once he is eligible.

Lowry is far from the only “fat” athlete to outperform many of his leaner peers. The aforementioned Sandoval made over $73 million during his 14 years in the major leagues, and the two-time All-Star was named Most Valuable Player in one of the three World Series that his teams won. Pat Maroon was fat shamed despite winning three straight Stanley Cups. Back in Lowry’s realm of basketball, Luka Doncic’s own boss criticized him for his weight despite winning Rookie of the Year, then being named an All-Star and making the All-NBA first team in the four seasons he has played since then.

However, the most concerning part of Felger’s opinion is that he seems ignorant of the impact that his sentiments have on people other than professional athletes. “We’re not talking about a teenage girl,” he said, but the reality is that fat shaming anybody breeds fat shaming in general. Discussing the reasons why criticizing Donald Trump for his weight is harmful, Ragen Chastain explained, “And make no mistake, when you engage in fat-shaming, your victim is every single fat person.” The ramifications of fat shaming athletes are clear, as I discussed in the Boston Baseball article I wrote about Sandoval back in 2016.

“Fans and media have labeled Sandoval ‘disgusting,’ ‘lazy,’ and ‘pathetic,’ implying that those same terms apply to everyone who has a body type similar to his.

The message is that fat is to be loathed, that larger individuals are not worthy of the respect enjoyed by the rest of us. We reject stereotypes based on race, religion, ethnicity, or sexual orientation but we inexplicably tolerate those based on body size.

The idea that we can tell how someone eats or exercises based on his shape or weight is a myth. Some people built like linebackers never lift weights. Some skinny-as-a-rail folks subsist on fast food. And some obese individuals are more active and have a healthier relationship with food than any of them, but inhabit bigger bodies for other reasons.

As we all know, pressure to be thin leads to dieting, which can lead to a variety of problems, including eating disorders. 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.”

Sounds like Felger’s intent was to focus his fat shame on professional athletes while sparing others – and good thing it was, for his behavior would be even more problematic if his intent was otherwise – but we all know that intent and impact are two different entities. Felger certainly should know this, as his co-host was suspended just three months ago for making a poor attempt at humor that came off as racially insensitive. Like Massarotti, Felger should have known better.

If Felger is unwilling to forego fat shaming professional athletes, then the time for him to quit truly has arrived.

Gentle Nutrition

Posted on by
Reply

What is gentle nutrition? Imagine a Venn diagram. In one circle, we have intuitive eating, which is an approach to making decisions about what, when, and how much to eat centered around our body’s internal cues. In the other circle, we have medical nutrition therapy, which is the use of nutrition to treat various health problems. In the area in the middle where the two circles overlap lives a concept that we call gentle nutrition.

For my patients who are working to rebuild their intuitive eating skills, getting a firm handle on what gentle nutrition means and how to implement it in their lives are often two of the trickiest steps they face. The most common reason is that people oftentimes do not trust that their body’s internal cues will steer them in the direction of eating in a way that is conducive to their health. This fear, which I otherwise think of as the “If I allow myself to eat whatever I want, all I will do is have [insert the name of your taboo food] all the time” expectation, implies that eating for health means overriding intuitive eating cues.

My counter to that concern is to cite the food journal analyses that I perform on some of my patients. When I look at the intakes of my seasoned intuitive eaters, their nutrient consumption almost always falls within their estimated needs because their body naturally guides them towards the food it requires. In other words, my clinical experience suggests that when we eat intuitively, the eating-for-health part largely takes care of itself.

But what if our body is an imperfect guide? What if we face a gap between how far our intuitive eating takes us and where medical nutrition therapy suggests we should be?

For starters, take a step back and remember that our behaviors have limited influence on our health. One of my patients recently told me about a colleague who was diagnosed with cancer, and as word spread around the office, her co-workers reacted with surprise because the woman is so “thin and healthy.” (And as my patient astutely pointed out, if her colleague was fat rather than thin, people likely would have felt that she brought her health woes upon herself, which is a whole other problem.) Hearing the story reminded me of a fellow healthcare practitioner who was diagnosed with cancer herself despite being clearly orthorexic. For people who erroneously believe that they can control their medical fates if only they engage in certain behaviors, counter examples like these can rock their world.

Given that we may suffer whatever ailment we hope to avoid regardless of our best efforts to steer clear of it, we have to consider the lengths that we are willing to go to – and what we are willing to sacrifice – in hopes of reducing our risk. Focusing on medical nutrition therapy may sound sensible in theory, but doing so can come at the expense of our relationship with food. Consider the following scenarios that someone with hypertension might face.

  • What if you feel like you should never have salty food because of your high blood pressure, or when you do allow yourself to have it, you feel like you are being “bad”?
  • What if you have a history of restriction and the mere thought of cutting down on salt feels traumatic?
  • What if you are a recovering binge eater and stocking salty foods is an important step in your treatment?
  • What if you are on the road and happen upon a restaurant famous for a high-salt dish you really want to try, but you feel like if you do, you are asking for a cardiac event?

Who wants this level of angst interwoven with their eating when the fact of the matter is they could die of a heart attack no matter how much or how little sodium they consume? Unfortunately, stress, guilt, second-guessing, and inner turmoil can be significant issues when we practice not-so-gentle nutrition.

We advocate for gentle nutrition because of the downsides that come with focusing too hard on medical nutrition therapy and because of the upsides of taking a more moderate approach that still respects intuitive eating. Consider how someone practicing gentle nutrition would approach the same scenarios that I listed earlier.

  • What if you feel like you should never have salty food because of your high blood pressure, or when you do allow yourself to have it, you feel like you are being “bad”? They understand that complete abstinence of salty food is neither necessary nor practical, and they can enjoy such foods without guilt.
  • What if you have a history of restriction and the mere thought of cutting down on salt feels traumatic? Before even tackling gentle nutrition for their blood pressure concerns, they first do the necessary work to heal their relationship with food, thereby making medical nutrition therapy feel less triggering.
  • What if you are a recovering binge eater and stocking salty foods is an important step in your treatment? They recognize that in order to make peace with salty foods and get to a place where “a little” does not automatically turn into “a lot,” they have to practice unconditional permission and abundance, which entails exposure, continuous access, and predictable overconsumption for a period of time.
  • What if you are on the road and happen upon a restaurant famous for a high-salt dish you really want to try, but you feel like if you do, you are asking for a cardiac event? They understand that no single eating experience is going to save nor doom their health, that food is part of culture and travel, and that they would probably regret forgoing a rare opportunity.*

How then is the nutrition part of gentle nutrition implemented? That same person with hypertension may use their intuitive eating cues to determine that they feel like having a piece of fruit for a snack, but both the apple and the banana sound equally appealing, so they opt for the latter since it has more potassium than the former. On the other hand, if they feel like solely the apple would hit the spot, they eat it, enjoy it, and look for other places in their day to get their potassium. If the whole day goes by without consuming much potassium, they do not worry, but rather trust that their intuitive eating cues guide them in different directions day to day, and tomorrow they could very well find themselves taking in a high amount of potassium.

After reading all this, you might be thinking to yourself, “Yeah, okay, I get that my health is not entirely within my control, but I want to do everything I can to minimize my risk.” If so, that is entirely your right. You are the expert in your own life, nobody is in a better position to decide your path forward than you are, and I commend you for weighing the pros and cons and making an informed decision that feels right for you.

However, that same autonomy applies to each of us, and many people conclude that not-so-gentle nutrition is just not worth its cons and that gentle nutrition is the way to go.

* Speaking from personal experience, I remember spending a night at a church on a Native American reservation in Montana during my Seattle-to-Boston bicycle trip. My hosts offered me one of their traditional dishes – something that I can only describe as a French-fried donut, although I am sure that is not at all what it was – and it turned out to be literally the best tasting food I have ever had in my life. Sometimes I think about what I would have missed had I turned down the food due to nutrition concerns.

Being Your Own Advocate at the Doctor’s Office

Posted on by
1

Going to the doctor has always been a fraught experience for me. As a child, I was consistently in the highest percentile for weight-for-height, and my pediatrician expressed concern from the get-go. He would talk to my mom about my weight in front of me, and it is probably one of my earliest experiences with the feeling of shame.

As the years went by, my experience with doctors didn’t improve. I would fear going to get check-ups, bracing myself for comments about my weight and how I would need to “do something about it.” Even on the occasions when I would go to the doctor having lost weight, I would be anxious and fearful that my doctor would congratulate me and tell me to “keep doing what you’re doing,” as that meant I would have to continue to restrict, over-exercise, and obsess about my weight.

When my PCP retired about six years ago, I made the conscious decision to try and find a weight-neutral doctor. A fellow non-diet dietitian recommended a concierge doctor as someone who did not push back when she was told that discussions of weight would be off the table. I met with this PCP and explained to her my concerns and my desire to be treated through a weight-neutral lens. While it was clear that she typically practiced from a weight-normative perspective, she said that she understood and would not push back on me regarding weight matters.

Despite having this conversation with her at the outset, I still felt anxiety and dread for my doctor’s appointments going forward. Even though I knew she would not bring up my weight in a negative way or push me to lose weight, the 35+ years of fatphobia I had experienced in the medical space up until then was not so easily erased. After many years of therapy, I’ve come to understand that all of those negative experiences I had with my doctors were traumatic events and that these types of experiences have led to my profound distrust and anxiety regarding physicians.

It wasn’t until about a year ago that I was able to find a doctor who expressly practices Health at Every Size®(HAES), and this has made a huge difference for me. The fact that she truly “gets it” and treats me as a whole person (i.e., not just a number on a scale) has greatly reduced my medical anxiety. I don’t hesitate to reach out to her with my health concerns as I know she will give me sound medical advice that is not tinged with weight stigma. In the event that I need to see a specialist, however, my old fears return, and I have to figure out a way to ensure that I get good medical care.

Many of my patients in larger bodies can relate to my feelings around going to the doctor. Most of them dread going to see doctors because they know that the topic of their weight will inevitably come up. In many cases, these patients have put off getting help for health concerns for fear that they will be weight-shamed. One of my patients struggled with indigestion for months before finally seeing her doctor only to find out she had multiple ulcers. Unfortunately, this experience is not unusual for fat patients. These kinds of instances are often noted as “noncompliance” in medical charts, further promoting the false idea that fat patients are to blame for their health issues when it is really weight stigma at play.

Over the years, I have worked with a number of patients on advocating for themselves in medical settings. In most cases, these strategies are successful, leading to the patient receiving respectful, weight-neutral care. I thought it could be helpful to share these strategies with our readers.

One strategy that has proven to be quite successful for my patients is reaching out to the new provider via email or the patient portal before their initial appointment. I have a template email that I recommend for my patients, but of course it’s best to tailor it to one’s own particular circumstances. In this initial message, I recommend telling the doctor that you are looking for weight-neutral care and providing examples of what that looks like. Some examples are not prescribing weight loss as a health intervention, not weighing the patient unless it is medically necessary (e.g., for proper dosage of certain medications), and not telling the patient the number if they do need to get weighed. In addition, it can be helpful to tell the physician that you have been practicing the concepts of HAES and intuitive eating and that you are happy to provide them with resources if they are interested in learning more.

Sometimes even if you have messaged your physician directly, that message does not get relayed to the rest of the medical staff. This can result in the staff being unaware of your no-weighing preference and lead to an uncomfortable situation at the first appointment. To lessen the chances of this happening, some of my patients have reached out to the medical office manager or the primary care nurse at the doctor’s practice ahead of time to specify that they do not want to be weighed at their appointments. You can also ask them to note it in your chart that you do not want to be weighed so that the staff is aware.

In the event that you are unable to reach the physician or medical office manager before your appointment, many of my patients have found it helpful to bring “Don’t Weigh Me” cards with them to their appointments. These cards were created by Ginny Jones, the founder of more-love.org, an online resource for parents who have kids with eating disorders. Ginny explains that in her own recovery from an eating disorder, getting weighed at the doctor’s office was always a major stressor for her. After investigating whether one needs to be weighed at every doctor’s appointment (hint: you don’t), she found that not being weighed at the doctor’s office greatly reduced her stress when going to these appointments. Ginny created small, wallet-friendly cards that you can use to facilitate the conversation with healthcare providers about not being weighed. Even if you don’t end up giving the card to your doctor, it can be helpful and empowering to look over it while in the waiting room prior to your appointment.

For some patients, even doing the above is not sufficient to allay their fears. In these cases, I recommend bringing a supportive family member or friend to the appointment as an ally. Ideally, this person should be someone who understands HAES and will help you advocate for yourself if you face weight stigma. Even if this person does not end up needing to intervene in any way, just having them next you can be an enormous help. When our bodies are flooded with anxiety, it’s often hard to remember all of the details relayed to us by our physician, so having someone there with you to take notes or ask follow-up questions is a helpful strategy.

Sometimes even doing all of the above does not work, and patients are still subjected to weight stigma at the doctor’s office. In these cases, I remind my patients that they have the right to find a different doctor who will respect their wishes regarding weight-neutral care. Though weight-neutral providers are few and far between, if you can find a fat-positive network in your area, often there will be a referral list of recommended providers (and ones to avoid). For instance, I am a member of the “Boston Area Fatties Meetup” Facebook group (a fat-positive group in Massachusetts), where members can ask for recommendations for fat-friendly doctors and other providers. This group also has an excel spreadsheet of fat-friendly providers in Massachusetts which can be searched by type of provider and location.

Currently, the Association for Size Diversity and Health (ASDAH) is working on compiling a list of fat-friendly providers into a database called the Health at Every Size® Provider Listing Project. According to the ASDAH website, they are working to create a better and more comprehensive listing of healthcare providers who are especially sensitive to the needs of marginalized groups including “Black people, trans people and superfat and larger people.” ASDAH has also provided a timeline of the different phases of this project, and currently (March 2023) they state that they will be launching their “new and improved” listing beta. We will be sure to keep you posted when the HAES Provider Listing is available for use.

Pancakes

Posted on by
Reply

Some months, coming up with a newsletter topic is unusually challenging. For the last few weeks, Joanne and I were both scratching our heads, as the ideas we had were for research pieces that would demand more time than either of us is able to dedicate at this point in time. Being silly, I facetiously asked our four-year-old daughter what I should write about this month. “Pancakes,” she responded, “Pancakes and maple syrup.” Joanne and I laughed, and I walked out of the room, but I quickly returned and told them I was going to use her idea.

Our daughter’s suggestion reminded me of a quote from one of my earliest patients many years ago, and what the latter said to me felt significant enough that I wrote it down as soon as she left my office. “One day, you will have a baby boy who will love you,” my patient said, “and then he will grow up to hate you. But then one day he will love you again and say, ‘Hey, Dad, let’s go out to breakfast, just us guys,’ and then you will go to Bickford’s, and you will have an apple pancake, too.”

At that point in my career, I was still doing the kind of work that most people figure dietitians do: putting people on diets in the pursuit of weight loss. My prescribed diets were low in carbohydrates, especially grains, and so restrictive of calories that if my patients were living in a different region of the world, the United Nations would have sent cargo ships full of food to help them. While I did not author these diet plans, which seemed concerning to me at the time because of their restrictive nature and the good/bad food dichotomy they established, I did dole them out as instructed, and for that I have nobody to blame but myself.

These diet plans typically “worked” in the sense that my patients lost weight, but rarely – if ever – did the weight suppression last long term. At the time that I left the medical center where I was working and stopped doing that kind of work, I did have some patients who had maintained their weight loss thus far, but I have no idea what happened to them later. Given that most weight regain happens two to five years after baseline, I can only assume that at least some of these patients, if not all of them, regained weight after I was out of the picture.

Diets fail for a number of reasons. Most significantly, the physiological mechanisms that kept our ancestors alive through periods of starvation kick in when we restrict and promote weight regain. Another factor, the one that my patient was trying to make me aware of via her aforementioned quote, is that diets are incompatible with real life. After all, if I were following the low-carb, low-grain, low-calorie diet that I had put her on, I would be unable to both remain on the plan and partake in her breakfast scenario. The dietary expectations I had set out for her were unrealistic, which was exactly the point she was trying to get me to see. Point taken.

Now that I am a dad myself, I have greater first-hand life experience to reinforce my theoretical understanding. Numerous times over the last few years, I have eaten foods I was not in the mood for because sharing an eating experience with my daughter was more important to me than eating exactly what I wanted. For example, the food at Chick-fil-A rarely sounds good to me, and I certainly would have preferred something else for dinner last Tuesday night, but I took her there because she loves it, she asked me if I would take her, and I prioritized making her happy and sharing one of her favorite meals over eating what I really wanted.

If I was on some diet plan that restricted foods like Chick-fil-A, such as the plan I had given to the patient in question, I would have had to choose between breaking the diet or missing out on a family bonding experience. When I was a young adult and somewhat orthorexic, I prioritized “healthy behaviors” to the detriment of other important areas of my life. After turning down plans with friends so I could exercise after work and go to bed early, some of them began to distance themselves from me and stopped extending invitations. My insistence on only eating food I had brought from home kept me from joining co-workers for lunch, and my rapport with them weakened. If you have ever been on a diet yourself, consider the ways in which sticking to the plan came at the expense of other facets of your life. My guess is that if you look back, you will find examples in your own life similar to the ones I just described.

Furthermore, remember how you felt when you inevitably deviated from your diet. In Reclaiming Body Trust, authors Hilary Kinavey and Dana Sturtevant succinctly describe the pattern of dieting with a diagram that they entitle “The Cycle.” At the 12 o’clock position, the circular diagram begins with “The Problem,” which then leads to “The Shame Shitstorm” at three o’clock, followed by “The Plan” at six o’clock, then “Life” at nine o’clock, and then back to “The Problem” as the pattern indefinitely repeats. Delving into the particulars of these positions is beyond the scope of this blog, but the overall pattern is one to which many of us can relate: We identify a problematic eating behavior, feel bad about it, desperately grab for a plan that will supposedly rescue us from ourselves, abandon the plan when it proves itself to be incompatible with life, and the cycle repeats.

If a diet puts us in a position to choose between (A) sacrificing important parts of life, such as sharing a bonding experience with our kids, in order to remain on the plan, or (B) breaking the diet and perpetuating a cycle of shame and unsustainable attempts to deal with our problems, then perhaps dieting and living a full life are simply incompatible.

A Few Scattered Thoughts

Posted on by
Reply

A few scattered thoughts as we settle into 2023 . . .

Caroline Garcia, a French professional tennis player ranked fourth in the world as of this writing, recently went public about her struggles with bulimia. She reportedly explained, “Everyone is different. Some don’t eat anymore, I was the opposite: I took refuge in food. These were times of crisis. You feel so empty, so sad, that you need to fill yourself up. It was the distress of not being able to do what I wanted on the court, no longer winning and suffering physically. Eating calmed me down for a few minutes. We all know it doesn’t last, but . . . It was an escape. It’s uncontrollable.”

She and I have never worked together, met, nor communicated with each other in any way, nor am I familiar with the particulars of her medical history and eating disorder history, so of course I am only speculating, but it sure sounds to me like she still has a ways to go in her recovery. For example, her discussion of “temptations” in the players’ restaurant suggests that she still might have some trigger foods and/or a dichotomous view of foods in which her mind sorts them into groups of good and bad.

Having said that, one of the positive steps she has taken towards recovery is allowing herself more freedom in her eating. For example, she is quoted as saying, “Now, if for two days, I want a pizza, I’ll take my pizza and it will stop obsessing me.” With every eating disorder – whether bulimia nervosa, anorexia nervosa, binge eating disorder, or anything else – removing restrictions is always part of the solution.

–

While I was lifting weights at the gym earlier this month, I overheard two high school boys questioning the bench press technique that their muscle-bound trainer was teaching them. Seeking a second opinion, the trainer asked another young man who responded to the boys, “This guy knows everything! Look at him; he’s a beast!” The boys were right to second-guess their trainer, whose directive to bounce the bar off their chest increases the risk of harm and decreases the exercise’s effectiveness.

The more macroscopic problem exemplified here is that some people continue to make the mistake of confusing appearance with expertise. Nearly a decade ago, I gave a presentation that I called “Looking the Part: Patients’ Size-Based Biases Toward Their Practitioners and How to Handle Them” at the 2015 Association for Size Diversity and Health (ASDAH) conference. As I prepared my talk, I found research indicating that patients make all sorts of appearance-based judgments about their practitioners. For example, patients indicated they were much more willing to discuss sensitive issues like their psychological, sexual, and social problems if their doctor was wearing a white coat. Research also shows that patients make assumptions about their caregivers’ abilities based upon age, gender, hairstyle, and even whether or not the practitioner is wearing a name tag. If some patients prejudge a practitioner’s expertise based upon something as silly as the presence/absence of a name tag, then it should come as no surprise that research shows that patients also make assumptions based upon a practitioner’s size.

Having been a personal trainer myself, I can tell you that clients and potential clients hold similar biases based upon a trainer’s size, physique, athletic achievements, and other factors, when really none of that has anything to do with a given trainer’s expertise and capacity to help the client at hand. My client load grew immensely after I rode my bicycle from Seattle to Boston because people assumed that I must be a great trainer if I could accomplish something like that. While I appreciated the uptick in business, the premise behind it was ridiculous, as I was certainly not a better trainer upon my return than I was before I left for my trip. If anything, I was probably worse due to the exercise science knowledge I forgot while I was away.

Trainers often – but certainly not always – have lean and/or muscular builds, but that does not mean they hold some secret that will help their clients to attain similar results. Because of their biases, potential clients tend to gravitate towards trainers who have the type of bodies they want for themselves, while other trainers, who might be great trainers in actuality but fail to look the part, starve for clients before ultimately switching professions. Furthermore, size-based bias also prevents some potential trainers from entering the field, such as a patient of mine who wanted to be a CrossFit coach, but she did not think she would be successful because of her body size.

The truth is that appearance and expertise are independent entities. Conflate the two at your own risk.

–

Back in November, I wrote a piece about a college buddy who recently died after being hit by a car. Shortly after publishing it, and thanks to some feedback that I received from a longtime friend, I realized that I made a mistake similar to the very one that I was criticizing. Whereas some people jump to blaming the victim without enough information, I did basically the same thing by blaming the perpetrator without taking into account the bigger picture.

We live in a society in which following the law is a suggestion that can be disregarded with little fear of consequence. Examples are numerous, but for the sake of brevity, here are a few that immediately come to mind: doctors who blatantly and knowingly commit insurance fraud yet are still impaneled; above-the-law politicians who are still in office instead of prison; maskless police officers, train conductors, and transit drivers who defied the mask mandate rather than enforce it; ubiquitous underage drinking; and dog owners who behave as if their pet is too special for the leash law.

My daughter used to like to watch cars and trucks, and I would see many drivers holding their phones despite the hands-free law that had gone into effect. Drive the speed limit and watch the line of tailgating traffic elongate behind you. Do pickup trucks even come with turn signals?

Sometimes I wish we had a list of the laws that we are actually supposed to abide by and those that are just for show so everyone could be on the same page. As it stands, each of us picks and chooses which laws to follow and those from which we rationalize our special exemption. The absence of both consistent enforcement and appropriate modeling from our leadership has neutered our system of laws. We tolerate this, and I have no idea why.

We also seem to be okay with huge billboards that are designed to literally distract drivers from the task at hand for the sake of capitalism. We could have floodlights that illuminate a crosswalk when a pedestrian pushes a button, but we do not. Instead of crosswalks, we could have underground passages or overhead walkways to avoid the risk of a car and pedestrian ending up at the same place at the same time, but such structures are rare. Instead of blinking little yellow lights or flashing red lights, we could have normal traffic lights that turn solid red for pedestrians in crosswalks, but I only see these at intersections where cars have to stop for each other anyway. Better yet, we could install the kind of solid red lights that have white strobe lights in the center for increased visibility, but these are few and far between. Guys, things do not have to be this way.

So, here comes my friend, a father of two young girls, entering a crosswalk unequipped with any of these aforementioned safety measures, on his way to meet his wife for dinner. And here comes the teenager – who has grown up and learned to operate a vehicle in a society that has normalized careless driving and repeatedly set the example that following the law is a personal choice rather than a requirement – who will soon kill him. Maybe it helps us to feel better to condemn the driver, to act as if their behavior is somehow an exception to the norm, and to claim that they alone are responsible for my friend’s death. The truth, though, is that we all are.

Blaming the Victim

Posted on by
4

Perhaps you caught last month’s news story about a tech CEO who was hit by a car and killed crossing a street in Acton. He was a friend of mine from college. The driver took away a leader from a company, a husband from a wife, and a father from two young daughters, and severely derailed the trajectory of their own life in the process.

Some of the details omitted from the published story include that he was crossing the street to meet his wife for dinner and that the driver hit him while he was in a crosswalk. Try telling that to the internet trolls who left some ignorant comments suggesting that my friend may have been looking at his phone or crossed without looking.

Their comments got me thinking, and I remembered that blaming the victim is largely about fear. Admitting that we have limited control over our fates is scary, so much so that some of us find some comfort in assuming that a victim must have made some error and brought their end upon themselves.

Looking back, I experienced some of this myself with my three back surgeries. When I had the first operation to remove a tumor, some people questioned how I could possibly have developed one and suggested that I must have grown up under high voltage wires or that I did not take care of myself. No, my environment was fine, I was an athlete, and I had a balanced diet (by adolescent standards). When I had my first spinal fusion, some people assumed I must have done something stupid in the weight room to necessitate the repair, but no, it was really just the fallout from a freak accident and residual structural issues from the tumor. The next year, when I had to have a second fusion because the first one did not work, some people figured the surgeon must have screwed up or that I did something wrong with my rehab. No, sometimes surgeons do everything right and the patient can look on paper like the ideal candidate to heal well, and yet, in a small percentage of cases – including mine – problems still arise.

Our health is no exception to the reality that our outcomes are only somewhat in our control. We live in a culture that blames “overweight” people for their size, that if they only were disciplined enough to eat less and exercise more that they would be thinner, while the reality is that long-term weight regulation is largely regulated by factors unrelated to our behavior. We look at scary diseases and hope we can ward off morbidity and mortality by creating and avoiding dietary demons, yet people of all ages and behavior profiles still get sick and die.

A few days after my friend was killed, my daughter and I had a close call ourselves while I was walking her to school. We got to a crosswalk, I hit the button to activate the flashing yellow lights, the cars in both directions stopped for us, and we began to cross. Before we could make it across, an SUV pulled out from the school’s driveway. Perhaps the driver saw the stopped cars and thought they were waving her in. Regardless, without looking in our direction, she turned onto the street towards us and hit the accelerator. I started running, and it was a close enough call that I arched my back in order to avoid the corner of her front bumper. When I glanced back at the driver, she looked horrified. As we continued on our way, the driver repeatedly yelled to us, “I’m so sorry!”

I was angry, just as I was when I heard my friend died. I was angry at both drivers, and I was mad at our society that normalizes and enables careless driving. However, beneath my anger was fear. We live in a world in which someone can do everything right and still have things go very, very wrong, which is horrifying, and we attempt to shield ourselves from this fear by assuming that victims brought their fates upon themselves.

Boundary Phrases for the Holidays

Posted on by
Reply

It’s November, so that means that holiday season 2022 is in full swing. The last couple of years, due to the pandemic, we have not been to an in-person family Thanksgiving (the last one being Thanksgiving 2019). While it has been sad to not be able to be in close quarters with our families during the holidays, I also have to admit that at times, I felt relief at not being able to attend in-person Thanksgiving. Inevitably, talk about food/dieting/bodies comes up (especially when we spend Thanksgiving with my side of the family), and it often feels exhausting to try to navigate my way through these discussions. Five years ago, I wrote the Holiday Survival Guide edition of our newsletter, detailing some strategies for dealing with weight/food/diet talk that many of us encounter at these gatherings.

While much of what I wrote in that blog still rings true for me, I have had some more thoughts about how to make these types of holiday gatherings less fraught for my patients. Specifically, I have been thinking about how having your own “boundary phrases” at the ready could be key in helping you get through these tricky situations. And, given that we will be going to an in-person Thanksgiving this year thanks to our daughter finally getting vaccinated and us having boosters, I am sure that I will be putting these into practice for myself.

Boundary phrases are phrases that one can use to establish a boundary with a friend, family member, or acquaintance who has overstepped your comfort level. While boundary phrases can be used in many different situations and for many different reasons, I think having some that are specific to weight/food/diet comments at the ready could help my patients feel more confident at holiday gatherings. As such, I thought it made sense to put together a list of some of my favorite body boundary phrases that have worked for me and for some of my patients. As always, these might not work in every situation, but I’m hopeful that you will see one that feels like a good fit for you.

1. In response to someone making comments on your (or others’) bodies in a negative way.

“Yikes…commenting on other people’s bodies is really not OK!”

“Please don’t comment on my body again.”

2. In response to someone saying fatphobic things to you when they “only care about your health!”

“The only person I discuss my health status with is my doctor.”

“If you truly care about my health, then please also care about my mental health as commenting on my body is harmful.”

3. In response to someone telling a fat joke or making derogatory comments about fat people in general:

“Huh. That’s a really odd thing to say – I’m not sure why you shared it with me.”

“Could you explain to me why that was funny?”

“I hope you aren’t saying this to me because you think I agree.”

4. In response to someone making comments about what you are eating, specifically if they are trying to be “helpful” in identifying “fattening” foods you should avoid.

“Thanks, but I don’t need any diet/nutrition advice. I’m all set!”

“Yeah, I’m not interested in talking about food in those terms. So please don’t do it with me.”

5. In response to someone talking to you about their own diet/ food restrictions for changing their own body size.

“I’m working on making peace with my body currently, so I don’t think I’m the right person with whom to discuss these things.”

“Yeah, that diet sounds pretty difficult and unsatisfying. I’ll pass!”

Again, I know that these phrases might not work exactly for every fatphobic conversation or comment you might encounter at your holiday gatherings, but hopefully, one or two of them could be helpful in setting some clear boundaries with your friends and family members.

Happy Holidays, everyone!

Mindful Eating vs. Intuitive Eating

Posted on by
Reply

In one of my recent blogs, I mentioned in passing that mindful eating and intuitive eating are different concepts, a topic that I am circling back to now because I frequently meet new patients who mistakenly believe they are synonymous.

Intuitive eating is an approach that leans upon our body’s internal cues and uses them to drive decisions regarding what, when, and how much to eat. People who eat intuitively generally use sensations of hunger and fullness to determine when to eat and the quantity of food to consume at a given time, and they may utilize a series of matching questions to determine which foods are going to best hit the spot. (Note the words “generally” and “may,” which I have included to reflect that intuitive eating is a set of guidelines that one can use to the extent that they find helpful, not a set of rules that must always be followed.)

Mindful eating, on the other hand, is broader and simply entails paying attention to one’s eating. Intuitive eating falls under the umbrella of mindful eating, but plenty of other versions of mindful eating exist. For example, one could mindfully portion out their dinner as they carefully strive to stay within the day’s points budget. One could be mindful of the texture and flavor of their Halo Top while wishing it were Ben & Jerry’s. One could mindfully savor every bite of their 100-calorie snack pack while knowing they are hungry for more food than they are going to allow themselves to have.

One must be mindful in order to notice internal cues, but one can be mindful of other things while completely ignoring what their bodies are telling them. In other words, one can eat mindfully without eating intuitively, but one cannot eat intuitively without eating mindfully.

If you have thought to yourself that you wish you ate more mindfully, consider looking deeper to discover what it is that you are ultimately hoping to achieve. If weight loss is the motivation, then mindful eating is likely just code for dieting, an attempt to put a rosier package around restriction while the contents remain the same. On the other hand, if recovering from disordered eating or establishing a more peaceful and healthy relationship with food is the goal, then intuitive eating specifically – not mindful eating in general – is the path forward.