Gentle Nutrition

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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

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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, 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.


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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

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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

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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

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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

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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.

So, what exactly do future dietitians do at a dietetic internship?

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Just a few months after passing my exam to officially become a registered dietitian (RD), one of my former professors asked me to come back to the University of Massachusetts Amherst (UMass) to talk with some of her nutrition students about my training and the process of becoming an RD. At one point, she asked me to talk about my dietetic internship. While I have no idea what I said, she could tell that I was holding back, and she interjected and assured me it was okay to be candid. So I gave it to them straight: My internship was the worst year of my life.

Before I get to why the experience was so horrible and what I learned during it, first let me introduce what a dietetic internship is and how it fits in with a budding RD’s training. Somewhat similar to a medical residency, a dietetic internship is a bridge between school and becoming a full-fledged healthcare practitioner. Unlike school, where students study concepts in an academic setting, internships provide hands-on opportunities to perform the roles of a dietitian while under supervision. Only after finishing their schooling can one begin an internship, and only after satisfactorily completing their internship can one sit for the exam to become an RD. The internship, in another words, is a required step in the career path.

Applicants indicate the programs they are interested in and rank them in order of preference, the internship programs themselves similarly rank their applicants, and then a computer figures out the matches. Placement in an internship is not a guarantee – one statistic that I read estimates that only 60% of applicants each year are matched to an internship –  and I remember classmates who applied multiple times without ever receiving a match. No internship means no career as a registered dietitian, a reality that I feel should have been mentioned at the beginning – rather than towards the end – of nutrition school so students would have adequate time to formulate a plan B. The computer matched me to Boston’s Beth Israel Deaconess Medical Center (BIDMC), which I had listed as my first choice.

Internships typically include rotations in clinical care, community nutrition, and food service settings, but the exact composition varies from program to program. For example, one of the internships I know of has an added focus on business while mine emphasized medical nutrition therapy. Each setting includes multiple rotations that give an intern a chance to perform a variety of duties in a range of settings. Most of my rotations took place at BIDMC, but some were off site in the surrounding community.


Food Service Management

My internship began with a rotation in food service management, which had me working in the hospital’s cafeteria. My tasks ranged from culinary duties, such as learning how to efficiently chop vegetables and then applying these skills by dicing about 60 pounds of winter squash, to studying the technical specifications of various pieces of industrial kitchen equipment. At no point in my career have I ever needed to know the details of the Alto-Shaam Combitherm Model 12-18ESG flash-steam combination oven/steamer, but for a few weeks of my life, I could have told you all about it.

They told me to spend an hour working one of the cafeteria registers. After about 45 minutes, I had developed a whole new appreciation for cashiers and the pain and degradation that they tolerate. While ringing up purchases and processing payments was straightforward, the boredom and rude customers led me to conclude that there is no way I would last long doing checkout.

One of my tasks was to design and implement a nutrition promotion in the cafeteria. For whatever reason, I chose lycopene, a chemical compound found in some fruits and vegetables, so I put together table tents, a PowerPoint presentation that I projected on a cafeteria wall, and other educational materials for our customers. Additionally, I created special menu options high in lycopene, such as stuffed red bell peppers and cherry tomatoes, to coincide with the day.

While I enjoyed the food service courses that I took in nutrition school, my food service management rotation was unpleasant and awkward. In no way do I look down upon people who perform manual labor, nor am I above doing such work myself; when I worked as a personal trainer, I spent extra hours at the gym washing towels, mopping floors, and wiping down equipment, and I found pride, enjoyment, and satisfaction in maintaining a clean and orderly environment for our members. But the interpersonal dynamics at the hospital were based on a hierarchical structure, even in the kitchen, which suggested not so subtly that some jobs – and therefore some people – were more important than others when in reality they are all necessary for the hospital to properly function. Shadowing a line cook for a few hours so he could teach me about his job before I moved along to more “important” duties while he continued to make food felt like disrespectful cosplay, which did not sit well with me.

Being an intern, I was considered pretty far down the pecking order myself. On the day of my special menu, my preceptor got mad at me because the menu ingredient list read cherry tomatoes while the dish that she assumed was mine contained chopped tomatoes. As she was laying into me, I realized that the discrepancy involved a different dish, one that was not part of my special, and the ingredient list for my entree was in fact accurate. She did apologize, but the incident illustrated her general attitude towards interns and her employees, which was to pass judgment before having an understanding of a given situation or behavior and to hold a default presumption that those under her were inept.


Patient Food Service

Lucky for me, my patient food service rotation was at a different BIDMC campus, and my preceptor this time around was great. She welcomed questions, invited my input, and even gave me her home telephone number so I could call her while she was out of the office if I needed something.

My duties included putting together patient meals, checking the trays against their order forms to ensure accuracy, and delivering the food. The room service associate – the job title for the people who deliver food to patient rooms – that I shadowed was great and demonstrated how to appropriately address the patients. Knock on the door, even if it is wide open, to alert the patient that someone is coming. If a medical professional or a visitor is present, discreetly and quietly leave the tray on the bedside stand. Otherwise, greet the patient and quickly leave unless they have questions or comments. Such guidelines may or may not seem obvious, but as someone who had never worked in a hospital before, I was grateful that she took the time to teach me proper etiquette.

As an intern, I was required to dress business casual and wear a white lab coat no matter what I was doing, even when I was delivering trays. Consequently, patients often seemed confused when I walked in wearing a lab coat and carrying a tray of food. On at least one occasion, someone mistook me for a doctor. The confusion was so immediate that some patients were already perplexed by the time I could identify myself as from the food services.

While working in the “nourishment kitchen” processing and preparing patient supplement orders, I sampled each supplement myself on the advice of my supervisor, as she felt that it was important for me to have tried them so that I could relate to the patients who needed to take them. Patients occasionally asked me for advice regarding which supplement flavor to choose, and I also noticed their moods improve when they complained about a given supplement and I was able to empathize because I had tried the same drink myself. Had I not sampled the supplements, these quality patient interactions would not have taken place.

Another series of taste tests involved ordering trays for myself as I tried to put myself in the position of patients who were on special diets. Selecting a complete and satisfying meal while satisfying the constraints of a strict sodium restriction was difficult, almost as challenging as consuming pureed turkey and broccoli and thickened orange juice.

One of my tasks was to interview 20 patients on various hospital floors about the food. The opinions tended to be a matter of perspective. Generally speaking, those who evaluated the BIDMC food in relation to other institutional food spoke very highly of it, while those who compared it to restaurant food were typically disappointed. While I found it interesting to hear what patients had to say about the food, the part of the experience from which I learned the most was simply talking with them. As one patient told me when I asked him about the food, “I have bigger things to worry about than the food,” pointing to a surgical scar and tubes protruding from various places in his body.


Clinical Care

Shortly after finishing my internship, I called a colleague whom I had met during the experience to discuss the next step in my career. Referencing the tradition that new dietitians are supposed to pay their dues by working in a clinical setting before moving on to other areas of employment, I told him, “I know I am supposed to work in clinical, but . . .” “Stop right there,” he said, cutting me off. He went on to explain how outdated and nonsensical this tradition is, as clinical work has little to do with other areas of nutrition. He was right.

The three things I like to do that are the reason I decided to pursue a career in dietetics are getting to know patients, talking about food, and facilitating long-term behavior change, yet rarely does a dietitian do any of them in a clinical setting. Forget getting to know patients, as mine were often asleep, sedated, or otherwise unable to communicate, and my interactions with them were typically limited to entering their rooms and gathering whatever data I needed from their bedside medical devices and their chart notes. Forget talking about food, as my patients were frequently unable to eat and were instead relying on nutrition via enteral (i.e., a tube or port into the gastrointestinal tract) or parenteral (i.e., a line directly into the blood stream) feedings. And forget facilitating long-term behavior change, as the goal was almost always just to get the patient well enough for discharge.

My clinical rotations took place at BIDMC, Boston Children’s Hospital, Somerville Hospital, and the Youville Hospital and Rehabilitation Center. The only memory that stands out to me regarding the last two rotations is that I remember eating lunch with one of my preceptors and commenting that I appreciated her sitting with me, as we were specifically told not to eat lunch with the BIDMC clinical dietitians, who did not want to sit with their interns. She told me that those dietitians should be embarrassed and ashamed of themselves.

Generally speaking, my duties at BIDMC, whether I was in the ICU, the transplant ward, or another unit, entailed gathering data from a patient’s medical chart – particularly their lab work – and then using it to make recommendations regarding their nutrition prescription. Patients who were eating, but still needed some nutrition support, typically saw a diet technician, who could offer some suggestions regarding supplements, such as Ensure. In contrast, RDs and we dietetic interns treated sicker patients who were usually not eating and instead needed the aforementioned enteral or parenteral (TPN) methods of nutrient intake. TPN formulations often required daily tweaking depending on a patient’s labs, so I would look at their blood results, come up with my recommendations, run them by my preceptor, and then call down to the pharmacy and direct them as to how to construct the composition of that patient’s TPN mix for the day. Sometimes I also made recommendations for supplementation, like banana flakes for a C. diff infection or zinc for a pressure ulcer. This is where I learned that giving too much zinc for too long can create a copper deficiency, as the two minerals compete for absorption.

Some specific moments stand out in my memory, such as the time I was present for a tracheotomy, which was way bloodier in real life than on television. As I was backing away from the patient for fear that I was about to faint, the doctor told me, “Don’t be shy, get right in there!” Another day, I arrived to find the unit abuzz with many of the nurses and residents giggling and talking quietly to each other. After asking around, I learned that they were readying to squirt warm maple syrup up a patient’s butt.

Other standout memories are humorless, like the time I was working in the ICU and went to assess a patient, but their nurse told me not to bother, as they were unlikely to survive the day. The last patient that I ever treated while I was an intern had terminal cancer and was barely eating. She quietly responded to my suggestions, none of which would have made any sort of meaningful difference. They never prepared us for how to respond to death or to talk with patients who were on its verge and their families. We were left to come up with the answers ourselves, and I am quite certain mine were lacking.

My rotation at Boston Children’s Hospital was perhaps the most miserable stretch of the internship, largely because I was directed to treat patients right off the bat before I felt I had a solid enough understanding of pediatric care. The dietitians acted like we interns were an annoyance and a disruption to their work – which, granted, we probably were, but that was not our fault – and questions often did not go over well. My preceptor seemed generally bitter about her situation, as she really wanted to be a doctor, but settled for becoming an RD because she did not think she could handle medical school. Her story was not unique, as I met quite a few dietitians working in clinical settings who wanted to be doing something else. It reminded me of freshman orientation at Tufts University, a place to which I had applied early action because it was the only college I wanted to go to, and I was surprised by how many of my peers were disappointed to be there, as Tufts was their safety school that they had to fall back on after failing to get in any of the Ivies.

As was the case in nutrition school, we got very little eating disorder training during the internship. One of my rare exposures occurred at Children’s, as I remember shadowing a dietitian who was gently trying to convince an anorexic girl to drink some milk. The girl – wearing a thick sweatshirt because her body’s metabolism had slowed so much that she was not producing adequate heat – was bawling.

A major source of my frustration was writing chart notes. The documenting itself, which at this time was still typically done by hand, was not the issue. Rather, the problem was that each of my preceptors wrote notes differently, yet each of them felt strongly that their way was the singular right way. Each time my clinical preceptor changed, they would initially be disgusted by my notes, and by the time I adjusted and was documenting to their liking, it would be time to switch preceptors and the cycle repeated. For example, one of my preceptors co-signed one of my notes and told me “very good.” My next preceptor looked at that same exact note and told me she would not have agreed to sign it. Then I modeled my notes after her own, but my next preceptor looked at them and tore them apart, including calling them grammatically incorrect, which they certainly were not. Sometimes they allowed me to cross out and initialize the words or passages they wanted rephrased, but they were not always so generous. One time, I remember having to stay late to copy over an entire page-long note because my preceptor took issue with literally one word. “Different” is not synonymous with “wrong,” but try telling that to these people.

Furthermore, now that I am a practicing dietitian, it turns out that how I write my notes does not matter. Nobody cares. The insurance companies who occasionally request my notes as part of their decision-making process for determining coverage do not care, and the doctors – who rarely read the notes that I send them – definitely do not care.

Criticizing our note-writing skills was just one of their ways of giving us a hard time and treating us as less than. The BIDMC clinical units had a class system with doctors at the top of the hierarchy, RDs somewhere behind nurses (hence the derogatory nickname for dietitians, “Jello ladies”) and dietetic interns even lower. Having a power structure makes sense in some contexts – if a patient codes, knowing who is in charge and what each person’s responsibilities are streamlines care and saves precious time – but other times it is counterproductive. Pushing people down is a lost opportunity to gain their insight, which in a healthcare setting means worse patient care. One of my fellow interns described our experience as being similar to pledging a sorority, and just like with pledges joining Greek life or rookies on a sports team, hazing and treating the new folks with disrespect has never made any sense to me.

Around the time of my rotation at Children’s, I realized how depressed I had become since starting the internship, particularly its clinical portion. My morning commute consisted of taking the 51 bus from my West Roxbury apartment to Reservoir, then taking the green line to the Longwood Medical Area, and it got to the point where I legitimately hoped my bus crashed so I did not have to go to work. Rationally, I knew that of course the internship would eventually finish, but my heart felt differently, as I could not see myself making it through to the end. It was at this point that I knew I needed therapy.


Outpatient Counseling

After my clinical rotations were over, things began looking up. A new calendar year began and suddenly the internship’s June end date felt attainable. Around this time, I also met Joanne. (People assume we met through dietetics, but that is not the case; it was just coincidence that we were both in the same field.) Also of significance, this is when my outpatient counseling rotations – which were my favorite rotations of the entire internship – began. For the first time in a long while, I could see the light at the end of the tunnel.

In my medical nutrition therapy rotation, I worked closely with BIDMC’s outpatient dietitian, who counseled patients with cardiovascular disease, diabetes, liver disease, and other ailments. One of the aspects of this rotation that I most appreciated was that I had a chance to observe her before I began to counsel patients myself. Given that I only had one counseling course in nutrition school, I valued the chance to learn more, especially from someone as seasoned as she was. It was from her that I learned that a dietitian can be simultaneously informal and professional, that keeping the vibe of an appointment relaxed can help patients feel more at ease.

When we were not in the clinic, we went out into the community on a roving healthcare van that stopped in some of the more impoverished areas of the city. We gave out condoms, took blood pressure readings and blood sugar checks, and answered nutrition questions for anybody who stopped by, all for free. The only specific nutrition discussion I can remember having with someone pertained to the sodium content of her favorite spice mix. During our breaks, my preceptor took me around the neighborhoods to visit restaurants, food pantries, and grocery stores. We talked with some of the regulars who relied on the pantries, and I was struck by the realization that food insecurity is not some abstract notion in textbooks or a relic of a bygone era, but rather a present challenge for many people in our own city.

One of my other outpatient rotations was with a BIDMC dietitian who specialized in Celiac disease and food allergies. As part of this rotation, I – along with one of my fellow interns – wrote the elimination diet manual that BIDMC went on to use, although I imagine they have long since replaced it with an updated version.

The bariatric clinic had two outpatient dietitians that I shadowed for a week, but I remember little of what went on there. They arranged for me to observe a lap band fill, and I also remember watching a Roux-en-Y bypass surgery being broadcast live to a monitor outside the operating room. One specific memory I have is of waking up and realizing I had just fallen asleep while sitting in on a counseling session. Both the dietitian and patient noticed. I was super embarrassed, but they were kind about it. After the appointment, the dietitian gently told me that I needed to figure out how to get more sleep. An aspect of the internship that I had not anticipated was just how much work we would have to do after hours. Typically, I woke up early, spent the day at the hospital – or wherever my particular rotation was – went to the gym, then stayed up very late reading, researching, or doing whatever other tasks I had to handle. The hours were certainly nothing like the legendary marathon shifts that medical residents work, but they were exhausting nonetheless and took a cumulative toll.

For another week, I got to spend time shadowing dietitians at the Joslin Diabetes Center. This was a fantastic experience. The nurses, doctors, exercise physiologists, and dietitians treated each other with a level of mutual respect that was absent at BIDMC. The staff did an excellent job of putting themselves in the patients’ shoes and empathizing with how scared and confused some of them were. Counselors often spent extra time with them and told them to call or email anytime with additional questions. This is how outpatient counseling is meant to be, I thought, and I have done my best to follow their example.



Given my experience and interest in research, I was looking forward to my rotation in BIDMC’s general research center. We implemented the eating protocols for whatever nutrition-related studies happened to be taking place there at the time. One morning, they let me try the metabolic hood, an indirect calorimetry device that covers the subject’s head like a motorcycle helmet and uses their oxygen intake and carbon dioxide output to estimate their resting metabolic rate.

A few months after the internship was over, I applied for and subsequently accepted a research position at another general research center in Boston. Before starting the job though, I came to realize that while I do like research, it is not my passion, and my heart was really in counseling. I felt awful rescinding my acceptance, as I knew I was putting the research center in a tough spot and harming my own reputation, but it was the right call.


Plan-Your-Own Rotations

For two weeks, we were left to plan our own rotations in subject areas where we wanted additional experience. Having performed statistical analyses for a professor in the Tufts University nutrition school when I was an undergraduate at the university, I reached out to her to see if I could do any similar work for her as one of my plan-your-own rotations. Looking back at my files from the rotation, I see a bunch of charts and graphs that I put together for her, but I have no idea what the subject matter was.

Given my background as a personal trainer, I wondered if I might have a future working at a health club doing both training and nutrition counseling, so I sought out a dietitian who had that exact job and shadowed her as my other plan-your-own rotation. Two specific memories stand out to me. The first was when she offered to counsel me, just as she would one of her clients, so I could get a sense of how she practiced, and she food shamed me for eating dessert. The experience made me realize how harmful judgment is and how fear of it can understandably inspire patients to misrepresent their eating as a defense, as I was certainly tempted to lie to her going forward after seeing how she reacted to my reported dessert. The second stand-out memory is of an argument she had with a woman in one of her group fitness classes. The woman insisted that she was following the meal plan that the dietitian had given her, while the dietitian insisted that she was lying because if she was truly following the meal plan, she would be losing weight, which she was not. The argument was uncomfortable to witness, and I felt badly for the woman. When I later learned about Health at Every Size, I remembered this argument as an example of the trouble that can arise when we think we have more control over body weight than we actually do.


Community Nutrition

One of my community nutrition rotations was with ABCD Head Start. Unfortunately, I have absolutely no recollection of this experience other than seeing one of the workers get reprimanded for bringing Reese’s peanut butter cups into the nut-free facility.

The other rotation was with Boston Public Schools. My main tasks were to create educational materials, such as bulletin board materials and newsletters, for students and their families. The administrative office was a very casual environment, and I remember my preceptor and her colleagues giving me advice regarding how to approach Valentine’s Day with Joanne, as they felt I had to walk a fine line between not being dismissive of the holiday yet not coming on too strong given that we had only been dating for about a month at that point. Like a true intern, I was sent to get coffee for my preceptor, who once playfully slapped me for writing material for a bulletin board by hand instead of printing it out.


Class Days

We spent Tuesdays through Fridays at our rotations, but Mondays were our class days. The eight of us BIDMC interns would get together – sometimes by ourselves, and sometimes with other interns from the area – to spend the day learning about a given subject. We spent one day learning about mindful eating (which, by the way, is not synonymous with intuitive eating, although I suppose that is a topic for a different blog) and another about pediatrics. A dietitian from Gatorade came to talk with us about sports nutrition. One of the hospital’s gastroenterologists taught us about, well, gastroenterology. We spent a day at the Army’s research facility in Natick learning about field rations. The other class day topics escape me, but there were certainly more.

Along the way, each of us had to give presentations of our own to the class. Inspired by my visits to Native American reservations during my cross-country bicycle ride, one of my research projects looked at the dietary patterns of the residents of these reservations. Another one of my research projects looked at how other populations around the world treat constipation, which is how I learned about Pajala porridge and that people in the southern hemisphere use kiwifruit the same way that we use prunes. Looking at my notes, I see that I had started research for a presentation on competitive eaters and how they are able to hold so much food in their bodies at once, but apparently I abandoned the topic for some reason. One of the other interns and I gave a joint presentation on VACTERL association, which I had to Google just now to remember what it is.


In the end . . .

This has been a difficult blog to write. Generally speaking, these are not happy memories. The stress, the exhaustion, and the frequent disrespect made for a difficult year in which I did not learn as much about nutrition as I expected.

Additionally, I was angry – mad at the internship for not being what I wanted it to be, and mad at myself for putting myself in this situation. During the application process, internship directors were telling me that due to my strong resume and being a minority in a female-dominated field, I could go to any internship that I wanted, that it was up to me to decide where I wanted to be. Because of the geographic constraints I put on myself and by process of elimination, I ended up at BIDMC, which was supposedly one of the most prestigious programs in the country, but in hindsight, it was not the right one for me.

At the same time, I hesitate to go so far as to say I regret having gone there. Changing any element of the past would result in a different present than the one I have now. As I stated both before and during the internship, I wanted to be an outpatient counselor, and now that is what I do. While I might not have enjoyed my time at BIDMC, it is part of the route that got me here.

So, what exactly do future dietitians learn in nutrition school?

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Our switch from holding in-person appointments to telehealth has yielded many benefits, one of which is that now nobody can see the various diplomas and certificates that are mounted on my office wall. Having these documents on display makes me somewhat uncomfortable, as it feels a bit like bragging, which is why I only put them up after some patients suggested I should. Looking at them recently, I began to wonder what these framed pieces of paper mean to the people who wanted to see them. In essence, they are just souvenirs from my education, so perhaps interest in them is really just indirect curiosity about my training. So, what exactly do future dietitians learn in nutrition school? The specifics depend on where and when they study, but if my experience is any indication, it probably looks something like this.

The Basics

As an undergrad at Tufts University double majoring in mathematics and English, I had little room in my coursework for science classes. Given that, before I could begin to directly study nutrition at the University of Massachusetts Amherst (UMass), the department required that I take some prerequisites. Therefore, my nutrition schooling started from the very beginning with the most basic biology, chemistry, and physiology courses.

Of these three disciplines, the greatest focus was on chemistry. We had two semesters of general chemistry followed by two semesters of organic chemistry and one biochemistry course, all of which had lab components. When I last studied chemistry in high school, I found it difficult to understand and I consequently struggled. With that being my history, the prospect of having to take these relatively advanced chemistry courses was so intimidating that I nearly backed out of the program on the eve of my first day of classes because I was doubtful that I could succeed. Instead, I plunged myself into the subject. Motivated by intense fear and intimidation, I did everything I could to survive. No matter how well I did, I figured failure was just around the corner, so I had better keep the pedal to the metal. In addition to regularly attending office hours, I went to the on-campus tutoring department for extra review. In my free time, I answered every question in the textbooks, including ones that were not assigned. At the peak of my anxiety, I even sat in on chemistry classes I was not enrolled in just so I could hear the material discussed again and again and again.

In the end, the university gave me a merit scholarship for being one of the top three organic chemistry students out of approximately 600. Given my history with the subject and how hard I worked, receiving this award was one of the proudest achievements in my life. However, all that knowledge has played virtually no role in my work as a dietitian. Sure, I can explain the chemical structures of sugar alcohols and omega-3 fatty acids, why some fats are solids at room temperature while others are liquids, and how a bomb calorimeter works, but these skills make me no better of a clinician than a colleague who cannot do these things. Hopefully, chemistry requirements have scaled down in the years since I was a student, as my curriculum could have easily included less chemistry without negatively affecting my abilities as a practitioner.

Food Service

If you had no idea that many dietitians end up working in food service management, then you are in good company, as I had no idea about that either before I started nutrition school. To prepare us for this possible career track, the department had us take two courses in the hotel, restaurant, and travel administration (HRTA) program and two more in the management school.

Sometimes I contrast the difference between the random bits of information that have stuck with me from a course versus what I imagine those in charge of my education hoped I would retain. From the first HRTA course, I recall learning what a physical hazard is, how baby carrots are made, and that a successful coastal New England restaurant was thriving because of their choice of oven. All I remember from my human resource management course is working my ass off to show our professor – who warned us at the beginning of the semester that she does not give out As – that, actually, she does.

My second HRTA class made more of an impression, as it was a hands-on course that had us working in a semi-mock restaurant. We prepared and served real food to real customers, but no money changed hands because free food was their reward for being our guinea pigs. Joanne could tell you that whenever we meet someone who works in a restaurant, I pepper them with earnest questions that reflect my curiosity, such as how many eggs their diner goes through in a day. Given that, I thought this course was fascinating. We devised menus, planned theme meals, and rotated between all jobs in both the front and back of the house. Never having worked in a restaurant before, this was my first time being the target of the rudeness that some customers – even those who were eating for free and knew students were running the show – inflict upon those who wait on them.


And finally, the nutrition coursework itself began. The most basic class, Nutrition 101, was a survey class about the profession. This is where I learned that the term “nutritionist” has no legal definition, and anybody can call themselves one. The professor told us a story about someone who took an online test and received a nutritionist certificate – for their dog. One of my classmates announced to everybody that she was studying nutrition because she wanted to become a millionaire by inventing a fad diet.

Meal management and scientific principles, otherwise known as Nutrition 210, was an interesting course in that it included a lab component. Our experiments involved making several versions of a recipe and tweaking a variable, such as an ingredient or a preparation technique, to see how the changes affected the finished products. For example, we broiled, poached, and microwaved flounder fillets and then compared the texture and flavor of the cooked fish. We counted how many chews it took to sufficiently masticate pieces of top round sirloin prepared with a variety of tenderizers. My friend and I gave a group presentation on artificial sweeteners in which we compared popular myths versus what actual scientific research had found.

Nutrition 230 was a basic nutrition course in which we discussed the chemical structures, functions, and metabolism of various nutrients. Our professor told us that one of the reasons she chose a career in nutrition is because whenever she meets people, such as at a party, they are always interested in what she does. In contrast, many of our colleagues (including myself) try to conceal what we do for work because the follow-up questions – which are almost always based on myths and incorrect assumptions about our profession – can be frustrating and exhausting to answer.

A few years ago, I emailed my former Nutrition 352 professor, who has since been promoted to an associate dean, and let her know that my greatest regret from nutrition school is having sold my textbook soon after completing her life cycle nutrition course. Despite my two part-time jobs as a personal trainer and an assistant to the university’s food service dietitian, money was tight, and I felt I could use the cash more than a leftover textbook. Besides, I did not imagine that all these years later I would still be having occasions in which I want to refer back to it, yet that has turned out to be my reality. Fortunately, the Academy of Nutrition and Dietetics’ online Nutrition Care Manual contains a section on pediatric nutrition, which has somewhat filled the void, but I still wish I had that textbook.

Nutrition 572, community nutrition, is where I began to understand that food scarcity is not some abstract notion or one that only afflicted our ancestors and people in faraway lands, but rather one that is still a reality for many of our neighbors. One of our assignments was to go to the grocery store and design a diet that would nutritionally satisfy the Dietary Approaches to Stop Hypertension (DASH) diet while also financially satisfying the Thrifty Food Plan’s allowance of $4.37 per day. Even with my math background and nutrition knowledge, I could not do it, as the closest I could come was $4.77 per day, still $0.40 over budget. This course helped me to appreciate the impacts that financial limitations and food availability can have on health. The simple truth that people can only buy what they can afford and is accessible to them sounds so obvious now, but it took studying community nutrition for me to really get it. When I rode my bicycle from Seattle to Boston that summer, I made a point to visit the grocery stores on the Native American reservations that I passed through, as I wanted to understand the options available to the residents of these relatively isolated communities. Had I not taken community nutrition, I am not so sure I would have had the same level of curiosity.

In Nutrition 577, aptly titled nutritional problems in the United States, we studied the impact of nutrition on some of this country’s most common health concerns, such as cancer, diabetes, cardiovascular disease, and osteoporosis. Our professor was excellent, perhaps the best I ever had in nutrition school. She expected a lot from us, and she held herself to the same standard. She was also fat. While I did not judge her for her size, I remember perceiving that it was awkward for her – a nutrition expert in a bigger body – to teach us about “obesity.” Whether it was her or one of the other faculty of a similar build in our department, I cannot recall, but I do remember one of them explaining how difficult it was for them to be taken seriously because of their size. Many years later, this seed grew into a conference presentation I gave entitled “‘Looking the Part’: Patients’ Size-Based Biases Towards Their Practitioners and How to Handle Them.”

Medical nutrition therapy, Nutrition 580, was where the rubber met the road. We learned how to utilize the nutrition knowledge we had thus far accumulated and apply it to treating a wide variety of medical conditions. What stands out to me though are not the disease states we learned about, but rather some key ones that were omitted, namely eating disorders. Each of us had to research a disease (Mine was chronic pancreatitis.) and present to the class about it, and if not for another student’s brief presentation on anorexia nervosa, I would have gone the entire way through nutrition school having learned literally nothing about eating disorders. Maybe I am just biased because I now specialize in treating eating disorders, but it is hard for me to fathom that such an important group of illnesses that affect so many people was barely even mentioned.

Speaking of missing curriculum, the only counseling course we had was Nutrition 585. Of course, learning about the hard science of nutrition is important, but if dietitians are unable to effectively convey their knowledge to patients, then the information is moot. Before finishing nutrition school, I was already of the opinion that students (and therefore their future patients) would be better off if the required coursework focused less on the hard sciences, particularly chemistry, and more on counseling skills. My professional experience has only strengthened this stance.

My final course in the department was Nutrition 731, nutritional assessment. During my presentation on anthropometric predictors of cardiovascular disease, I demonstrated how hydration status introduces a source of error into bioelectrical impedance device readings that estimate body fat percentage by using such a device on myself at the beginning of my talk, then putting on a bunch of extra layers of clothes and giving the bulk of my presentation while riding an exercise bike, and then using the device again after having worked up a sweat.

Outside the Department

While taking the aforementioned nutrition courses, I also took classes in other departments, such as energy metabolism in the exercise science department. One of my takeaways from this class is just how difficult it is to design research studies that yield definitive answers. For example, our professor was confident that walking a mile and running a mile require the same caloric expenditures, but he could neither confirm nor reject this hypothesis because he could not design a study that would adequately control for all the confounding variables. He was also the first person to introduce me to the “fat-but-fit” concept, which is that someone can be both healthy and live in a bigger body.

The microbiology course I took in the food science department centered on foodborne illnesses. We learned about salmonella, staph, spores that survive cooking and freezing, and other scary things that to this day continue to make me think twice about some potential eating decisions. All these years later, I am still not brave enough to roll the dice with fried rice.

My psychology course was an introduction to the field’s basics with a focus on the nervous system’s structures and physiology. One of my takeaways was how important dietary fat is for maintaining the myelin sheaths that insulate our neurons and enable rapid transmission of electric impulses.

The nutrition program required some other courses that I was able to place out of due to my previous studies. For example, my English degree got me out of their nutrition and writing course, and my math degree similarly meant that I need not bother taking statistics. The child development course I took at Tufts enabled me to skip the same class at UMass.

Although I was fairly certain that I wanted to be a dietitian, I toyed with the idea of becoming a physical therapist, so I took some additional physics and anatomy courses that were prerequisites for physical therapy programs just to cover all my bases. Learning about anatomy was interesting, not so much because of the subject matter itself, but because it taught me the importance of speaking a patient’s figurative language. With my personal training clients most comfortable with colloquial terms like “chest” and “quads,” knowing the scientific names of hundreds of body parts proved fairly useless, and the knowledge soon escaped me.


Now you know what it took to earn the nutrition degree on my wall. One of the other significant documents that hangs near it is from my dietetic internship, which is somewhat like a future doctor’s residency and must be completed before dietitians-to-be can sit for their registration and licensing exam. Because this blog is already so lengthy that pretty much everybody has stopped reading by now (Hi, mom!), I will save discussing my internship until another time.

Continuous Glucose Monitoring

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“We start to, you know, numbers start to be overlaid onto everything like we’ve got some kind of headset on and we’re looking through it and there’s little value numbers attached to our foods and to the actions we take in our lives, and that’s tremendously unhealthy, I think, and can descend – you know, people I’ve interviewed and I’m sure people that you work with – can descend into pathology, right, where you’re constantly afraid that that equation is not right and you need to keep upping it and the output needs to be better and that you’re falling short. That’s not a good place to be.”

Dr. Alan Levinovitz, PhD, to Christy Harrison, MPH, RD, CEDS, in Food Psych #94

Earlier this month, a friend asked me about an email he received from a company trying to sell him a subscription to their continuous glucose monitoring (CGM) service. Since some of you are likely unfamiliar with it, CGM technology allows its user to automatically track their blood sugar levels around the clock. The monitor itself is a small sensor typically placed on someone’s abdomen or arm, and it contains a needle that measures sugar concentration in the skin’s intercellular fluid. A transmitter attached to the sensor sends the information to a separate device, such as a smartphone, on which the user can view their blood sugar data. As the American Diabetes Association discusses, CGM is a legitimate medical tool that diabetics can utilize to help manage their condition.

What was surprising about the email that my friend received is that the solicitor was not marketing their CGM service to diabetics, but rather to the general population. Their subscription service provides users with CGM devices, tools for tracking their food consumption, and access to a team of dietitians who analyze the data and help clients to examine the link between their eating and blood sugar levels. That may sound innocent enough, but I have concerns.

Their website (to which I am purposely not linking in order to avoid driving traffic their way) features enticing language like “Reinforce Good Habits,” “Promote Longevity,” “Manage Weight,” and “Gain Energy.” With approximately 51% of adults wanting to lose weight and some estimates claiming that 45% of the general population experiences fatigue, these calls to action seem designed for mass appeal. Their pitch continues, “While each journey is unique, we’ve found that remarkable improvement to your health and well-being can be achieved in just a single year,” and includes alluring testimonials, such as, “I was really in a place where I thought I kind of knew my body and I know what I’m feeling. I WAS WRONG.”

When I clicked on the “Get Started” link, the following page presented me with a multiple-choice question regarding my goals. This is the first of approximately a dozen questions, each on its own page, that opened up for me to answer. Between questions, a quote from one of their staff dietitians affirmed – based on my answer to the preceding question – that I was in the right place and they could help me. Using the back button, I changed my answers a bunch of times to see if I could produce a different result, one in which they would say their service is not appropriate for me, but that never happened. My impression is that they welcome everyone as a customer, which must make for a great business model.

Dangers exist in overemphasizing a single parameter of health and insinuating that everyone can benefit from focusing on it. While people may debate the quantity and identities of the various aspects of health, all of the models that I have seen agree that health is multifaceted. Depending on the particular model in question, categories may include emotional health, social health, and physical health, among others. Taking a closer look at physical health yields subcategories, such as anthropometric, biochemical, and clinical measures, and each of these has numerous parameters within them. Casting a bright light on one variable, such as blood sugar, while leaving the others in the twilight is an oversimplification of health, and to suggest that everyone – not just those with a known issue with their glycemic control – would benefit from doing so is at best misleading.

An overarching danger is that someone could pursue better blood sugar levels at the expense of other aspects of their health. For example, a user could adopt eating behaviors that may keep their blood sugar in check, but create or exacerbate issues with their cholesterol or blood pressure. Perhaps someone else begins to view foods that spike their blood sugar as “bad” and others as “good,” thereby bringing about or worsening disordered eating. Others may pursue better blood sugar at virtually any cost, eliminating or severely restricting certain foods, socially isolating themselves so they can eat exactly as they think they should, all the while feeling that what they are doing is not good enough and they need to be more diligent, thereby taking their disorder up a notch with each iteration.

Thinking about this CGM service reminds me of the debate surrounding full-body CT scans that some suggest could enable doctors to catch budding diseases in their infancy. Check out this 2017 Food and Drug Administration article, particularly the following quote, and note the parallel between the problem with these scans and what this CGM company is doing.

“CT is recognized as an invaluable medical tool for the diagnosis of disease, trauma, or abnormality in patients with signs or symptoms of disease. It’s also used for planning, guiding, and monitoring therapy. What’s new is that CT is being marketed as a preventive or proactive health care measure to healthy individuals who have no symptoms of disease. Taking preventive action, finding unsuspected disease, uncovering problems while they are treatable, these all sound great, almost too good to be true! In fact, at this time the Food and Drug Administration (FDA) knows of no scientific evidence demonstrating that whole-body scanning of individuals without symptoms provides more benefit than harm to people being screened.”

Similarly, while CGM can certainly be a helpful tool for some people with known blood sugar stability issues, whether the potential benefits outweigh the potential risks of applying the technology to someone without such a diagnosis is murky. In essence, this pros-vs.-cons question is what Dr. Levinovitz seemed to be getting at in his quote that kicked off this blog. It’s not that applying quantitative measures to our bodies and behaviors is always a negative; it’s that doing so is not always a positive either. Oftentimes, whether signing up for a CGM subscription service, buying a Fitbit, or downloading a calorie-tracking app, people go into such endeavors based solely on sales pitches and what they hope to get out of the experience while unaware of the risks that come along for the ride.