Tag Archives: weight loss

Busted

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Football player Rob Ninkovich announced today that the league has suspended him for four games for taking a banned substance. Ninkovich explained, “Few things are more important to me than my name and reputation. This might call that into question for some, which has me heartbroken. I don’t want to cut any corners. I want to do things the right way, with high integrity, and that’s what I have always wanted to stand for.”

He continued, “Any supplement I’ve ever used was bought at a store. I was unaware something I bought had a substance in it that would give me a positive test because it wasn’t listed [as an ingredient]. One thing I have learned is that if a supplement is not NSF certified there are no regulations that ensure that what is on the label is 100 percent accurate. That is a hard lesson for me to learn at this stage in my career, but I take responsibility for it. It’s a mistake I made and it hurts that I won’t be there for my teammates.”

Patients frequently ask me about supplements, particularly protein powders. Pop culture nutrition is fickle. Not too long ago, we emphasized carbohydrates and feared dietary fat. Today, we are scared of carbohydrates and worship protein. As such, people who are already getting more than enough protein often feel they need even more and turn to a protein supplement.

Protein powders, like other supplements, are largely unregulated. Generally speaking, we have no idea if the contents match the listed ingredients or if the quantities reported on a bottle’s nutrition label are accurate. Back in 2008, I read a study (which I unfortunately cannot find right now) that analyzed actual protein content in various powders and found that most did not contain nearly as much protein as advertised.

Furthermore, as odd as it may initially sound, realize that manufacturers have incentive to add secret ingredients. Competition is fierce; a quick search of GNC.com yielded 512 different protein supplements. Consumers often make their selections based upon the perceived results or testimonials of others. If you are a supplement manufacturer and you want your product to stand out among the rest, to be the one that is perceived as yielding the best results, the one that gets talked about and recommended in the locker room, you may decide it is in your best interest to slip in an unlisted ingredient that produces the desired effect.

Whenever an athlete like Ninkovich gets busted and blames his supplements, the common reaction is to assume they are lying and covering for having purposely taken a performance enhancer. That may indeed be true, but we have to remember that what we often see as an excuse is also a completely plausible explanation.

You may or may not get drug tested the way that many professional athletes do, but the uncertainty of supplement contents can still impact you. Might an ingredient, listed or otherwise, interact with one of your medications, make you nauseous, give you a headache, accelerate your heart rate, or damage your liver? You could have no adverse reactions at all, wind up dead, or anywhere in between. That’s the risk.

If you use a supplement or are considering taking one, think about the potential ramifications, and remember that the lesson Ninkovich apparently learned today is actually an important lesson for us all.

Hold Off On Time-Delayed Eating

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You may have caught a recent New York Times piece entitled “Time-Delayed Eating Leads to Better Food Choices” in which the author writes, “A series of experiments at Carnegie Mellon University found that when there was a significant delay between the time a person ordered their food and the time they planned on eating it, they chose lower-calorie meals.”

Dr. Eric VanEpps, the post-doctoral student who led the research, elaborates, “If a decision is going to be implemented immediately, we just care about the immediate consequences, and we discount the long-term costs and benefits. In the case of food, we care about what’s happening right now – like how tasty it is – but discount the long-term costs of an unhealthy meal. [When we order a meal in advance], you’re more evenly weighing the short-term and long-term costs and benefits. You still care about the taste but you’re more able to exert self control.”

Self control, unhealthy, lower-calorie . . . Based on the language Dr. VanEpps uses and the undercurrent of a good/bad food dichotomy, time-delayed eating sounds like yet another dieting tool right up there with drinking a glass of water before sitting down to a meal, consuming caffeine to stave off hunger, or not eating after a certain time of evening. We all know by now that dieting rarely works, right?

Regarding the research at hand, two of the pieces discussed in the New York Times article are hidden behind pay walls except for their abstracts. While I can only comment on what I am able to read, the information available to me leads to many important follow-up questions.

What happens when the time comes to eat and the food you ordered long ago does not meet your intuitive needs in the moment? Will you eat it anyway? If not, what is plan B? If you do eat it, might you consume more of it than you really need in an attempt to satisfy yourself through sheer quantity? Will you overeat by beginning your feeding with your pre-ordered food only to follow it up by eating something else that you actually want?

Consider a personal example. A little over a decade ago, I went through a phase where I was modifying cookie recipes in all sorts of ways in an effort to make them “healthier”: nuts and dried fruit instead of chocolate chips, oil instead of butter, whole wheat instead of white flour, reduced sugar, etc. These changes sounded good in theory, but who was I kidding; these “cookies” were only cookies by name and bore a stronger resemblance to pancakes. They never quite hit the spot. When you want cookies, no amount of pancakes will satisfy. Either I ate the healthier cookies by the batch in an effort to quell my cookie craving, or I chased them with traditional baked goods anyway. Now that I make normal cookies full of butter, sugar, white flour, and chocolate chips, I only need to eat one or two in order to feel satisfied.

Consider the short-term and long-term ramifications of time-delayed eating. If you just consumed a meal you did not really want but ate anyway, what happens at the next meal, or later that evening? How do you eat the next day? The next week? The next six months? The restriction/binge cycle of dieting suggests that sooner or later there will be consequences somewhere down the road.

One of my patients is coming off a serious health scare and has completely revamped his way of eating over the last year. On the weekends, his family maps out exactly what they will eat each day of the upcoming week and then they shop only for the ingredients necessary to implement their plan. When Thursday evening rolls around and the dinner entree he scheduled five days earlier no longer sounds appealing, he eats it anyway. He may not love it, but he can tolerate it.

Right now, he does not mind taking a utilitarian approach to his eating. So far, it seems to be working for him, and who knows, maybe it always will, but as his dietitian I have to think ahead to what might happen in the coming months and years as the fear associated with his medical incident subsides and leaves him with a different picture of motivation than the one he holds today. In other words, how long can one tolerate eating foods that may seem healthy on paper, but on the enjoyment scale are only meh?

Similarly, I encourage you to consider the aftermath you are likely to have on your hands if you try time-delayed eating and find yourself trying to reconcile the food you pre-selected for yourself and what you actually want to eat in the moment. If the research teaches us anything, it’s that such discrepancies are a virtual certainty to occur.

Wishful Thinking

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Last December, I stumbled upon a very interesting article on the website Ravishly. The piece, entitled “Being Thin Didn’t Make Me Happy, But Being ‘Fat’ Does,” written by Joni Edelman, caught my attention for pretty obvious reasons. In it, Edelman included two pictures of herself, one with the caption “Before” and one “After.” As you might have guessed, her before picture is of her when she was at a much lower weight at the age of 35. The after picture is of her and her family, five years later when Edelman was at a much higher weight. Edelman goes on to describe the extreme measures she took to achieve her “physical hotness” displayed in the first photo, including counting calories obsessively (limiting her calories to 1000 per day), exercising excessively (running 35 miles per week), and overall living a very restrictive lifestyle.

While Edelman concedes that being at this low weight came with some “benefits” such as being able to fit into size 4 clothing and receiving positive attention from men, she says that the amount of effort, sacrifice and mental energy it took to maintain this weight significantly diminished her happiness. She found that the time and energy it took to keep her figure ended up taking away from her relationships, especially with her children, as she was preoccupied with her food and working out.

Realizing that “happiness does not require thinness” and “fatness does not presume sadness,” Edelman stopped her extreme dieting and exercise behaviors. As one would expect, she gained weight, and with medication changes to treat her bipolar depression, she gained even more weight. Despite this, Edelman wrote that she had found a “stillness, a joy, and a peace” that she had never had and that “it’s worth 10 pounds.” The article ended with Edelman telling her readers to “be fat and happy. Be unapologetically fat. Wear a bikini, and mean it. Eat pizza and ice cream and enjoy it. Drink up your life and a bottle of wine, and make no apologies.” It was a refreshing article and one that I imagine took a great deal of courage for her to write. In our fat-shaming, thin-exulting world, it’s rare to hear someone (especially a woman) talking about being both fat and happy.

A few weeks ago, one of my patients forwarded me another piece written by Edelman. Apparently, Edelman has decided to start writing a bi-weekly column entitled “Beyond Before & After,” (BB&A) where she hopes to discuss “living without dieting, fostering self-love and healthful choices made on our own terms. No scales, no calorie counting, no before, no after. Because we’re so much more than that.” Sounds promising, I initially thought to myself.

In the first installment of BB&A, Edelman talks about her blog from last December. How she received so much praise and attention for writing so bravely about something that many woman would be afraid to do – to call themselves “fat” and be okay with it. But then the article takes a turn. Edelman writes that even though she fully believed that she could be fat and happy, something started to shift. She describes instances in which her body started to fail her, such as not being able to sit on the floor without falling because she was not able to bend due to her stomach getting in the way. How she was tired of feeling breathless after walking up 13 stairs and how her weight was making it nearly impossible to heal an injured ankle. All of a sudden, Edelman writes that being fat “stopped working for [her],” and that she wanted to change this by losing weight, that “if being fat doesn’t work for you, you can change, or you can at least give it your best effort.”

Oh dear. I don’t know where to begin with this. First of all, this piece makes me sad. Here was someone who was fighting the good fight, who really seemed to get it: that weight and health and wellbeing are not inextricably linked. That there are plenty of thin people with health problems and plenty of fat people with none. Interestingly, Edelman talks about how she got her blood work done (in addition to numerous other health tests) and surprisingly enough, her labs were nearly impeccable, with a low thyroid as the sole issue that arose. Other than this (and being diagnosed with peri-menopause), Edelman was in excellent health. But, even with this positive information, Edelman is resolved to change her body.

Okay, time for some full disclosure: part of me understands where she is coming from. I am also living in a larger body and there are times that I think to myself, “you know, your knee pain and plantar fasciitis would likely improve if you lost weight.” Biomechanically, I understand that carrying more weight translates to more stress and strain on my body. But, then my rational mind kicks in and reminds me of several facts: 1) There are plenty of thin people with knee pain and plantar fasciitis (just ask nearly all of my slender tennis teammates) 2) There are numerous ways to address these health conditions without losing weight (just ask my podiatrist and my physical therapist) and, most importantly, 3) Permanent intentional weight loss is impossible for 95-98% of those who try to achieve it. So, even if losing weight did improve my issues, no one has found a way to keep the weight off. In fact, most people end up gaining even more weight than they had lost in the first place, resulting in an even higher weight.

The other issue I want to shed light on is Edelman’s admission that she has struggled with an eating disorder (ED) in the past (namely exercise bulimia). Even if she is not actively engaging in restriction and over-exercise, her weight loss goal is simply ill advised. Recovery from an eating disorder is a life-long process and it is completely at odds with purposefully losing weight. You can’t be in recovery and be actively trying to lose weight. They are incompatible. Even Edelman realizes how tricky her endeavor is going to be, admitting that she has already been weighing herself more than once a day and has been drinking copious amounts of water to help her feel full. I will not be surprised to see her get back into an ED mindset if things continue this way.

Listen, I get it. Being fat can be tough in our society, and it’s easy to blame our physical maladies on our body size. But just deciding that being fat isn’t working for you and that you are going to change your body permanently is at best wishful thinking and at worst a very dangerous endeavor. I hope that Ms. Edelman figures this out before it’s too late.

He Said, She Said: Parents

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He Said

June 2nd was World Eating Disorders Action Day, which was an important occasion that helped to cast desperately needed light on these conditions that are so common, yet receive so little attention.

Many of our colleagues shared articles, blog posts, and memes on social media to commemorate the day. One particular meme caught my attention because it read in part, “Families are not to blame, and can be the patients’ and providers’ best allies in treatment.”

To be candid, that statement is only partially true. On one hand, eating disorders can certainly arise in the midst of even the most loving and supportive family dynamics. On the other hand, environment is an important factor in the development of eating disorders, and this broad term that encompasses television, social media, print media, teachers, friends, coaches, co-workers, and many other influences also includes family.

Neither Joanne nor myself is here to pass judgment on anybody. Parenting is hard work, and all of us, parents and otherwise, make mistakes sometimes despite our best intentions. If we are to help families become the supportive allies that the meme correctly states they can be, then we must acknowledge the reality that even well-meaning and loving parents sometimes inadvertently contribute to the problem.

This month, Joanne and I discuss some of the most common mistakes parents make that can promote or exacerbate an eating disorder or otherwise hinder their child’s nutrition care, and we suggest alternative behaviors that can be more helpful. Joanne tackles the behaviors most related to eating disorders while I address others that I see in my side of the practice, although overlap certainly exists between the two.

Mistake 1: Modeling disordered behavior

“I can’t do moderation,” one of my patients insisted. She was 12 years old. With both of her parents out of the room, she explained to me how her parents oscillate between restriction and overconsumption. The former might take the shape of cleanses, clearing the house of “junk food,” enrolling in weight-loss programs, or other similar actions, while the latter might manifest itself through binges, lamenting their eating behaviors, or expressing concerns about a food “addiction” or feeling out of control.

The patient in question was well aware when one of her parents was about to transition from one state to another. “You cracked the seal!” her mother reportedly exclaims to her father (or vice versa) when a “bad” food is brought into the house. Because this is the behavior modeled in my patient’s household, no wonder she similarly feels, at such a young age, already destined for and incapable of anything beyond an all-or-nothing relationship with food as well.

Improvement: Model a healthy relationship with food

Children often learn through observation. Family meals in particular are an excellent time for parents to model their healthy relationship with food. Serve and consume a wide variety of foods. Destroy the good/bad food dichotomy by incorporating “bad” foods and showing that one is neither guilty for having them nor virtuous for sticking solely to “good” foods.

Similarly, keep a wide variety of foods in the house, as attempts to restrict the food supply typically backfire sooner or later. Children are bound to encounter “bad” food at friends’ houses, camp, and other environments, so better to help them build a healthy relationship with these foods early in life before they grow into young adults who do not know how to handle the newfound freedom that accompanies all-you-can-eat college dining halls.

In order to model a healthy relationship with food, parents must first of all have one. Be candid with yourself and realize that the best way to help your child might be to recognize and seek help and support for your own eating issues.

Mistake 2: Putting too much responsibility on the child

Encouraging autonomy and empowering children have their upsides, but parents sometimes take these actions too far. They step so far back that children are left without the parental support that they need to succeed. Parents might leave their children alone with us for more time than would be ideal, decline invitations to meet with us without the children or to check in with us between sessions, opt not to reinforce at home the ideas we discuss in session, or fail to implement action steps that necessitate parental involvement.

Improvement: Work together as a team

Just as children of all ages look to their parents for a variety of resources, everything from physical needs to unconditional love, they need similar help with their nutrition. Children have their own feeding responsibilities, but so do parents. In order to suss out who is responsible for what, parents must actively participate in the process. Initially, parents may not see eye to eye with us or have questions or concerns about our approach, and these thoughts are best expressed in private so as not to confuse the child with conflicting paradigms. In short, working together as a team tends to yield the most fruitful results.

Mistake 3: Assuming their children can lose weight because they did it themselves

Many of the children at our practice have parents who are high achievers. Through hard work, discipline, sacrifice, and other life choices and factors, they have reached the pinnacle of their respective fields. Some of these parents have applied these same traits to their own weight-loss endeavors with similar results. They assume that if their children take a similar path, they will reach the same outcome.

Improvement: Differentiate between typical and atypical results

If you have lost weight and kept it off, recognize that you are the exception, not the rule. Approximately 95% of people who attempt to lose weight will regain it one to five years down the road, and roughly 60% of these individuals will end up heavier than they were at baseline. Weight regain is common even if someone maintains the behaviors that promoted the weight loss in the first place.

Contrary to popular myth, our weight is largely out of our hands. The calories-in-versus-calories-out paradigm is a gross oversimplification of the complexities affecting weight regulation. While we might be able to manipulate our body size through behavior changes for a short while, biological mechanisms promoting weight regain almost always win out in the end.

Even genetics and behaviors together do not tell the whole story. For every Griffey or Boone family, we have hundreds of major league ballplayers whose offspring will never make it in the pros. Set aside the notion that what worked for parents will work for a child, and accept that your child may never lose weight and keep it off no matter what he or she does.

Mistake 4: Encouraging weight loss

A desire to lose weight leads to dieting, which is a predictor for eating disorders, worse health, and ultimate weight gain. Parents may understand the dangers and futility of dieting and instead encourage “lifestyle change.” Unbeknownst to them, the behaviors they have in mind, such as restricting calories or certain food groups, keeping a food journal, weighing or measuring portions, or staving off hunger by filling up on liquids or low-calorie foods, are still tricks of the dieting trade. Different packaging, but same contents.

Improvement: Promote size acceptance

Weight stigma is real and widespread. Children encounter it on the playground, on television, on social media, in the classroom, and maybe even at the pediatrician’s office, but they do not have to face it at home. Promote size acceptance and discuss the stigma they inevitably bump into as they move about the world. An additional and important lesson: Teach them not to contribute to said stigma.

Mistake 5: Talking about “health” as a euphemism for “weight”

Sometimes parents have a sense of the dangers associated with focusing on a child’s weight, so they substitute in the word “health” instead. Children are perceptive, however, and they learn about our cultural obsession with weight and size at an early age. When their parents say, “I just want you to be healthy,” they interpret this in context and hear, “I just want you to lose weight.” When they start talking to the big kid in the family about “health” and bring him to a dietitian while his skinnier siblings receive no such treatment, trust me, he knows exactly what is going on.

Improvement: Recognize that health and weight are not synonymous

Health and weight are not nearly as synonymous as we have been led to believe. Studies have shown that weight loss does not automatically lead to better health, and other research that controlled for behaviors found that health risks between groups of people of different body weights were nearly identical when engaging in similar behaviors. If health itself is indeed the priority, then apply it to everyone in the family, regardless of body size.

 

She Said

June 2nd was World Eating Disorders Action Day, during which numerous organizations and activists all over the world brought to light the prevalence of eating disorders (ED) and the need for comprehensive treatment. Jonah and I noticed a meme that was circulating on that day which outlined nine facts about EDs. While overall I felt like the meme was accurate and could be quite helpful for those unfamiliar with EDs, I felt like one of the “truths” was not completely accurate. This “truth” states, “Families are not to blame, and can be the patients’ and providers’ best allies in treatment.” My issue does not lie with the second part of the sentence, as I fully believe that parents can be wonderful allies in helping someone recover from an ED. But I do not agree with the statement that families are not to blame.

Let me be clear: I am not saying that it is solely the parents’ fault if their child develops an ED. But absolving parents of any blame doesn’t ring true to me.  As in most diseases, genetics play a large role as does environment. One way of thinking about it is this saying: “Genetics load the gun, but environment pulls the trigger.” Well, parents are part of the child’s environment, and therefore they can contribute (even unwittingly) to the development of their child’s ED.

99% of the time, parents are acting out of love for their child. They don’t want their child to suffer and only hope that he or she will be happy and healthy. But even with the best intentions, sometimes parents (and other family members) can inadvertently trigger an ED in a genetically predisposed patient. The following are some examples of how this can occur:

Example #1: The parent speaks negatively about his or her own body.

This might be surprising to some people, but children of parents who speak disparagingly about their own bodies (i.e., not their child’s body) are more likely to develop issues with eating and body image. I’ve had numerous patients whose parents only tell the patient how beautiful/handsome/perfect he or she is, or that there is nothing wrong with the child’s body. However, oftentimes the child will overhear their parent complaining about their own “love handles,” saggy body parts, or “unsightly bulges,” and even though these comments aren’t directed at the child, he or she learns to internalize these messages and can start to believe that his or her body is “wrong” too. The best way to prevent this from happening is for parents to avoid negatively talking about their own bodies, especially in the presence of their child. All bodies are good bodies, and stressing this message can help kids develop a more positive body image.

Example #2: The parent puts too much responsibility on the child and does not take an active role in his or her ED recovery.

Sometimes I encounter parents who want to take a step back from their child’s ED, as they believe that the child should be in charge of his or her recovery. While I agree that the patient needs to take an active role, most kids are dependent on their parents for food, as parents are the ones who go grocery shopping and who do the meal prep and planning. A child who is dealing with an ED cannot be counted on to feed himself or herself appropriately. Very few kids with EDs take the initiative to prepare a snack or meal for themselves. I had one patient that often would skip meals and snacks because she knew that her parents weren’t watching her. My advice would be that parents need to take an active role in their child’s ED recovery, especially if that child is a younger teenager. This means that parents might need to supervise meals and snacks, make sure that there are ample and appropriate food choices in the house, and hold the child accountable for food eaten outside of the house. Regarding the latter, signs may suggest that a child is not following her meal plan while at school, for example. In such instances, parents have the responsibility to arrange for a teacher or school nurse to supervise the child’s eating to ensure compliance with the meal plan.

Example #3: The parent encourages their child to lose weight.

This is a tough one. In our fatphobic and fearmongering culture, being overweight or obese is seen as a terrible fate. With the help of Michelle Obama, every parent is vigilant about their child becoming a part of the “childhood obesity epidemic.” Even if a parent feels like their child is “fine,” pediatricians can scare parents into seeing their child’s weight as a ticking time bomb. I’ve had too many patients to count whose parents bring them in because their doctor wants the child to lose weight. In some cases, these kids are encouraged to go on diets, and they receive praise for every pound lost. I had one patient in particular whose parents promised her a new iPad if she lost a certain amount of weight. Obviously, I feel that encouraging one’s child to lose weight is very problematic. Study after study has shown that kids who start dieting from an early age are actually more likely to become overweight or obese in adulthood. In other words, the end result is the exact opposite of what these parents are hoping for. My best advice is to stop focusing on your child’s weight. Instead, focus on his or her health, as we know that health and weight are not necessarily synonymous. Also, I would recommend talking with the child’s pediatrician (without the child present) to discuss taking the focus off the child’s weight, as negative messages about the child’s weight can lead to a preoccupation with food and even development of an ED.

Thus, while I really agree overall with the “truths” outlined by the meme, I would modify #2 to say that family dynamics can play a role in the development of an ED. While it is true that parents are not solely to blame for their child developing an ED, they can use some of the above strategies to make it less likely that their child will go down that treacherous path.

An Important Shot Bricked Off the Glass

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If ESPN is going to advertise their story with a provocative before-and-after pictorial of Kevin Love’s body transformation, then let me begin my response by pointing out that the chiseled-armed latter version of Love is arguably a worse player than his earlier, pudgier self.

Sure, now that Love is LeBron’s sidekick in Cleveland rather than the focal point of offense in Minnesota, one might expect some of his numbers to be down. However, his points per game, rebounds per game, and assists per game have all worsened despite nearly identical minutes per game and playing in the midst of what should be his peak basketball years. That’s tough to do. Given that, someone will have to explain to me why we are focusing on his physique instead of his noteworthy and curious decline.

That someone, however, might not be Jackie MacMullan. Normally a fantastic sports journalist, one of the best in her field, she took a shot at an important subject with her ESPN article entitled, “From Kevin Love to Draymond Green, NBA players struggle with food more than you think,” but uncharacteristically threw up a brick.

Her piece begins with a detailed account of Love’s meticulous and rigid eating habits. “Not 10 almonds, not 18 almonds — 14 almonds,” his trainer reports. “Kevin is exactly on point. If he’s supposed to eat every two hours, then on the days when he wants to sleep in, he’ll wake up, eat and go back to sleep.” Even his teammates raise their eyebrows at his eating behaviors, which also include bringing his own food on the team plane rather than “be tempted by a postgame spread that might be high in calories and carbohydrates.”

The aforementioned content and the article’s title set up perfectly to discuss disordered eating, which is sorely in need of more attention and dialogue. “NBA players, in truth, are just like us,” the author writes, before listing various eating behaviors common to both professional athletes and laymen. A glaring omission from her list is that professionals are susceptible to dysfunctional relationships with food, eating disorders, and nutrition myths just like the rest of us. Sometimes abnormal behaviors are so prevalent that we mistake them as normal, and I think the author may have fallen into that trap.

More troubling is that instead of discussing Love’s eating habits as a red flag of concern, the author presents them in the context of his lower weight and improved endurance. Consider the impact this kind of message has on readers. For you parents out there, do not be surprised in the least when you walk into the kitchen and find your teenager counting out his or her almonds.

Furthermore, while Love is no doubt eating in a way that he believes serves him best on the court, we must remember that professional athletes often focus on the here and now while long-term risks take a back seat. The stakes are simply different for them. Professionals put their long-term health on the line for short-term rewards that are unavailable to the rest of us. Love just rushed back on the court from a concussion so he could continue playing in the NBA finals. If you suffered a similar concussion, would you risk permanent brain damage in order to play out the remainder of your YMCA rec league’s spring season? Similarly, readers must understand that following an eating plan as rigid as Love’s is risky and makes little sense for the general population.

The author turns her attention to Oliver Miller, “. . . who at his peak weighed over 375 pounds, ate so much of it [pizza] that the Suns took drastic measures, including hospitalizing him and hooking him up to IV fluids. ‘But then they found out he was ordering Domino’s from the hospital,’ [former teammate Danny] Ainge says. ‘They had to put a security guard outside the room.'” Under a photograph of Miller is a caption reading, “Oliver Miller had to be hospitalized because he couldn’t keep his eating under control. The root of his career-long battle? Pizza.”

Look, I have never met Oliver Miller or viewed his medical records, but whatever was going on with him during his playing days, I promise you that the root cause was not pizza. By talking about pizza, or any other specific food, in this way, the author further propagates the myth of food addiction. When we abandon the diet mentality, uncouple moralization from eating behaviors, break up the good/bad food dichotomy, build intuitive-eating skills, and make trigger foods available in abundance, “food addiction” typically resolves, which is the exact opposite outcome that an addiction model would predict in response to such treatment.

Even if Miller was suffering from binge eating disorder, which, as with other eating disorders, is a mental illness that gets played out through food, pizza is still not responsible for his struggles. More importantly, neither you nor I know whether or not he had such a disorder. Hopefully, one of our takeaways from our shameful treatment of Pablo Sandoval over the winter is the lesson that we cannot determine someone’s relationship with food or the presence of an eating disorder based on his or her body size or weight. The notion that we can is yet another myth.

“But it’s not as easy as simply losing weight. Becoming lighter, in many cases, often doesn’t translate into peak performance,” the author later writes. While I completely agree, the article’s subsequent content seems tenuously related at best. She discusses Roy Hibbert, who lost weight upon request by one coach and then put it back on when the Pacers hired a new coach who asked him to regain it, but that was apparently related to differing philosophies in team play between the two coaches, not a change in Hibbert’s performance. A more direct and relevant example would have been to discuss Love’s aforementioned regression despite his body transformation.

The article’s most important passage reads, “Dallas Mavericks coach Rick Carlisle says the one thing he has learned in his 27 years in the league is not to judge a player by his body type. Mavericks guard Raymond Felton, for instance, is more diligent about his diet than Russell Westbrook, yet you’d never know it by a simple eye test.” So true, but these 54 words are drowned out in a 2,910-word article largely about dieting and weight. Besides, in an age in which attention spans seem to rarely exceed 140 characters, how many readers even make it far enough in the article to reach this important paragraph?

While I commend the author for taking on this topic, her article could have been so much more than it is. She could have brought to light the societal prevalence of disordered eating, eating disorders, and nutrition misinformation so widespread that they infiltrate professional locker rooms. She could have explored how the eating habits of star athletes impact the general population, especially minors. She could have addressed the dangers and damage stemming from coupling weight with performance. Instead, she did none of those.

Ms. MacMullan, an important story is begging to be written here, and I believe you can still author it. Please consider grabbing your own rebound and putting up another shot.

Thoughts on the 2016 Multi-Service Eating Disorders Association (MEDA) Conference

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On May 14th, I attended the 21st annual two-day conference held by the Multi-Service Eating Disorders Association (MEDA). This year’s conference theme was “Thinking Outside the Body: Empowering Yourself, Your Clients and the Community.” I was only able to go to day two of the conference, but I feel like I learned a lot during that one day of presentations and thought it would be helpful to summarize some of what I learned.

The first talk I attended was the day’s keynote address, “Gender Identity, Gender Expression, and Eating Disorders,” presented by Carly Guss, MD, Allegra Gordon, MPH, ScD, and Jerel Calzo, PhD. Obviously, the topic of gender identity has been on the forefront of many people’s minds given the latest legislation around transgender individuals being able to use public restrooms. While I am familiar with transgender issues, I have only worked with one transgender individual in my practice, so I was very interested in hearing what the presenters had to say on the matter.

While the presenters gave a helpful primer on gender identity, their main focus was on the prevalence of eating disorders (EDs) in the transgender community. According to the presenters, two recent studies found that compared to cisgender heterosexual women, transgender men and women have 4.6x odds of past-year self-reported ED, were more than twice as likely to have used diet pills and purging in the past month, had 4.8x risk of being “underweight,” and had 2.5x risk of being “obese”.  Two other studies on ED risk in the transgender community found that the majority of participants (transgender men and women) reported a history of disordered eating and that there was a “strive for thinness” to suppress unwanted secondary sex characteristics, particularly in people who were gender assigned “female” at birth but identified as males. It makes a lot of sense if you think about it – if one were to identify as a male but were born female, that person might want to prevent the development of curves and beginning of menstruation that naturally occur as a girl becomes a woman. Restriction and maintaining a very low body weight can prevent these developments from occurring.

My takeaway from this talk was that it is important for practitioners to be aware of the challenges that transgender individuals face in our society (particularly in healthcare) and their increased risks for EDs and body-image issues. It also made me examine my own practices when working with transgender clients, including how to make them feel most comfortable (e.g., using the client’s preferred pronoun[s] and having gender-inclusive language on our patient forms) and incorporating the best strategies to help them recover from their EDs.

The second talk I attended was “What You Need to Know about Trauma and PTSD: A Personal and Professional Perspective for Working with Eating Disorders.” The first presenter was Jenni Schaefer, a very well-known figure in the ED community. Ms. Schaefer is a self-described individual who has fully recovered from an ED and has written a number of books on her recovery journey. What I (and perhaps many others in the audience) was not aware of was that Ms. Schaefer is also a survivor of trauma. Her presentation was quite an eye-opener as it described how her trauma and ensuing Post Traumatic Stress Disorder (PTSD) were impacted by and complicated by her ED. This part of the presentation was especially illuminating for me, as I have a number of patients who have been victims of trauma and struggle with both PTSD and EDs. The second presenter was Luana Marques, PhD, and she discussed the different therapeutic options for patients struggling with both disorders. While the content was not exactly geared towards registered dietitians, it gave me some insight into how PTSD can affect recovery from ED and vice versa.

After an hour lunch break, I was thoroughly excited for the third talk of the day. As many of you know, Jonah and I identify as Health at Every Size® (HAES) practitioners and are supportive of the size acceptance movement. Well, we were absolutely thrilled to learn that Ragen Chastain (blogger at Dances with Fat), a world-renowned , self-described fat activist and proponent of “behavior-centered health,” was going to be presenting on both HAES and Size Acceptance in her talk entitled “The World is Messed Up, You are Fine – Helping Clients Deal with the Culture of Body Shame.”

Ragen gave an absolutely electrifying talk about how our society gives extremely damaging messages about our bodies via the medical community, the media, and even our politicians (e.g., Michelle Obama’s fight on childhood “obesity”), and how these messages can make recovery from an ED very difficult. She started the presentation by giving a quick primer on the principles of HAES and Size Acceptance, stressing the point that people of all body sizes have the right to exist and that healthy habits are more likely than body size to determine healthy outcomes.

After this introduction, Ragen displayed a number of images taken from popular magazines and websites, each showing how the media tries to manipulate celebrities’ appearances by using Photoshop. All of these manipulations aimed to make the subjects appear thinner and younger, perpetuating the idea that everyone (especially women and girls) are only beautiful if they are young and slender. A number of years ago, I never would have thought about how these images are manipulated, but now in my work with ED clients, I am super sensitive to how these images can be extremely damaging to girls and women, and I often suggest to my clients that they avoid certain magazines and publications for fear of triggering negative body image thoughts.

Ragen continued on to talk about the role of HAES in ED recovery and how important it is for ED healthcare providers to give consistent body positive messages that counteract the negative, fat-phobic messages that our patients receive every day. She gave examples of how practitioners could create a safe environment for their ED patients, such as providing a space that includes positive representations of diverse body sizes, creating “body affirming” spaces by having chairs that can accommodate people of all sizes, and being aware of our own beliefs and assumptions around weight and size.

While I was familiar with nearly everything Ragen discussed, for I am an avid reader of her blog, it was interesting to observe those in the audience who were hearing this information for the first time. There were a number of thought-provoking questions that were posed during the Q and A section at the end, and Ragen adeptly answered all of these queries with the grace and presence of someone who is confident as well as extremely knowledgeable about the topic on which she was presenting. Her talk finished with a standing ovation from the audience, something that I have rarely witnessed at any of the MEDA conference presentations I have attended. It was truly a special moment.

The presentation that followed Ragen’s was called “Taking the ‘Th’ Out of #Thinspiration – Utilizing Social Media to Encourage, Empower and Bring Hope to Those Battling or In Recovery from Eating Disorders”. The first half of the talk was presented by Donald Blackwell, a man whose own daughter had suffered from an ED and who himself became very active in ED recovery. Mr. Blackwell’s part of the presentation centered on the many different social media platforms that people use today. While I am already quite familiar with Facebook, it was helpful to learn more about the other commonly used social media vehicles, including Twitter, Tumblr, and Instagram, and how they are used in pro-ED (people who believe that EDs are “lifestyle choices”, not illnesses) as well as ED-recovery circles. I have always been aware of the numerous pro-ana (promoting anorexia nervosa [AN]) and pro-mia (promoting bulimia nervosa [BN]) websites out there, but this talk gave me an even clearer picture of the amount of harmful information that circulates on the internet.

The second part of the presentation was given by Joanna Kay Mercuri, an ED sufferer who is now in recovery. She went into even more detail about the pro-ED websites and their content as well as the pro-recovery websites and what they focus on. Ms. Mercuri also discussed her own blogging and how it helped her in her recovery, as it gave her a platform to discuss her feelings and struggles while connecting with others. The end of the talk centered on how we as a society can actually respond to the pro-ED social media and bring the pro-recovery content front and center. All in all, this talk was helpful in showing the influence and use of social media platforms regarding EDs, and it gave me a lot of insight into what my patients might be seeing online possibly every day.

The conference’s endnote address, “Overview of ARFID: Avoidant/Restrictive Food Intake Disorder,” was given by Ovidio Bermudez, MD. It was very interesting to learn about this relatively newly recognized group of disorders as it has recently been added to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). ARFID is defined by the Center for Eating Disorders as an “eating or feeding disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:

  • Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
  • Significant nutritional deficiency.
  • Dependence on enteral feeding or oral nutritional supplements.
  • Marked interference with psychosocial functioning.”

Those struggling with ARFID are not the same as those with AN or BN, as ARFID sufferers typically have no fear of weight gain and no body image distortion. Instead, individuals with ARFID are those who, due to a problem with eating, aren’t able to take in enough nutrition through their diet. Some examples of eating problems are difficulty with digestion of certain foods; strong aversions to colors, textures or smells; no appetite; or being afraid to eat as a result of a frightening episode of choking or vomiting. Sometimes individuals with ARFID can develop BN, AN, or other EDs, but not in every circumstance. I myself have worked over the past few years with several clients who have struggled with ARFID, so I found this talk most helpful in recognizing the signs and symptoms, treatment plans, and prognosis.

All in all, I found my day at the MEDA conference one filled with interesting ideas, helpful tips, and above all, support from my fellow colleagues. These types of conferences are not only a wonderful opportunity to reconnect with familiar ED treatment practitioners, but they are also a terrific time to meet the “new kids on the block.” I look forward to returning to the MEDA conference next year, for I am sure I will learn even more!

The Tipping Point

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You probably heard about Gina Kolata’s piece in the New York Times earlier this month detailing commonplace weight regain among Biggest Loser competitors, but you may have missed Dr. Sandra Aamodt’s excellent follow-up piece in which the neuroscientist shares research showing just how unlikely long-term weight loss is for any of us, not just the show’s former contestants.

While this information might be news to some of us, data showing commonplace weight regain among people who attempt to lose it has been available for quite a while, yet it has not garnered much mainstream attention despite years of efforts from researchers, advocacy groups, activists, and practitioners around the world, including myself.

Regardless of what our goals are, nobody wants to hear that they are probably unattainable, which partially explains why the myth of weight loss has survived. Unfortunately, yet understandably, people are reluctant to listen when receiving a message they do not want to hear.

The problem, however, runs deeper. The notion that we can lose weight and keep it off if only we try hard enough has taken on “everybody knows” status. We hear it in our fitness centers, around the proverbial office water cooler, up in the bleachers at Little League games, and at spring cookouts. The message is so commonplace that we do not stop to question its validity.

Doctors, dietitians, and other healthcare practitioners can inadvertently contribute to the mess. We are human and vulnerable to the same “everybody knows” paradigm too, and sometimes we take treatment guidelines at face value without looking into them for ourselves.

Lump the green version of myself in there as well. I shake my head with embarrassment and shame at some of the advice I doled out early in my career before I knew better, and I wish my profession as a whole would get up to speed.

We see the “success stories,” the people in our lives who were able to lose weight and keep it off, at least so far. The Massachusetts State Lottery website features pictures and stories of its recent million-dollar winners, but their enticing smiles do not change the reality that the most likely outcome of buying a ticket is financial loss.

Children observe their parents looking critically in the mirror, associating guilt and virtue with eating and exercise behaviors, and oscillating between rigid restriction and binges. The torch of dieting and weight obsession passes to the next generation.

If the myth of weight loss dies, so do the $60,000,000,000-per-year diet industry and the privilege enjoyed by the thin in a culture thick with fat shaming and weight stigma. They keep the fantasy alive and have plenty of incentive to make sure we continue to feel bad about ourselves.

Cognitive dissonance is a powerful force to overcome, not just for laymen, but for everyone. Given the strong headwind, I am pleased to see this information finally receiving the widespread attention it so desperately needs.

Ms. Kolata and Dr. Aamodt certainly deserve credit for their parts, but so does everybody who has ever made an effort to get the word out – practitioners and researchers who risked career suicide, activists for whom death threats are a daily way of life, and patients who have stood up and demanded evidence-based care – as they have also contributed to what I hope is finally the tipping point.

An Iatrogenic Condition

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Joanne and I were watching Shark Tank the other night and I found myself wondering if the negotiations and business analyses might be so bogus that venture capitalists and MBAs get a good chuckle out of the reality show. Maybe real estate agents, general contractors, and interior designers watch Love It or List It and shake their heads. Since these programs cover topics outside my area of expertise, their content could be spot on or largely misleading and I might not know the difference.

Yesterday, the New York Times exposed the Biggest Loser for some of the long-term harm it does to its contestants and the unrealistic expectations it sets for viewers. Most notably, weight regain is pervasive despite the ex-contestants’ best efforts to keep it at bay.

For myself and other practitioners who use a similar approach to ours, some of the minutiae may have been new to us, but generally speaking, the Times piece went right into our “Yeah, no sh-t” folders, as we have known the show to be fraudulent and problematic since its inception.

Having said that, it occurs to me that for readers whose expertise lays elsewhere, this might have actually been news. If that includes you, and you were surprised to learn about the contestants’ weight regain and struggles, I hope you do not feel gullible. How were you supposed to know?

However, any seasoned obesity or metabolism researchers who found themselves surprised by these results ought to be embarrassed. Data showing commonplace weight regain among people who attempt to lose it has been available for quite a while. Even some of the most ardent weight-loss supporters reluctantly admit that although we have several methods of inducing short-term weight loss, we have no idea how to produce long-term weight loss for more than a tiny fraction of the people who attempt to achieve it.

What we see more commonly, not just in Biggest Loser contestants, but in people across the board who attempt to intentionally lose weight, is ultimate weight regain that often exceeds their baselines.

As an example, consider the following growth chart, which is from a real patient of mine (All information that could possibly reveal her identity has been removed.) Looking at her chart, hazard a guess as to when her parents and doctor first attempted to intervene with her weight. Do you think it was at age 17, when she first came to see me?

Example

No, it was just after age eight, when her BMI-for-age, which was in the 92nd percentile at the time, was deemed a problem. She was naturally a bigger kid, okay, but this fact’s implications have more to do with stigma than health. The focus on weight and a belief that an intervention would help to lower it created an iatrogenic condition. In other words, her weight became a problem because it was viewed as one.

Not only was the diagnosis off base, but the attempted interventions worsened the problem. The first diet produced a slimmer 10-year-old, who subsequently rebounded into a chunkier tween. Based on the research, this was to be the most likely result. As the patient’s teenage years began, subsequent attempts to lower her weight produced similar patterns of weight gain.

They took a child in the 92nd percentile and dieted her up to the 99th percentile, and in the process screwed up her relationships with food, her body, her doctor, and her family, all of which she is now working hard to untangle and fix.

None of that was the child’s fault, nor are the parents to blame, for they were just doing what they thought was right by following instructions from trusted practitioners.

And really, I do not blame the doctor either. Pediatricians and other primary care doctors are tasked with a tremendous responsibility to maintain basic knowledge about a myriad of conditions, everything from sore throats, to sexually transmitted diseases, to early signs of cancer, but this very demand limits them from being experts in any one field, including weight regulation.

The chain of education and direction has to begin somewhere. While these data on Biggest Loser contestants might have come as a surprise to laymen, the researchers who are responsible for the foundation of our healthcare policies should have seen them coming. That it took a New York Times article to wake them up is shameful, but they sure seem to be paying attention now, at least for the time being.

Leave the Fat Kid Alone

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Note: A slightly edited version of this piece appears in the April 2016 issue of Boston Baseball Magazine.

If you are like me, you wonder what the baserunner and first baseman talk about between pitches. When an athlete meets a peer, the dynamic is presumably different from an interaction with a fan that likely centers around adulation and an autograph.

When dietitians get together, chances are that at some point, we will touch on whatever nutrition-related myths and stereotypes are currently damaging our society, such as those reflected in the widespread negative reaction Pablo Sandoval received for his weight upon arriving at spring training.

Consider the following separate, but related, questions:

If Sandoval loses weight, will he play better?

Maybe, but not necessarily.

We look at Sandoval’s physique and dream about the offensive and defensive punishments he could inflict upon the league if only he bore a closer resemblance to Adrian Beltre or Evan Longoria. These fantasies have some merit, as a leaner, smaller, or lighter body can certainly have athletic upsides sometimes.

However, a significant difference exists between an athlete who naturally has a given size or shape versus someone who tries to force his body into that mold. Since weight loss does not happen by magic, we have to consider whether the behaviors Sandoval adopts in pursuit of weight loss would improve his game.

The outcome could go either way. We have seen in a variety of sports, including baseball, examples of athletes who played worse after losing weight, in part because over-exercise and/or food restriction left them depleted and vulnerable to fatigue, injury, impaired concentration, nutrient deficiencies, depression, sleeping difficulties, eating disorders, muscle atrophy, and other unintended consequences, none of which are conducive to top performance.

If Sandoval decides to lose weight, will he be able to do so?

In the short term, probably, but in the long run, he will most likely gain it back plus more.

Approximately 95% of people who attempt to lose weight will regain it one to five years down the road, and roughly 60% of these individuals will end up heavier than they were at baseline. Weight regain is common even if someone maintains the behaviors that promoted the weight loss in the first place.

Contrary to popular myth, our weight is largely out of our hands. The calories-in-versus-calories-out paradigm is a gross oversimplification of the complexities affecting weight regulation. While we might be able to manipulate our body size through behavior changes for a short while, biological mechanisms promoting weight regain almost always win out in the end.

If you subscribe to the theory that Sandoval’s weight is affecting his play, what level of performance do you expect out of him in the most likely scenario that he ends up bigger?

What does our treatment of Sandoval say about society?

Fans and media have labeled Sandoval “disgusting,” “lazy,” and “pathetic.” By the transitive property, these derogatory terms apply to everyone who has a body type similar to his.

The message is that fat is to be loathed, that larger individuals are not worthy of the respect enjoyed by the rest of us. We reject stereotypes based on race, religion, ethnicity, or sexual orientation while we inexplicably tolerate those based on body size that are no more accurate than the others, yet are just as abhorrent.

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

Weight stigma oftentimes inspires people to sacrifice health for the pursuit of a size. Pressure to be thin leads to dieting, which is a predictor of a variety of problems, including eating disorders. These life-threatening illnesses are so common in Massachusetts that if the crowd at a sold-out Fenway Park represented a random sample of the state’s population, those in attendance with a diagnosed eating disorder would likely fill section 41.

Okay, but professional athletes like Sandoval constitute a different and special class of people, right?

Let’s take a step back and look at the bigger picture. Sandoval is a professional athlete because his talent, practice, and opportunities have coalesced into a skill set that lends itself to strong performance in an activity mankind recently created called baseball and he lives in a culture in which we pay such people to play it for our entertainment.

None of that means he has any more or less ability to manipulate his weight differently from the general population. Sandoval is a product of evolution just like the rest of us, and he has come into being because his ancestors’ physiological mechanisms that resisted weight loss allowed them to survive periods of starvation and reproduce while others perished. In this regard, professional athletes and spectators are all in the same boat.

Fans have every right to feel whatever emotions they may have about a player. If they want to get on someone for not performing, they can absolutely do that. However, I would encourage fans to criticize athletes for lack of production or work ethic directly rather than using body size, weight, or shape as a proxy, as the latter behavior is fueled much more by myths and stereotypes rather than science and sends a dangerous message to everyone who hears it.

BostonBaseball2016-03-27

Zootopia

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Generally speaking, Zootopia is a really nice Disney film. As Joanne and I were walking out of the theater and talking about how much we both liked it, she turned to me and said, “There was only one thing about it that bothered me, and I am guessing you know what it is.” Sure enough, I did, as the same problem had caught my eye as well.

The main reason I like the film is because it teaches some wonderful lessons about having the courage to be different, break down barriers, and acknowledge and overcome prejudice. However, the writers missed an opportunity to apply these same themes to body size and instead reinforced widely-held stereotypes about larger individuals.

Although the film does feature characters of various shapes and sizes, both protagonists are stick thin while the rounder characters are generally presented in a more negative light, such as the main character’s portly father, who in his first scene explains how he was too afraid to go after what he really wanted in life and settled for one spent as a carrot farmer.

The most glaring example is Officer Clawhauser, a large, dopey, and disorganized character often shown with food or in the act of eating. An early scene in the film portrays him as so messy and oblivious that he is unaware that he has a donut lodged in his collar.

How ironic, and unfortunate, that in a film that is largely about breaking down stereotypes, Disney glaringly reinforces one. The writers probably never even considered there might be an issue with this because the sad truth is that in a society in which we generally reject stereotypes based on race, religion, ethnicity, or sexual orientation, we inexplicably tolerate those based on body size that are no more accurate than the others, yet are just as abhorrent.

If you bring your children to see Zootopia, consider using the occasion to talk about body size and its associated prejudice. The film does a solid job of teaching that not all prey animals are cowardly, predators need not be savage, and the symbolism contained therein about the human race, but it misses an opportunity to shut down the stereotypes that heroes must be thin and larger individuals are glutinous, lazy, or unkept. This is where you, the parents, can come in and complete the lesson.