Tag Archives: needham nutritionist

Prediabetes

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Prediabetes. Lately it seems like many of my patients have been diagnosed with this condition. After receiving this diagnosis from their health provider, usually accompanied by some scary warnings about eventually developing diabetes and often with a side of weight shaming, these patients end up in my office feeling freaked out and worrying about the (seemingly) rapid decline in their health. A number of these patients have been advised by their doctor to start medications such as Metformin or GLP-1s to help manage their blood sugar. And more than I care to count have been advised to cut out carbohydrates and lose weight. While I do think that having information about one’s blood sugar and looking out for changes are important, I also believe that some members of the medical community are creating panic around this condition while simultaneously pushing medications and diets that are unwarranted.

What is prediabetes? Well, it’s a relatively new diagnosis that was first introduced in the late 1970s to describe patients whose blood sugar levels are higher than “normal” but not yet high enough to be in the range for type 2 diabetes. There are currently four different blood tests that can be used to diagnose someone with prediabetes (and diabetes): random blood sugar test, fasting plasma glucose (FPG) test, oral glucose tolerance test (OGTT), and hemoglobin A1C (A1C) test, but the majority of patients receive their prediabetes diagnosis following the A1C test. The A1C test measures average blood sugar levels over the previous two to three months. A level under 5.7% is considered “normal,” a level between 5.7% and 6.4% is considered “prediabetes” range, and over 6.5% results in a diagnosis of type 2 diabetes. Originally, the range for prediabetes was an A1C between 6.0% and 6.4%, but after extensive lobbying by the pharmaceutical establishment, the range was lowered to 5.7%-6.4% in 2010 by the American Diabetes Association (ADA), resulting in 72 million new cases in the USA. As a result of lowering the threshold for prediabetes, about one in three people in the USA is prediabetic.

So what does the research say about prediabetes and risk of developing diabetes? According to a 2018 comprehensive review of 103 studies, most people in the prediabetes range do not progress to diabetes over any period studied, with 59% of the prediabetes patients studied returning to normal blood sugar within one to eleven years without any treatment. In a 2019 article for Science.org, Charles Piller reports that the Center for Disease Control’s data show that less than 2% of prediabetics go on to develop diabetes per year. But despite this, the medical community continues to put forth the message that a diagnosis of prediabetes is basically a guarantee that diabetes will ensue. And what do these medical professionals recommend to their patients to “reverse” their prediabetes? Weight loss, primarily by way of cutting carbohydrates.

As we know, dietary and exercise interventions for weight loss are unsuccessful for the majority of people, with 90-95% of dieting individuals regaining the weight within five years. In addition to this, weight cycling, or losing and gaining weight over and over again, can result in a number of negative health outcomes such as cardiovascular disease and (you guessed it) diabetes. Telling a patient to try to lose weight to reverse their prediabetes is honestly just lazy doctoring. There are plenty of things people can try to improve their blood sugar levels that have nothing to do with weight loss. Some of these include: making sure to pair carbohydrates with protein, fat, and/or fiber at meals and snacks to help slow down the digestion of carbohydrates, resulting in steadier blood sugar; consistently getting seven to nine hours per night of sleep (as poor sleep quality has been associated with an increase in insulin resistance); engaging in moderate cardiovascular movement (such as walking) which immediately lowers blood glucose, an effect that can last up to 24 hours. But most importantly, if you are diagnosed with prediabetes, please do not panic. While it makes sense to get your A1C tested regularly to look for changes, having A1Cs in the prediabetes range does not mean that you are destined for diabetes.

Misguided and Deplorable

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You already know that last fall in New York City, a gunman murdered Brian Thompson, CEO of UnitedHealthcare. Yet, as I sit here watching the executive branch of our federal government simplistically blaming scapegoats for complex issues, this piece of old news feels relevant.

What a misguided and deplorable act, but we can understand the gunman’s anger, right? It is hard to be worse than Medicare – which once rejected an 18-page application that I filed without telling me why, and it turned out it was because I listed my five-digit zip code instead of also including the four-digit extension – and yet United found a way. In fact, I would estimate that we have had more issues with United than with all of the other insurance companies we deal with combined.

On the provider side, our problems with United began very soon after we applied to be credentialed as in-network providers. Based on the paperwork we received, our impression was that we became in-network providers in the spring of 2013, but United subsequently told our billing manager that we were not in network and never had been, so we reapplied in early 2014. They sent us letters notifying us of our acceptance, but the contracts we were supposed to sign never arrived. As the redacted fax that I sent them in August 2014 shows, United provided contradictory information and made getting a straight answer very difficult.

Contradictory information seems to be United’s trademark, as I have lost count of the number of times they told our patients that their appointments with us would be covered, only to later reverse course. It got to the point where I now candidly warn our new patients with United that there really is no way of knowing for sure ahead of time what their coverage will be, that we all just have to wait until the reimbursement statements arrive to find out.

The worst United story that I have heard came from a woman I know personally who was telling me about her sister. Before undergoing joint replacement surgery, her sister contacted United to make sure the operation would be covered. She shared all of the details, and United assured her that they would cover the procedure. Soon after the surgery, she received a six-figure bill from the hospital, as United had gone back on their word and declined to cover the operation. Their reason? Apparently, in addition to the surgeon, another doctor had been present in the operating room during the surgery, and this doctor was out of network with United. Based on the presence of the out-of-network doctor, United decided not to pay. The patient had made sure ahead of time that her surgeon was in network, she was literally unconscious during the procedure and had no control whatsoever over who else may have ended up in the room, yet United left her hanging with a bill on par with that of a mid-range Porsche.

Right around a decade ago, Joanne and I were talking with a colleague and bemoaning the difficulties of working with United and other insurance companies. She encouraged us to remember that the job of insurance companies is not to pay, that the challenges we were facing are by design. The more barriers that they put up during the reimbursement process, the more likely that the patient will ultimately get stuck with the bill, which just serves as a reminder that for-profit healthcare will never make any sense except in the minds of the depraved.

Then again, neither does committing murder as a form of protest. A man lost his life, the gunman effectively threw away the remainder of his own, and for what? Mr. Thompson was a high-ranking executive in a wicked and deeply flawed system, he has been readily replaced by another executive who will carry on the same mission, and nothing will change except the addition of a security detail.

Our healthcare system has serious problems, and we need thoughtful, intelligent, well-informed, and compassionate leaders to sort them out, not someone who resorts to scapegoating, hate, and violence. Same goes for our country.

The Potato Diet

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A couple of decades ago, a nutrition professor told me that one of the reasons she loves being a dietitian is because when people hear what she does for a living, they are interested and want to talk with her about the field. In contrast, most practicing dietitians I know dislike talking about their work, so much so that some of them purposely shade what they do, such as saying, “I work in healthcare,” or “I am a therapist,” in order to discourage follow-up questions. It’s not that these dietitians hate their jobs or anything; rather, they do not want to get sucked into irritating conversations during their free time.

Personally, I have found that quickly adding that I specialize in eating disorders tends to keep at bay the annoying questions and commentary that are more likely to arise when I simply say that I am a dietitian and leave it at that. My approach, while usually successful, still has its failures, as evidenced by an experience we had last month in a Puerto Rican swimming pool.

Joanne and I were on the island vacationing with our daughter, and we ended up in conversation with another couple who were also enjoying the hotel pool with their son. Upon hearing what we do for work, the father began talking about a favorite dietary approach of his: the potato diet.

Given that the potato diet is actually a real thing, let’s talk about this guy’s diet of choice. According to him, the potato diet consists of eating nothing but potatoes and supplementing with vitamin E because, according to him, potatoes – when eaten in abundance – contain sufficient amounts of all nutrients except for vitamin E. He also claimed that the diet “works” without ever defining what constitutes success in this context, although he did make mention of a celebrity who supposedly lost a significant amount of weight on the potato diet, thus suggesting that “works” means something along the lines of “will cause someone to lose weight.”

Okay. So, according the USDA’s nutrient database, a generic large russet potato, including its flesh and skin, is said to provide 292 calories. For a generic person who needs 2,000 calories per day (and many of us need more), that means eating nearly seven of these large potatoes a day. Putting aside the feasibility of that for the moment, would seven potatoes per day really contribute enough of each nutrient besides vitamin E? Let’s take a look.

The low end of the recommended carbohydrate range is 45% of total calories, so the person needing 2,000 calories per day would need at least 900 calories, or 225 grams, of carbohydrate from these seven potatoes. Because potatoes are densely packed with carbohydrates, they would easily exceed this minimum. Check mark.

What about protein? Estimated protein needs are based on body weight, activity level, and medical conditions, so let’s say that the person in question weighs 130 pounds, is generally sedentary, and has no medical conditions that would influence their protein needs. The low end of their protein range would be about 47 grams per day. Their seven potatoes would contribute 55 grams, so check mark again. If the person is heavier, more active, or has higher protein needs for any other reason, this check mark is probably replaced with a red X.

How about fat? The low end of the recommended fat range is 20% of total calories, so this person would need at least 400 calories from fat, or approximately 44 grams. Their seven potatoes only contribute a couple of grams total, so a huge red X here.

Unfortunately, the low fat content spells trouble for the fat-soluble vitamins. Russet potatoes do actually contain some vitamin A and K, but too bad the dieter’s body will be unable to absorb it due to the lack of dietary fat. The same would be true with vitamin D if the potatoes actually contained any, which they do not.

The seven potatoes do contain enough vitamin C to stave off scurvy, and the thiamin content is enough to prevent beriberi disease, but the lack of vitamin B12 would likely cause fatigue and, if sustained long enough, possibly anemia. We could go on, talking about other micronutrients, phytochemicals, and other nutrients, but you probably already realize that the potato diet is not a great idea if the goal is any semblance of health.

But what if the goal is not actually better health but rather, say, weight loss? (And remember, weight and health are not synonymous.) Personally, I imagine that the first couple of potatoes on day one would taste great, but by potatoes six and seven, I would already be sick of them. In subsequent days, I would probably be so tired of them that I am not sure I could continue to stomach all seven even if I was still hungry. Restricting variety to just one food carries the likely intended side effect of restricting one’s intake overall, and while restriction does not always lead to weight loss, sometimes it does, at least in the short term.

And isn’t that really what the potato diet is? Just another fad diet to bring about short-term weight loss that will likely be regained plus more? Instead of focusing on our daughter and having a good time, we had to spend a portion of our vacation talking with this guy about this nonsense. See, this is why so many dietitians hesitantly offer some version of, “Umm, I work in healthcare,” and then try to change the subject.

Weight Loss Wagering

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When I began working on this piece, I was trying to remember when I first learned about the idea of betting on weight loss and what my reactions to the concept were back then. As far as I can recall, I think it was around 2009 or 2010, and I believe I was intrigued, as this was at a point in my career when my work was centered around instigating weight loss (or its close cousin, improved body composition) and the assumption that of course such pursuits lead to better health. So, if wagers could be a useful tool in my proverbial toolbox, I wanted to know about it.

While the idea of wagering on weight loss continued to exist, it never really took off or hit the mainstream either, at least as far as I could tell, but it caught my attention again early last month when I noticed that HealthyWage [Note: They seem to use HealthyWage and HealthyWager interchangeably on their website.] was running ads during the US Open tennis tournament. My reaction now, 14 or 15 years later, was quite different than when I first heard about betting on weight loss.

Using weight as a proxy for health – which a younger me left unquestioned and unchallenged for way too long – is problematic in itself, but we have already covered that elsewhere, so I am going to put that aside, as many other topics are going through my mind: Does the prospect of winning or losing money in the short term actually induce long-term behavior change? How do outcomes differ when someone wagers against themselves as opposed to engaging in a weight loss competition against a friend or others?  Addressing these and other questions that I have in mind would be too lengthy for a single blog, but perhaps I will circle back to them one day.

Meanwhile, I want to take a narrower focus and examine a few of the company’s claims and pieces of information that most stood out to me when I spent some time exploring HealthyWage’s website.

Clicking the “Get Started” button on the homepage brought me to a calculator where I could change my prize range by manipulating how many pounds I want to lose, how much money I want to bet each month, and how long I need to reach my weight loss goal. Regarding length, I noticed that the more time I asked for, the higher my prize range, which runs counter to the old adage that trying to lose weight slowly and steadily is more likely to be successful than rapid weight loss, advice that I used to echo early in my career and that some doctors still repeat to their patients. In reality though, this advice is nonsense, as weight loss endeavors will likely fail in the long run no matter how they are pursued. While we can be relatively successful inducing short-term weight loss, the weight almost always comes back in the end. HealthyWage’s algorithm suggests that they understand that long-term weight loss is less likely, as evidenced by their willingness to fork over more money to the people who achieve it and less money to those who quickly lose the same number of pounds.

Going back to the homepage and scrolling just below the “Get Started” button yielded testimonials from three “Success Stories,” including names and locations of three individuals who won between $1,463 and $3,007 via losing 101 to 160 pounds in contests that ranged from nine to 18 months. In addition to their statistics, these profiles also feature before and after photos as well as quotes from the individuals. You know who else posts success stories? The Massachusetts State Lottery Commission, for one, whose website lists hundreds of winners per day across the state. According to a study by Bloomberg, state lotteries “have the worst odds of any form of legal gambling” in the country. To put things in perspective, one is reportedly four times more likely to get hit by an asteroid than they are to win Powerball. Testimonials – whether they are lottery winners posing with oversized checks, Weight Watchers leaders touting their own journeys in front of their groups, or HealthyWage winners – sure are enticing by inducing fantasies of what is possible, but possible and likely are vastly different adjectives.

One question on the HealthyWage FAQ page asks, “Is HealthyWage legal?” to which the company responds, “Yes. Although we use the word ‘bet’ to explain the concept, HealthyWager isn’t gambling in the legal sense because you are in control of the outcome at all times. It’s up to you to lose the weight.” Okay, first of all, suggesting that weight loss is entirely in one’s control is incorrect, reckless, and contributes to stigma. Joanne and I have both had patients who were still fat despite struggling with very restrictive and dangerous eating disorders, and I take issue with the false narrative that someone is whatever size they are solely because of their behaviors. Furthermore, the “at all times” phrase flies in the face of solid evidence showing that weight regain is the norm, not the exception.

HealthyWage can call their service whatever they want, but the fact remains that it is a gambling operation similar to state lotteries, casinos, or any other for-profit entity that invites customers in with splashy hooks and enticing testimonials. When we put our fantasies of victory aside and get back to reality, we remember the basic truth of this industry: The house always wins.

Biting Lollipops

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Don’t bite your lollipops, I always warn our daughter. Well, I failed to follow my own advice, broke a tooth, and ended up with my first crown.

Sometimes we have to learn our lessons the hard way, a theme that I often think about when I am working with my patients. In motivational interviewing, the urge a practitioner may feel to tell their patient what to do is called the “righting reflex,” which is generally an unhelpful tactic that I do my best to avoid.

Sometimes I worry when my patients make choices that seem unlikely to work out in their favor (setting out to lose weight, spacing out appointments differently than I feel they should, declining to read a book that I think would be helpful for them, choosing to work with a therapist or doctor whose area of expertise is a mismatch for their conditions, keeping a scale in their home, just to give a few examples), but such concerns are my problem, not theirs.

After all, my patients are the stars in their own lives while I am part of their supporting cast, and they have the autonomy to consider all aspects of a decision before making the choice that feels best to them. The choice that I think I would make in their shoes or what I believe they should do are irrelevant, unless the patient asks for my opinion and wishes to consider it along with all of the other factors at play.

Although I am open to offering my opinions upon request, my job is much less about telling someone what to do and much more about helping them to understand and consider the pros and cons of their options. For example, over the summer, one of my patients received weight loss advice from their doctor, guidance that is outdated and highly unlikely to achieve the doctor’s expected results. Being caught in the middle between treatment team members with differences of opinion is confusing, frustrating, and just no fun. The appointment that we had in which I warned them of the dangers inherent with the doctor’s advice was a tough one. Ultimately, I hope they understood that my dissent was not really about trying to sway them, but rather about helping them to see the whole picture, thereby enabling them to make an informed decision regardless of whatever that decision might be.

Someone might understand that biting lollipops is a dangerous idea, but they love biting them so much that the risk feels worth taking. Fine. On the other hand, to break a tooth on a lollipop without knowing that biting them is risky, that would be a tragedy. Sometimes, intellectually understanding that something is a bad idea is insufficient; we have to make our own mistakes in order to learn. Sometimes we need to break a tooth of our own to truly understand that biting lollipops is perhaps a roll of the dice best not taken.

We are all going to die!

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One of my patients, who has been working hard to refine their intuitive eating skills, recently asked me to explain the concept of gentle nutrition in general terms. Although I already wrote a piece about this topic just last year, I want to revisit it because I realize in hindsight that I failed to adequately emphasize a basic truth that is of upmost importance to remember: We are all going to die!

Yes, yes, eye roll, we are already aware of our mortality, but thinking about our demise can be so unpleasant that it can be easy to put to the side and ignore. As scary and sad as it can be to think about, sometimes we need to remind ourselves that no matter how fast and how far we run, death will always chase us down. Always. Unless we get hit by that proverbial bus or suffer some sort of other physical trauma, a health condition of some form will do us in. That’s just how it is.

While death is a certainty, how exactly it will happen will remain a mystery until it actually unfolds. Some smokers never develop lung cancer while some non-smokers do. Predictions, like weather forecasts, are still just guesses. Sometimes the weatherman calls for a 5% chance of precipitation and we get a downpour.

Of course our overall dietary pattern has some influence, albeit limited influence, over our health, but the impact of any single eating occasion is likely negligible. Unless the food blocks or closes our airway or somehow inflicts catastrophic injury to our gastrointestinal system, tonight’s dinner is not going to kill us, nor will it save us from our ultimate fate. Given that an elementary eat-this-not-that approach fails to account for our nuanced reality, how, then, are we supposed to make decisions about what, when, and how much to eat? This is where intuitive eating and gentle nutrition can help.

My patient gave me an example of a situation they found themselves in, and we talked through how one might approach it using intuitive eating and gentle nutrition, but I am going to tweak the specifics a bit for the sake of their privacy. My patient is reassessing their intake of red meat after reading an article linking such meat with colon cancer, which runs in their family. Furthermore, their go-to order at the local pizzeria is a steak and cheese sub. Should they be reducing their intake of red meat and perhaps be ordering something else, they questioned, or would that be running counter to intuitive eating?

My response began by reminding them that having a steak and cheese tonight will not kill them, nor will opting for a salad save them. We talked about using matching questions to help guide their food choice. If the matching process squarely lands on the steak and cheese, then yes, of course, go ahead and order it. On the other hand, if the criteria they identify are broader, they anticipate that they could take or leave the steak and cheese and be equally happy, and since reducing their intake of red meat is a goal they are trying to achieve, then opting for a different menu item probably makes the most sense. In essence, gentle nutrition utilizes medical nutrition therapy as a tiebreaker of sorts, not a driving factor.

Furthermore, we talked about increasing their options by considering items on the pizzeria’s menu that perhaps they had overlooked. In other words, the choice need not be binary between a steak and cheese sub or a garden salad, but also include a pizza with chicken and broccoli, a Greek salad with shrimp, or any of the other menu items that omit red meat.

During the course of our conversation, my patient realized that sometimes they order the steak and cheese by default, not because they necessarily have a craving for it, and that sometimes it leaves them with a stomach ache. This information is important to consider too. Sometimes their desire for the steak and cheese is so strong that it will feel worth risking a stomach ache, but other times the craving will be low enough that it will be overshadowed by wanting to feel good the rest of the night. Even more importantly, realizing and acknowledging that they sometimes make their ordering choice on autopilot offers an opportunity to make more conscious decisions going forward.

Hopefully, this addendum to the piece I wrote last year helps to clarify the concept of gentle nutrition. Perhaps, as I continue to think of better ways of explaining, you will see me release a third installment at some point. That is, if I live long enough to write it, and if you are still around to read it.

Cottage Cheese Is Having A Moment

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If you are someone who spends a good amount of time on social media apps like TikTok and Instagram, chances are you have seen that cottage cheese has now become that “it” food that everyone is using to add more protein to their recipes. I remember when I was growing up, fat-free cottage cheese was the ultimate diet food and, honestly, it tasted as such. As I got older, I tried 2% and full-fat versions of cottage cheese and found that I enjoyed them as a satisfying part of a snack, pairing either version with pretzels, crackers, or everything bagel chips if I was in a savory mood or mixing one of them with fruit if I felt more in a sweet mood. I’m not sure how I ended up on #cottagecheesetok, but my “For You Page” on Tiktok started showing video after video of people using cottage cheese in interesting (and sometimes off-putting) ways, and I became fascinated by this trend. As someone who does enjoy cottage cheese from time to time, I decided to try out some of these recipes to see if they might be something I would want to add to my meal/snack rotation. The results were varied, so I thought I might share with you all some of the cottage cheese “adventures” I have taken over the past three or four months and their letter grades.

 

Cottage cheese pancakes (A-)

I gotta be honest, I was not so sure about these when I first heard of them, but I decided to give them a whirl as my usual breakfast of eggs was starting to get a bit boring. The recipes I have seen basically have the same formula: cottage cheese, eggs, flour (or oats), baking powder, vanilla, and a sweetener. Going on a tip from another cottage cheese enthusiast, I tried blending the cottage cheese with an immersion blender to make it smoother and less chunky, and I think this made a big difference. This recipe is one of the times when I didn’t really taste the cottage cheese that much and that was okay with me. My only criticism of this method is that the pancakes come out “wet” and not fluffy, but if you are okay with that, then this could be a solid breakfast idea. I also like that you can make them and then freeze them/defrost them for future breakfasts. Topped with fruit, syrup, and/or any toppings you like (chocolate chips, whipped cream, Nutella, anyone?), these were satisfying and tasty.

 

Cottage cheese ranch/French onion dip (B-)

This is one of those really quick and easy cottage cheese ideas that I thought sounded promising. Basically, it involves blending up the cottage cheese (see above) and then adding different spices/flavorings to it to mimic ranch dip or French onion dip. Since I enjoy both of those dips with chips, veggies, etc., I thought “why not?” Well, I would say that the cottage cheese versions of these dips were okay, but not great. Texturally, they just weren’t creamy enough, and I felt like the cottage cheese flavor overpowered the other ingredients. For clarification, I added a packet of Hidden Valley Ranch powder to one batch and a packet of French onion soup mix to another batch. Were they edible? Yes. But if I was in the mood for chips and dip, this wouldn’t do the trick for me.

 

Adding cottage cheese to egg salad, chicken salad, tuna salad (C-)

I am someone who enjoys an egg/tuna/chicken salad on occasion, so I was curious to see how adding some cottage cheese to these would affect their taste. Spoiler alert – I did not like it in any of the above. Again, I tried blending the cottage cheese ahead of time to make it smooth, and while that did help texturally, I found that the saltiness of the cottage cheese negatively impacted whatever protein I was using. Just as with the dips above, I felt like the cottage cheese taste overpowered the proteins it was mixed with, and it was not enjoyable for me.

 

Adding cottage cheese to pasta dishes (A)

I have seen so many creative ideas when it comes to using cottage cheese in pasta dishes and, honestly, most of the ones I have tried have been tasty. Basically, all of the recipes take blended cottage cheese and mix it in with whatever pasta sauce you are using for the dish. That could mean adding it to marinara, pesto, Alfredo, or mac and cheese. Blending cottage cheese into the sauces gives them a nice creaminess, and I didn’t feel like the cottage cheese flavor overpowered the pasta. I even tried using blended cottage cheese in lasagna (instead of using ricotta), and I thought it was great. Definitely my favorite cottage cheese adventure.

 

Cottage cheese ice cream (D)

File this experiment under “I knew it would be bad, but tried it anyways.” The recipes I saw online called for blending up cottage cheese and then mixing it with various sweeteners/additions and then freezing it to create “ice cream.” While some of the flavors I tried were edible, none of them resembled ice cream and could never take its place. Do yourselves a favor and skip this one. Trust me.

 

I’d say my cottage cheese adventures were variably successful, and I have found myself adding some of the above creations to my repertoire (mostly the pancakes and the pasta dishes). It’s good to experiment with food, and you never know unless you try something. Do any of our readers have some foods that they have experimented with? What did you like? What didn’t work? Let us know!

Experimenting With Food

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Once upon a time, many years ago, I packed myself a peanut butter and broccoli sandwich for lunch and brought it to work. Peanuts are legumes, just like chickpeas, I reasoned, so I had a reasonable basis for thinking that swapping out hummus for peanut butter would taste good. Not only was I wrong, but the sandwich was horrendous and bordered on inedible.

When I recently reminded Joanne about my experiment gone wrong, she was unsympathetic, insinuating that I was nuts for inventing such a strange combination of foods. Some of her own food experiments have turned out poorly as well, but she defended them by explaining that she has generally gotten her ideas from TikTok and elsewhere on social media. But someone out there was the first person to try each of those ideas, I explained, and they had to have the flexibility and imagination to try something new before discovering that they liked the result enough to post about it for others to see. If my peanut butter and broccoli combination had turned out great, I would have told other people about it, and maybe it would have become a thing.

Just as the results of experimenting with food are all over the place, so are the reasons for trying new combinations in the first place. Out of mayo earlier this month, Joanne made tuna salad with yogurt, and the tangy result was terrible. Unsure what to do with leftover Halloween candy corns a couple of decades ago, I put some on top of mint Oreo ice cream, and I loved the weird combination so much that I have made it every fall for the last 20 years. After finding that her breakfasts were not holding her for very long, Joanne tried adding Orgain powder to her coffee and cottage cheese to her eggs, and the increased protein leaves her satiated for a longer duration. Because I wanted to increase my fiber intake, I tried marinara sauce on chickpeas and found that I like it just as much, if not better, than on pasta. On paper, drinking soda during endurance events is a questionable choice, but after some experimentation with different hydration options, I set my marathon personal record on Coca-Cola Classic. Without allowing her to experiment, we never would have learned that one of our daughter’s favorite drinks is pickle juice.

While necessity sometimes leads to new creations, imagination is often a driving force, but creativity means little without the freedom to experiment. If you have food rules, consider how they are affecting your ability to experiment with food. While I am not advocating for food rules, I do acknowledge that they can have some upside. For example, someone who feels that they must have a vegetable with dinner may feel inspired to try a wide array of vegetables for the sake of variety and keeping things fresh within the limitations that their food rule demands. On the other hand, one of the many downsides of food rules is that they limit the scope of creativity. For example, the aforementioned individual who insists on having a vegetable with dinner has fewer options than someone who is flexible regarding a vegetable’s inclusion. Given that, if you have food rules, consider downgrading them to food guidelines in order to give yourself more freedom.

If you put food rules and norms to the side and give yourself permission to put your creativity to work, what might you try?

“Food Noise”

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Over the past year or so, a concept has been popping up on my radar: “Food Noise.” It seems like with the growing popularity of the newish weight loss/diabetes medications Ozempic, Wegovy and Mounjaro, there has been more discourse around how these drugs are getting rid of the “food noise” in many people’s brains. Anecdotally, most individuals who take higher doses of these medications report feeling “less obsessed” about food. In fact, they almost stop thinking about food altogether. For many of these folks, this comes as a welcome change, as previously their brains felt like they were constantly perseverating on food and on what, when, or how much they should or should not be eating. People describe feeling relieved to no longer be overly focused on food and the “noise” that their brains create around it.

On the surface, I can completely understand how getting rid of the “food noise” can come as a relief for so many people. Constantly thinking about food uses a lot of mental energy and can be exhausting. To be freed from these thoughts can feel like one is breaking out of diet prison. But, as a dietitian who helps folks with intuitive eating, I also have some concerns around this concept. A number of my patients who are on these prescriptions report having no hunger cues whatsoever, that they have to remind themselves to eat, and when they do, they do only want to eat a little and get full quickly. While this might seem like a dieter’s dream, it is in exact opposition to what our bodies were built to do. We are born as intuitive eaters from the start; babies are quite adept at communicating when they need nourishment. It is normal for us to experience hunger multiple times per day, and, in response, to fuel ourselves as the need arises. Hunger is a basic biological function that is vitally important for survival. When hunger cues are removed, we are at risk for undernourishment and malnutrition.

One of the ways that these weight loss/diabetes medications works is by slowing down our digestive process so food lingers longer in the stomach. Unsurprisingly, when our digestive system slows down, we feel less hungry and feel hungry less often, which results in eating less. This process also helps our body to improve its ability to manage its blood glucose. While smaller/moderate doses of these drugs have been shown to be helpful for those with type 2 diabetes to manage their blood sugar, doctors are now prescribing them in much larger doses to “aid in weight loss.” The higher the dose, the more likely it is that one will experience gastrointestinal side effects such as nausea, vomiting, diarrhea, cramping, and bloating, which in turn leads to a decrease in appetite and ensuing weight loss.

Is this (or any kind of intentional weight loss) healthy? I would argue not in the slightest. These drugs are basically making it easier for folks to underfeed their bodies. It makes food restriction tolerable. It can seemingly get rid of the “food noise,” but at what cost? As we have learned over the years, intentional weight loss, especially when it is rapid, takes a huge toll on one’s health and almost inevitably results in weight regain. Weight cycling is a risk factor for many health conditions that the medical community blames on weight, such as cardiovascular disease and metabolic disorders. While we do have plenty of research on these medications and their efficacy in managing type 2 diabetes, the research on using these medications for weight loss is much sparser and of shorter duration. In a way, these weight loss medications feel like the weight loss medications of the past (e.g., Phen-Fen in the 1990s), promising to be the “miracle cure” for so many struggling with weight issues, only to be eventually pulled from the market due to the serious health risks they inevitably cause.

I would argue that for those who are able to eat intuitively – listening to their bodies’ hunger and fullness cues, responding accordingly, and rejecting the diet messages we get constantly in our weight-obsessed culture – “food noise” is not really a thing. Many folks feel like they are “food addicts.” While I certainly want to validate someone’s feelings, the research we have at this point does not confirm that this is a real, physiological issue, such as substance addiction. Much of the “food addiction” research that is out there currently does not account for the subjects’ previous or current dieting behavior which has had a considerable effect. Restriction, whether it is mental or physical, begets food preoccupation.

When someone learns to listen to their body’s cues and feed oneself in accordance with these cues, and when one gives oneself unconditional permission to eat, food preoccupation lessens greatly and, in some cases, disappears. We are supposed to feel hungry several times per day; this is our body’s way of telling us we need fuel throughout the day. Our bodies are constantly giving us cues and feedback, but we are taught that our hunger cues are “wrong” and are not to be trusted.

I will be curious to see how those who are taking these medications will fare in the future, specifically around “food noise.” Many studies have shown that most people are unable to tolerate these medications for more than a couple of years (despite the medical community and drug companies saying that these drugs need to be taken for the rest of one’s life). And for those who continue with these medications, we have yet to see the long-term health effects that they will cause. My hope is that more and more people will come to realize that we do not need to be at war with our bodies and that listening to our bodies’ wisdom is the best course of action.

The Lingering Effect of Scarcity

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Cleaning up the house earlier this week, I came upon a bottle of hand sanitizer that was functionally empty, as the remaining liquid was too shallow for the pump to reach. If I had found it in 2019 or earlier, I would have dumped out the little bit of sanitizer and recycled the bottle without even considering any other option. But that was before COVID-19, before cleaning products became precious commodities, before I went from store to store in search of them only to find empty shelves, before opportunists were reselling them online for ten times their sticker prices, and before a friendly pharmacy clerk discreetly slipped me a pocket-sized bottle of sanitizer as though she was passing off a top-secret document in a spy movie.

After all of that, even four years later, no way could I bring myself to waste any amount of hand sanitizer. And really, that comes as no surprise. Several decades after the Great Depression, my grandparents still could not bring themselves to leave any food uneaten, so much so that they once finished Chinese food leftovers despite knowing that my brother and I had found a boiled insect in the rice.

As I was doing my best to transfer the remaining hand sanitizer to another bottle without spilling a drop, I thought about patients of mine who are still working to recover from food scarcity that ended many years ago. Remember, food scarcity has several etiologies, including famine, financial hardship, political blockades, food deserts, and limitations imposed by oneself or by someone else. Intellectually, we know the difference between going hungry because flooding destroyed this year’s crop and putting a cap on our eating because we are on a diet, but on a biological level, all our bodies know is that they are not getting what they need. When the restriction ends, we are driven to get as much as we can of what we missed for fear that another period of restriction will come.

The solution is indefinite abundance. The more we surround ourselves with food, especially ones that were previously restricted, and the more we reaffirm that we are done with self-imposed limitations, the more the drive to overconsume decreases. (Side note: Overeating can have several different roots. Here, I am referring specifically to overconsumption that comes from restriction.) If someone finds that a specific food is particularly a trigger, the stocking technique might be helpful.

Certainly, the concept of abundance entails a great deal of privilege, such as access to foods, money to buy them, and places to store them. Some of the factors that influence access are beyond our control. To the extent that we are able to give ourselves consistent and ongoing access to a wide variety of foods and pledge that the days of restricting ourselves are over and never to return, we help to curb the frenzied drive for more and more.

And of course it takes time, maybe even a long time, to shake scarcity’s impact. Understandably, we want to reach a more peaceful relationship with food sooner rather than later, but there is no way to rush the process. We just have to be patient, ride the wave of everything that comes up along the way, and continually remind ourselves that we will always do our best to maintain our access to hand sanitizer – I mean food – going forward.