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He Said, She Said: Celebrity Diets

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He Said

In an interview with ESPN at last month’s Major League Baseball All-Star Game, Mark Teixeira, first baseman for the New York Yankees, fielded questions about the gluten-free, dairy-free, sugar-free diet he has reportedly been following since the off-season. Although he nicknamed his set of food rules the “no fun diet,” Teixeira praised his diet for bringing about his return to health and all-star-worthy performance based on his belief that the foods he had eliminated are inflammatory to the body.

Each time an athlete speaks up about his or her fad diet and its associated pseudoscience, life gets a little bit harder for the rest of us. Already, so much of my time with patients focuses on reeducation involving the food myths and misinformation that are so prevalent in our society. The Teixeira interview and others like it add fuel to the fire.

The problem is not that Teixeira has excluded gluten, dairy, and sugar from his diet. This is his body, his career, and his life, and I am in no position to judge him for the choices he makes regarding these entities or for whatever he believes, accurate or otherwise, about food. We all get to decide for ourselves how we want to lead our lives and what we want to believe, and he is subject to the same freedom.

Rather, the problem is how the dietary choices of athletes are framed and conveyed to the rest of us, the incorrect information and insinuations that often come along for the ride, and the bizarre phenomenon existing in our society whereby we put more stock in health advice doled out by celebrities than actual licensed healthcare professionals.

As a general theme, people tend to be more vocal about their dietary successes than their disappointments, which gives us a warped view of reality. Teixeira is not at fault for discussing his diet at the All-Star Game, not when the interviewers made a point to ask him about it. But would his diet be the subject of such conversation if his year was not going so well?

Consider his teammate, CC Sabathia, who lost a bunch of weight (temporarily, at least) after adopting a low-carbohydrate diet a couple of years ago. His diet and its associated weight loss got plenty of media attention back then, but hardly anybody seems to be talking about it now. Perhaps ESPN would have asked Sabathia about his diet at the All-Star Game if he was invited to be there, but as it turns out, he is in the midst of the second worst statistical season of his 15-year career, both of which have come after he went low-carb.

Did cutting carbs and losing weight cause Sabathia’s career to suffer? Possibly, but neither you nor I know for sure. While a correlation certainly exists, causation remains a question mark. Nutrition definitely impacts sports performance, but so does a host of other factors. Regarding Sabathia, elements like age, injury history, and general wear and tear are at play as well, not just his eating and weight.

Just as we cannot scapegoat Sabathia’s diet and lost weight for his poor play, we cannot automatically credit Teixeira’s newfound food rules for his bounce-back season. Perhaps he is simply healthy again for the first time in a long while after undergoing wrist surgery a couple of years ago. After all, except for 2013 and 2014 when he was injured, Teixeira has been one of baseball’s best players for over a decade, and it sure sounds like he was eating gluten, dairy, and sugar during all those years of dominance earlier in his career.

We see these same themes in other sports as well. A televised Novak Djokovic tennis match cannot go by without the commentators throwing in at least one mention of his gluten-free diet, which he credits for catapulting him to the status of number one player in the world. Yet, never once have I heard anybody in the media talk about the eating habits of Roger Federer, arguably the best player in the history of the sport and someone who has continued to compete at an elite level at an age well past when most tennis professionals retire. His diet consists largely of foods like cereal, pancakes, and pasta – in other words, plenty of gluten.

Could it be that Djokovic’s career took off not so much because he cut out gluten, but rather because his years of training, practice, and experience have come together during the window of prime age for a tennis player to produce great results? Similarly, perhaps Federer’s longevity, ability to stay healthy, and years of domination have less to do with pancakes and syrup and are more due to talent, hard work, smart coaching, and efficient mechanics.

If you find yourself tempted to adopt a fad diet because a successful athlete is preaching it, look at the big picture and remember that most of his or her peers are probably not following his or her diet and are also doing quite well for themselves, but their eating patterns are not as sensational and therefore not garnering the same attention.

On a more macroscopic level, challenge yourself to consider how much sense it really makes to be taking nutrition cues from an athlete or any other celebrity. My computer and telephone are essential for my work as a dietitian, and I use them daily, but I only know how to use what I believe works best for me. It would be a mistake to fancy me an IT expert, assume that I really know what I am doing in that regard, and emulate my choices. Similarly, looking to professional athletes and other celebrities as you shape your own eating makes little sense either.

 

She Said

About two months ago, there was a big buzz on the Internet (and news media) that superstar songstress/actress/business mogul Beyoncé had an “amazing” announcement to share with everyone. The plan was for her to make this announcement to all of her fans on the Good Morning America TV show, and it was going to blow everyone away. Of course, the Internet was shivering with excitement. Could it be that Beyoncé and Jay-Z are having another baby? Does Bey have a new album coming out, and is she going out on tour? Has she discovered the cure for cancer? The suspense was killing everyone!

Well, it appears that all she had to tell us was that she has found the secret to losing weight (and keeping it off) and living a fabulously healthy life. How did she achieve this, you ask? Well, by following a diet, of course! Per its website, the “22-Day Revolution” diet is a “plant-based diet designed to create lifelong habits that will empower you to live a healthier lifestyle, to lose weight, or to reverse serious health concerns.” The diet’s author, “world-renowned exercise physiologist” Marco Borges, is on a mission to help his clients find “optimum wellness” by eating a completely vegan diet. According to Borges, by eating “nutrition-packed” vegan foods, people will be able to “transform their lives, bodies and habits.”

Ugh. Can we please just stop the insanity? Every time a new celebrity announces their latest and greatest diet discovery, it makes me cringe. Given that the majority of my patients are those that struggle with eating disorders (ED), I am fully aware that these diets can be the gateway to a life full of pain and suffering, as most EDs start when one decides to diet. Young girls are especially vulnerable to these celebrity diets because they often put these actresses, musicians, and models on an impossible pedestal. Even though most magazine images are photoshopped nowadays, most young girls are not aware of this and aspire to be as lean and slender as Gwyneth Paltrow or as fit and toned as Kate Hudson.

The fact of the matter is that celebrities are not like the rest of us – they are the minority, not the majority. Even if they did not diet like they do, I doubt that their physiques would be much different than they are now. It’s genetics, pure and simple, and they have “won” in the genetics lottery of life. So, even if you go low-carb like Gwen Stefani or Paleo like Megan Fox, it’s highly unlikely that you will end up looking like these celebrities.

These diets or “lifestyle changes” touted by celebs do much more damage than good. Not only do these diets tell us that we cannot trust our bodies’ hunger and fullness signals (and therefore need to follow food rules to be “healthy”), but they also give us a nearly impossible goal of looking like these celebrities if we eat like them. And if someone is predisposed to EDs, each new celebrity diet is like lighting a match and tossing it into a powder keg – nothing good will come from it.

My advice? Whenever you hear about a new celebrity diet that promises to help you lose weight and keep it off, turn back the clock, or magically cure your health condition, please change the channel, toss out the magazine, or click on another website. Celebrities don’t know what’s healthiest for you to eat – only your body knows that!

“Looking the Part”: Patients’ Size-Based Biases Toward Their Practitioners and How to Handle Them

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On July 19, 2015, I was part of a two-member panel at the Association for Size Diversity and Health (ASDAH) Conference in Boston discussing motivational interviewing. My specific task was to examine the size-based biases that patients often hold toward their practitioners and how best to respond to them using motivational interviewing techniques.

The audience was largely comprised of other clinicians, and as such I shaped my remarks in the context that I was talking with colleagues. Because this information can be helpful for others as well, I have reworked my main points in the framework of talking directly to you, our patients.

 

Background

In the year between finishing my nutrition degree and earning my license to practice dietetics, I interned at a Boston hospital where I did everything from work in the transplant unit to chop squash in the cafeteria kitchen. It was an interesting year, indeed.

One of my rotations was in the bariatric surgery clinic where two dietitians worked. Because I shadowed both of them closely, I know they were both excellent at their jobs, had virtually the same approach, and taught the same material, yet patients perceived them differently because of their size. Relative to each other, one of the dietitians was bigger and the other was smaller. Some patients looked at the larger one and made comments along the lines of: “Look how big she is! How can she possibly help me?” Meanwhile, other patients referenced the smaller dietitian and questioned, “Look how small she is! How can she possibly know what it is like to be me?”

As a budding dietitian just about to step out into the field, these comments made me look myself up and down and consider, well, what exactly am I supposed to look like then? That question always stuck with me and planted the seed that eventually grew into this piece you are reading now and its accompanying talk, which I nicknamed “Looking the Part”: Patients’ Size-Based Biases Toward Their Practitioners and How to Handle Them.

Practitioners are patients themselves in other contexts, too, so understand that this is not about judgment or one party versus another. For healthcare to be most effective and for us to give ourselves the best odds of attaining whatever the desired outcome might be, patients and practitioners must work together, not oppose one another. We all have incentive to break down the walls of bias.

 

Other Biases

First, let us give ourselves some context by realizing that patients judge practitioners for other factors that are seemingly independent of size. For example, one study looked at how physician dress affects patient trust and confidence. The researchers found that white coats elicited greater trust and confidence by far compared to scrubs, formal business attire, or casual business attire. In fact, patients indicated they were much more willing to discuss sensitive issues like their psychological, sexual, and social problems based on the presence of said coat.

In another study, white-coat-wearing doctors were also found to be the preference of parents bringing their children to the emergency room. That is, unless their children were there for surgical emergencies, in which case they preferred doctors wearing scrubs, suggesting that perhaps clothing is interpreted as a sign of experience or perhaps expertise.

Other studies have found similar biases related to factors like hairstyle and even whether or not a practitioner wears a name tag, but of course all of these factors are readily modifiable. In other words, while practitioners can restyle their hair, wear different clothing, or put on a name tag if they so choose, other sources of bias are not so easily changed.

For example, a study found that parents selecting orthodontists for their children had significant biases toward young females. Youth was seen as more up-to-date with modern techniques, while females were seen as better at communicating and expressing empathy. While this might be great news for up-and-coming women working in orthodontics, it is not such good news for their colleagues who happen to be older and/or male.

 

Size-Based Biases

Just like there is not a whole lot we can easily do about our age or gender, our size (contrary to popular belief) is largely out of our hands as well. Let me share with you three of the studies that looked at patients’ size-based biases.

The first study was conducted at Yale where a team of researchers sought to examine what impact, if any, physician weight has on clinician selection, trust, and willingness to follow medical advice. The subjects were split into three groups with each group receiving the same exact survey except for one difference: the physical description of the doctor, who was listed as either normal weight, overweight, or obese in the different versions.

Their results showed that patients had less trust in overweight and obese doctors, were less likely to follow their medical advice, and were more likely to change to a different provider compared to normal weight doctors. In other words, subjects were so shaken by the doctor’s weight that not only were they less likely to follow said doctor’s advice, but they were more likely to switch to another provider. These weight biases remained present regardless of the subjects’ own body weight.

Anecdotally, we see examples of this. A colleague of ours recently told me a story about an experience she had. “I had a patient who was coming to see me to figure out if she wanted to be abstinent from substances. At the second session, she was crying and couldn’t look at me. [The patient said] ‘I have to talk to you about something . . . Look at the size of you. How could you possibly help me?'”

The second study, done at Johns Hopkins, found a different result. The researchers there looked at the impact that physician body mass index (BMI) has on the trust held by overweight and obese patients. Instead of verbally describing the doctors as normal weight, overweight, or obese, as the Yale study did, these researchers used pictograms to convey the same information.

They found that while the surveyed patients generally trusted their doctors, they more strongly trusted dietary advice dispensed by overweight physicians compared to their normal-weight colleagues. The results for other forms of advice, such as exercise advice, were similar, although not statistically significant.

This finding is probably the opposite of what many of you expected. In their discussion section, the researchers suggested that perhaps a patient and his or her doctor being roughly the same size creates some sort of bond of trust, and that is behind their findings. Of course, that is just a hypothesis that would require further study.

Meanwhile, we do see examples of patients who show preferences for larger providers. A fellow dietitian told me about an experience she had where a patient refused to let her intern sit in on their session. “When I sat down to do her session, she told me she was sorry that she asked the intern to leave, but she didn’t want another skinny dietitian telling her she can’t eat more than 1,200 calories and must record everything . . . She was relieved when she saw me.”

The third study was done at the University of Gloucester in the United Kingdom where the researchers sought to determine the influence that sports dietitians’ appearance has on selection and perceived performance. They surveyed 100 competitive athletes from 17 different sports in the United Kingdom and showed them computer-generated images of the same woman that were manipulated to feature her at four different sizes designed to represent BMIs ranging from 23 to 38. The athletes were then asked to rank which of these dietitians they would most like to work with and how effective they believed the dietitians to be at their jobs.

The two images of the dietitian as smaller fared best in both questions. In other words, based on nothing more than size, the athletes were significantly more interested in working with smaller dietitians and assumed those women to be better dietitians.

When I was talking with a fellow dietitian about the topic, he had this to say about how his size impacts his work: ” . . . more than anything I’ve really noticed the looks more than the comments. I can see someone look at my stomach as I talk to them and then back at my eyes. For some people, I can see how their body language changes in a negative way when they see what I look like.”

 

Discussion

So, back to the question I asked myself as an intern: What am I supposed to look like? The answer, to be quite candid, seems to be: Who knows! Some research suggests that patients prefer smaller practitioners, other research indicates they want larger practitioners, and of course some patients do not care, and they understand that the practitioner’s size has nothing to do with his or her ability to provide quality care.

However, whether the majority of patients prefer me at a particular size, or whether only the minority want me at that size, honestly does not matter too much. The nature of my work is one-on-one counseling, so the only person whose feelings really matter is the individual sitting at the table with me. When I am in an appointment with someone, who knows what feelings or biases he or she might have about my size. Although I need to be cognizant of the likely existence of size-based bias, if I make assumptions about the nature of said bias, then I am being biased myself, and that helps nobody.

If I want to provide the best quality care that I can, then my job is not to try in vain to hit some ever-changing target with my appearance, but rather to create a safe space where we can neutrally and non-judgmentally explore the size-based biases that patients bring into my office. This is where motivational interviewing can be so helpful.

 

Motivational Interviewing

My fellow panelist, Ellen Glovsky, gave a comprehensive overview of what motivational interviewing is and how it works, while I focused on how it applies specifically in the instances of patients’ size-based biases toward their practitioners.

First, let me draw a distinction between two motivational interviewing terms: resistance and discord. Resistance is known as sustain talk, arguments for the status quo, or reasons not to change. For example, a patient talking with his or her doctor about smoking cessation might say, “Smoking is so relaxing; I’d really hate to give that up.”

Discord, on the other hand, is not an issue of changing versus staying the same, but rather an issue in the patient-practitioner relationship. Think of some of the anecdotes I mentioned. If a patient walks into his or her practitioner’s office and says something along the lines of “How can you possibly help me? Look at you!” we know that discord is present.

When I encounter discord, the first point I try to remind myself of is to remain neutral. Although it is human nature to get defensive if we feel we are being attacked, practitioners must remind themselves that in professional relationships, the focus is on helping the patient, not getting into an argument.

Instead, I use techniques common in motivational interviewing, such as open-ended questions, affirmations, reflections, and summaries, to further the conversation in an effort to learn more about where the patient is coming from. Through the course of discussion, educational opportunities often present themselves. For example, the conversation might lead to the topic of social norms that are off base, such as the notion that one need be a certain size or weight to be healthy.

During these conversations, it can be tempting for practitioners to self-disclose further information about ourselves. After all, if my body is already the topic of conversation, why not throw in more information about it? The answer is because doing so typically does more harm than good. Instead of self-disclosure resolving discord, oftentimes it widens the gap between the patient and the practitioner, which is why I say so little about myself during my sessions and save self-disclosure for my blog.

 

Summary

The research confirms what many of us anecdotally already knew: Patients do often judge practitioners for their size. However, the specifics of the bias are inconsistent and instead vary from person to person, so it is important that practitioners like myself continue to treat you like the individual that you are and not make assumptions about what you think about our size.

Similarly, I encourage patients to acknowledge and keep in mind two points: (1) You cannot tell anything about how your practitioner leads his or her life based on his or her size with any degree of accuracy. (2) Your practitioner’s size is independent of his or her ability to help you.

If you do have feelings about your practitioner’s size, I encourage you to say so, as keeping it inside might hinder your work. In contrast, bringing it out into the open is an opportunity to learn. The two of you can then have a neutral, open-minded, and non-judgmental discussion about your feelings and point of view and then move forward together.

 

Guarantees

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Nearly two weeks ago, I checked into the hospital for what was supposed to be a relatively minor procedure to address an “extremely rare” complication related to last year’s spinal fusion.

When the surgeon got in there, he unexpectedly discovered that my body had reabsorbed the implanted bone grafts while the rods and screws were loose and moving around. This happens in 3% of cases, he said, and he has no idea why it happened to me, as I do not have any of the risk factors for poor healing. As he delivered the bad news to me upon my awakening, he expressed surprise that I was even able to walk around in that condition.

In response to the situation, he had to completely redo the fusion, making for a much longer recovery than we anticipated. One planned night in the hospital became four. One week of missed work will now likely be three. One month of taking it easy now becomes a season, at least.

Twice I fainted in the hospital, and my blood pressure and pulse dropped so low for no apparent reason that they ran tests to see if I had suffered a heart attack, but really the hardest part of the whole ordeal has been coming to grips with the reality that everything I went through last year I must now do again.

However, the situation has been made easier thanks to the help and support of friends, family, an excellent team of nurses and physical therapists at the hospital, and of course my wife, who is now picking up the slack for me in every facet of our life.

Just 12 days before the surgery, I ran the Mount Washington Road Race and we celebrated at the summit. We thought we were at the top; little did we know we were heading back to the beginning. The lesson: I will never take days like that for granted, as they are never guaranteed to come again.

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He Said, She Said: 1,500-Calorie Diet

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A patient sent Joanne the following email. “I overheard a coworker talking about food/calories/etc. and noted her saying, ‘We should all be on a 1,500-calorie diet as women.’ For some reason this really got to me and I normally don’t let these stupid comments affect me, especially when I know better. Thoughts?”

 

He Said

Yes, I do have thoughts about this, several in fact, but for the sake of time and space, I will leave aside tangential issues of practicing dietetics without a license (If someone without a medical license made a statement along the lines of, “As women, we should all be taking [insert name of a medication] daily,” would you be cool with that?) and the virtually-constant propagation of nutrition myths throughout our culture. Instead, let’s focus on just how incorrect this coworker’s assertion is.

Caloric needs are surprisingly difficult to determine. The most accurate method is direct calorimetry, which utilizes a metabolic chamber in which the subject occupies a compartment that measures the heat that he or she emits during whatever state of activity happens to be taking place at the time. Unless you enroll in a research study that involves one of these chambers, you will most likely never gain access to one in your lifetime.

Indirect calorimetry, which involves measuring oxygen and carbon dioxide intake and expulsion, respectively, is less invasive in some ways and easier to utilize. Large hospitals typically have metabolic carts that can perform such measurements in their research laboratories, and lesser models exist for office settings. The tradeoff, however, is accuracy, as even the best indirect calorimetry tools are a step down from direct calorimetry.

Next we have the Fitbits of the world, devices that use algorithms to estimate caloric needs based on a crude set of variables. Dietitians use similar equations sometimes as well, and when I do, I always stress to patients that the results are just rough estimates that cannot and should not be taken too literally.

These equations have numerous sources of error, such as the reliance on subjective measures of physical activity. Anybody can Google how many calories certain activities supposedly burn, but really these numbers are general rules of thumb at best. Running a mile burns 100 calories, we are told, but is this right? What about the size and body composition of the runner, or his or her mechanics? Does he or she have short, quick strides or long, less frequent steps? What about swings of the arms, point of contact between the foot and the ground, head bobbing, or any number of other factors that can influence the results?

One of my patients occasionally asks me how many calories one burns during sex. Unless you get two people to have intercourse in a metabolic chamber, who knows? Even then, the heat generated would pertain only to those unique individuals in that specific encounter, so what do you do, divide by two and make the assumptions that their efforts were equal and that these results apply at other times and to other people as well? Logistical hurdles and the countless variables involved make estimating caloric expenditure a guessing game not just for sex, but for pretty much any activity.

As a consequence, estimates of caloric needs are just that – estimates – and vary widely from person to person. My degree in mathematics reminds me that I like numbers as much as the next guy if not more, and I can certainly understand the appeal of having a short, sweet, and specific target for which to aim, but really the best method to determine your caloric needs is to set quantifiable data aside and look internally to your hunger and fullness signals. Despite all of the proliferating nutrition myths and overarching messages we are taught from childhood on that we cannot trust ourselves regarding food, our bodies are actually pretty good at telling us what and how much they need. We just need to relearn how to pay attention and trust those signals again.

 

She Said

Ahhh, the 1,500-calorie diet. It’s amazing how some arbitrary number has gotten stuck in the minds of so many people. 1,200 calories is also a popular number. Flip through any of your typical women’s health magazines and you are likely to read that all women should be consuming no more than 1,500 calories per day to be “healthy.” Unfortunately, there really is no such thing as the “perfect” number of calories for each and every person. 1,500 calories (or 1,200 calories or 1,750 calories) is a myth. It makes no sense to say that every woman should be on a 1,500-calorie diet; we all are unique human beings with unique needs.

As I tell my patients over and over – every body has different caloric needs. Age, height, weight, gender, muscle mass, and activity level are just some of the factors that can affect our calorie needs. Even the Mifflin-St. Jeor equation, the equation most often used by most dietitians to determine calorie needs, does not take into account all of these factors. Our caloric needs will vary over our lifespan for a number of reasons. Women who are pregnant or breastfeeding need many more calories, while as we age, we typically need fewer calories. Anyone who has lived with a teenager can attest to the fact that calorie needs go way up during adolescence! When someone is recovering from an injury, his or her caloric needs might be elevated. For instance, the caloric needs of burn patients can be as much as double what the “average” person’s needs are. The best way to figure out what your calorie needs are? Eat as you normally would. If you see no large shifts in your weight (think plus or minus five pounds), you are meeting your calorie needs!

When working with patients who struggle with eating disorders, I try to steer clear of talking about calories. Many of my patients have spent countless hours logging the calories they ate (and burned), and most of these patients would say that they were “obsessed” with doing so. I had one patient who would log her calories daily, and if she consumed more than 1,300 per day, she felt like she had “failed.” Another patient would try to stick to no more than 1,800 calories per day, and if she went over by just a few calories, she would binge because she had “blown it.”

Instead of talking about calories, I try to use the “exchange” system with my patients. Exchanges are groups of foods that have similar nutritional profiles. For instance, a carbohydrate exchange (sometimes called “grain” or “starch” exchange) contains approximately 15 grams of carbohydrate per serving. This might look like an average piece of bread, a ½ cup of cooked pasta or rice or ½ of a large potato. By using exchanges, we can take the focus off of calories and how we need to limit them and instead talk about making sure we get enough carbohydrates, protein, fats, vegetables, etc. Calories have a negative connotation for many of my patients, while exchanges feel a bit more abstract and neutral.

In short, instead of setting an arbitrary calorie goal for oneself, I think it would be much more beneficial to set other goals. Getting five fruits and vegetables per day, being physically active for 60 minutes per day, and eating intuitively would be much better goals (in my opinion) than making sure one never goes over 1,500 calories per day.

He Said, She Said: Marathon Nutrition

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He Said

When I made the decision to leave behind my career as a research analyst for the U.S. Department of Transportation, I began looking for jobs in healthcare and landed a position working on a clinical trial with a kinesiology professor.

Given her background and expertise in exercise science and her personal interest in athletics, I shared stories of my marathon experiences with her and happened to include that I preferred Coke to Gatorade during long runs. “Ugh, that’s the worst thing you could do!” she disgustedly told me. Actually, no, I had figured out through trial and error that my body best tolerated plain old Coca Cola Classic over any other liquid with which I experimented, so I would argue that drinking Coke was the best thing I could do for athletic performance.

Sometimes, quite often actually, approaches that seem most sensible on paper do not function the best in real life. That is why guidelines are nothing more than their name suggests and should not be treated as gospel. Guidelines are helpful because they give us a place to begin, but I always emphasize to runners the importance of experimenting with various nutrition approaches during training to determine which eating and drinking strategy functions best for them and therefore will be used on race day.

In truth, marathoners take all sorts of different approaches to fueling themselves before and during marathons. Gatorade and water are supplied to the masses at various points along the Boston Marathon route, but the elite runners skip those tables and have their own hydration stations where each of them has a custom-made concoction waiting for him or her in labeled bottles. Some runners, for example, drink flat, non-alcoholic beer. A friend of mine used to eat gummy bears during marathons. Another friend made it through the running portion of his Ironman triathlon by alternately consuming oranges and bananas. As for me, I ran most of my marathons fueled by Coke and pretzels.

When Joanne and I first began dating, I was in the midst of a demanding dietetic internship, and I dealt with the stress by going for long runs on the weekends. Although it was clear that she found my behavior a bit odd, only she could tell you which struck her as weirder: the fact that I chose to spend my Saturday afternoons going for 20-25 mile runs, or the fact that I spent my Saturday mornings driving around and stashing bottles of soda and bags of Oreos in various hiding places along my running route. Just because gels, goos, sports jelly beans, and salt tablets exist and work well for some athletes does not mean they will have everybody running their best.

Commonalities do exist among the various approaches that people take, such as the importance of replacing the carbohydrates, electrolytes, and fluids lost during running, but numerous methods of achieving these nutrition goals exist, and that is where the importance of individualization enters the paradigm. Therefore, when you see or hear of another runner taking a different approach to his or her nutrition than you take to yours, remember that multiple “right” answers exist, and stay true to what you know from experience works best for you. Remain confident: Your training, both the running itself and your nutrition experimentation, has gotten you this far, and it will get you to the finish line, too.

 

She Said

April is one of my favorite months of the year. The winter is over (At least it should be!), little green things start sprouting out of the ground, and the promise of warmer days is ahead. Having been born and raised in Massachusetts, I have also come to associate April with the Boston Marathon. As a little girl, I would walk down to Route 16 with my mom, and we would cheer on the runners as they jogged past us. I was always amazed at how these individuals could just go and go and go. And how many of them there were!

From time to time, the subject of marathon running comes up in my work with patients struggling with eating disorders. Many of my patients are exercise enthusiasts who often have to cut back (or completely avoid) exercise in the early stages of ED recovery. As the individual makes progress in his or her ED, the subject of when he/she can start to exercise again will often come up. Of course, when figuring out whether to clear a patient for exercise, the primary care physician really needs to make the final call. Often this means that the patient should be having his or her vital signs taken regularly, and if his or her blood pressure, heart rate, and weight are routinely found to be in the “healthy range” for a good period of time, he or she may be cleared for exercise.

The word “exercise” can have a number of different meanings depending on whom you talk to. For the average person, perhaps going for a 30-minute walk 3-4 times per week would be exercise. But more often than not, for the person dealing with an ED, exercise usually means much more intense activity for more extended periods of time. That’s where the marathon piece comes in. I have had a number of patients state that they would like to resume (or start) running, not with the intent of managing their weight, but to strive for some goals. Usually, it will start with training for a 5K race, then a 5-miler, then perhaps a 10K. In and of itself, these races aren’t a problem vis-a-vis eating disorder recovery as long as the individual is competing and training due to the love of running rather than trying to control weight.

Sometimes I will have a patient announce the plan to run a ½ marathon with the goal of running a full marathon eventually. This is where things can get a bit dicey. As anyone who has run a marathon can attest to, the act is not an easy one. Although I have never run one myself, I have had people tell me it’s a lot like childbirth – after a period of time, one “forgets” the physical agony and only remembers the joy of finishing. In reality, running a marathon takes a huge toll on the body and can be quite grueling. For someone whose body is recovering from a life-threatening ED, training for and running a marathon can put a lot of stress on an already stressed body.

In general, I would suggest that the individual really delve deep into why he or she wants to run a marathon. Is it for the thrill of accomplishment, to check something off on one’s bucket list? Or is it a sanctioned way to exercise excessively, “permitting” the individual to eat with abandon and maintain or lose weight? Personally, I believe that someone needs to be in recovery for a significant period of time before attempting such a demanding physical endeavor. That period of time depends on a number of factors: How long has the individual struggled with an ED, and how long has the individual been in recovery? Has he/she maintained a healthy weight, heart rate, and blood pressure for a significant period of time? Is the patient’s mindset healthy or weight-centered?

If the individual is determined to be healthy in mind and body and the treatment team supports it, I think someone in recovery from an ED could in fact train for and run a marathon. However, it would be advisable for this patient to continue to engage in regular therapy and see his or her doctor weekly to make sure his or her marathon goals aren’t interfering with continued ED recovery. In addition, this patient should consult with a registered dietitian who specializes in both EDs and sports nutrition to make sure that he/she is getting in the right amounts and types of fuel and hydration needed for running a marathon. As long as the above conditions are met, there is no reason why someone who has struggled with ED couldn’t run a marathon.

He Said, She Said: Supplements

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He Said

As both a practitioner and a patient myself, I support the idea that everybody should have the freedom to pursue the healthcare path that feels right to the individual in question. The same freedom, I believe, should also extend to practitioners to be able to offer the modes of care that meet their own standards of ethical practice.

Approaches often evolve in response to new education and research. Earlier in my career, I worked at a medical center where selling supplements to patients is a significant part of their way of doing business. As I learned more about the science behind supplements and about the industry itself, I grew increasingly uncomfortable with this approach. Because of that background, you will not find any supplements or products of any kind for sale at Soolman Nutrition and Wellness LLC.

During our sessions, the topic of supplementation does occasionally arise, usually brought up by patients who have heard or read that a particular supplement regimen may help with whatever conditions are ailing them. However, we must remember that supplement manufacturers are allowed to make whatever health claims they would like – well-founded or otherwise – on the bottle just so long as they also have the standard disclaimer, “These statements have not been evaluated by the Food and Drug Administration (FDA). This product is not intended to diagnose, treat, cure, or prevent any disease.”

In other words, the claims made on the bottle may be wildly inaccurate and have absolutely no credible research to support them, but the FDA does not have the power to intervene. Generally speaking, regulation within the supplement industry is reactionary, not proactive. Not only can manufacturers say whatever they want about their products, but they also do not have to prove their products are safe before they go to market. The FDA only steps in when a problem arises, as it did in the 1990s when people died from the anti-obesity supplement commonly known as fen-phen.

Furthermore, the FDA does not regulate the contents of supplements themselves, and oftentimes actual products do not contain what is listed on the bottle. Back in 2008, for example, I attended a talk during which a dietitian presented an independent research study that found that the hardly any of the tested protein powders contained the amount of protein advertised on the label. John Oliver, in his funny yet factual breakdown of the Dr. Oz debacle and the supplement industry in general, reveals that one in three supplements contains no trace of the plant advertised on the bottle. “If one in three milk bottles didn’t contain milk,” he says, “you might think twice about pouring the white mystery liquid all over your cereal.”

Even information regarding legitimate substances, such as vitamins, is skewed. Vitamins get their distinction because a deficiency in any one of them can cause a specific disease. For example, vitamin C deficiency causes scurvy, which is one of the reasons why the British navy began providing limes for their sailors in the 1800s. During Europe’s Industrial Revolution, children no longer received the same sunlight exposure as they did in generations past and consequently developed rickets, an indicator of vitamin D deficiency.

However, just because an adequate amount of a vitamin will prevent a deficiency-related disease does not mean that a benefit exists to taking excessive amounts. The United States Department of Agriculture’s Dietary Reference Intakes include tolerable upper intake levels, defined as “the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population,” for most vitamins, yet we can easily – and unknowingly – exceed these upper limits through supplementation.

For all of these reasons, unless a patient’s situation suggests the contrary, I recommend doing our best to get our nutrients through food first and only bringing in supplements when necessary. If it does look like a supplement is warranted, I suggest my patient run it by his or her primary care physician.

 

She Said

The topic of supplementation often comes up in my nutrition counseling sessions with patients and their families. Since I am not a medical prescriber, I always refer patients to their primary care physician when it comes to questions about supplements. While I usually suggest that patients try to receive most of their nutrients from actual food sources rather than pills or powders, there is some promising research on specific supplements that may help those struggling with eating disorders (EDs).

As one would guess, those struggling with EDs are usually deficient in many different nutrients due to extreme restriction and/or purging or laxative abuse, and this can compromise every organ in the body. These nutrient deficiencies can lead to a number of medical issues for the individual, including (but not limited to) osteoporosis, anemia, and heart and kidney problems.

Many supplements have been studied in their relation to EDs. For example, zinc supplementation has been linked to improvement in appetite, taste perception, and mood as well as enhanced weight restoration and menstruation in anorexic girls and women. Supplementation with essential fatty acids, specifically EPA and DHA, has also been found to aid in weight restoration while decreasing preoccupation with and anxiety around food in those with anorexia. For those struggling with bulimia, supplementation with electrolytes such as potassium and magnesium is often prescribed due to the large amount of electrolytes that are lost through purging.

A number of my patients struggling with EDs are either vegetarians or vegans, which can result in nutrient deficiencies including calcium, iron, and vitamin B12. Calcium deficiency can lead to osteoporosis, which can be tested for by doing a DEXA bone scan. Iron and vitamin B12 deficiencies can be detected by blood tests. In some cases, supplementation with these nutrients might be suggested to aid in the prevention or management of medical conditions.

At the end of the day, I try to focus on food with my ED patients, as most nutrients are best absorbed from dietary sources. But in some severe cases, supplementation might be indicated if the individual is unable (or unwilling) to eat the foods necessary to attain these nutrients. Refeeding can be a very uncomfortable experience for those struggling with EDs. Most of my patients who are refeeding experience painful bloating, cramps, constipation, and delayed gastric emptying, which can make it feel nearly impossible to eat anything at all. In those situations, supplementation with certain nutrients might be indicated until the individual is able to start eating normally again.

If you are considering supplements for either your own or your child’s ED, please consult with your physician before trying anything on your own. Your physician will be able to assess any nutritional deficiencies through a number of diagnostic tests and then can guide you in the right direction.

Intuitive Eating

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Thanks to a colleague’s tip, one counseling technique I sometimes implement is a one-on-one book club of sorts where a patient and I read a book together that is relevant to his or her care. Recently, I have been reading Intuitive Eating with a patient who is working hard to overcome decades of approaching eating from the vantage point of dieting and to build a new relationship with food.

He has impressed me by how open-minded he is to a new way of looking at eating and by how candidly he has shared the thoughts, questions, and concerns that have come to mind during his reading. Now about a third of the way through the book, he reports that he sees himself in many, but certainly not all, of the case studies that the authors present. However, the idea of not depriving himself feels scary. Specifically, he notes that he loves having dessert, but that he is better off skipping it because one brownie so easily turns into four. Besides, he says, health must come into the picture somewhere, so there must be a “but . . .” caveat to the notion of not depriving oneself. He is waiting for the other shoe to drop.

His concerns are common among people who are at the early stages of putting aside the dieting mentality and learning intuitive eating. He is right that we certainly consider health. After all, I am a licensed health care practitioner. Before we take into account the hard science of nutrition though, we have to address the emotions that affect eating.

Sure, physiological mechanisms exist that yield pleasure when we consume foods that are high in fat, sugar, or salt. You are alive to read this because these mechanisms gave your ancestors an evolutionary advantage and they passed them down to you. However, the reason that one brownie turns into four has less to do with physiology and more to do with the morality that gets attached to them.

When we experience guilt for eating a particular food or virtue for abstaining from it, these emotions block us from being able to truly experience and honor the internal cues that our bodies give us regarding our eating. We eat the first brownie, feel guilty for having done so, and say “screw it, today is ruined” and then reach for three more. In essence, the idea of not depriving ourselves feels scary because in our minds it translates to opening the flood gates. In other words, brownies all day, every day.

In reality, that is not how the body tends to operate. When we strip away the morality of food and see our choices on a level playing field, we discover that the appeal of previously-forbidden foods drops considerably. Some days we may want an apple for dessert, other days we may not feel like dessert at all. And what if we go through the question tree of asking ourselves are we hungry, how hungry are we, what texture/temperature/color food do we want, do we feel like something salty, savory, or bitter, and how much of that food do we really need to be satisfied, and we determine that a brownie will indeed do the trick? Then we find the best brownie we can get our hands on, eat it slowly, enjoy every bite, stop when we are feeling satisfied, and know that we can have another one whenever our bodies are asking for one.

Ideally, the hard science of nutrition comes into play after this sort of relationship with food is established. We can talk about the advantages of one kind of cereal over another, or one kind of yogurt over another, or what have you, but we have to take into account the human element. Whole wheat bread is probably a better choice for someone with high cholesterol than is white bread, for example, but if forcing down the whole wheat because it has a better nutritional profile on paper is going to trigger some sort of overeating in search of satisfaction, then he or she is probably better off just having the white bread in the first place and getting his or her soluble fiber someplace else. On the other hand, if the two breads are pretty much equally enjoyable, then sure, he or she is probably better off with the whole wheat.

Learning to eat intuitively involves taking a leap of faith that we can largely trust our bodies to tell us what and how much to eat. Reestablishing that trust involves dialing down the noise of guilt and virtue that makes our internal signals difficult to hear. If you find yourself consuming piles of brownies, or none at all, consider whether or not you are truly listening to your body.

You Are Not Tom Brady

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Leading up to today’s Super Bowl, a Boston television station aired a piece examining how Tom Brady, the quarterback of the New England Patriots, eats. The segment teaches us that among other eating behaviors, Brady does not consume any added sugar or processed foods and he abstains from alcohol.

Celebrities often influence our own behaviors, which is the driving principle behind sponsorship deals. Lump me in there as well. When Andre Agassi, my all-time favorite athlete, was endorsing Nike, much of my workout apparel bore the “Just Do It” slogan. Later in Agassi’s career when he signed with Adidas, the logo on my sneakers quickly changed from a swoosh to three black stripes.

Whether consciously or subconsciously, the sentiment we tell ourselves is along the lines of, “If those sneakers [or racquet, or sports drink, or watch, etc.] are good enough for him, then they are more than good enough for me,” or perhaps, “If I use those sneakers [or racquet, or sports drink, or watch, etc.] too, then maybe I can play like him.” It is only natural that the same message may extend to our perceptions of how professional athletes eat, but if you are considering emulating Brady’s diet, think again.

With sport being the primary focus of a professional athlete’s life and so much financially riding on performance, they frequently make choices that would not necessarily be prudent for the rest of us. In a recent conversation, a physical therapist pointed out to me how professionals are quick to undergo surgery and rush through their recoveries, while an amateur with the same injury is more likely to opt for a longer, but safer, rehabilitation program rather than an operation.

In other words, the life of the professional athlete is often focused on the here and now while the long-term risks take a back seat. Look no further than how the National Football League dealt with concussions for decades – largely minimizing the significance of brain injuries and rushing concussed players back on the field with little regard for the depression, memory loss, and suicidal urges that often came with retirement – until very recent legal action inspired change.

This philosophy bleeds into nutrition as well. Following rigid food rules comes with upsides for professional athletes, but similar payoffs are unlikely to exist for amateurs. Therefore, while it may make sense for Brady and his peers to follow strict diets, the same does not hold true for the rest of us. In other words, Brady’s diet may serve him at this stage in his life, but if implemented by one of us, the same eating behaviors may be described as orthorexic.

According to the National Collegiate Athletic Association, 6.5% of high school football players will continue the sport in college, and 1.6% of college players will go on to play in a professional league. In other words, only 0.08% of high school football players will ultimately play professionally. The statistics that they report for basketball, baseball, hockey, and soccer are on par with these figures. Given the extremely high probability that student-athletes will have to make their livings in a capacity other than turning pro, they often have backup plans for their lives (well, at least hopefully they do) in the form of academic educations so they have somewhere to turn when school and their athletic careers end.

Similar benefits exist in thinking long-term about nutrition as well. With all due respect to Brady and other professional athletes who are doing what they feel they need to do in order to perform their best, all-or-nothing approaches to eating rarely serve people for too long. When an athlete retires and suddenly the incentive for restriction ends, how will he deal with previously-taboo foods? This is akin to children who grow up in rigid eating environments with strict rules regarding quantities and/or forbidden foods, and then they go off to college and binge on late-night pizza delivery and all-you-can-eat soft serve in the dining hall. Such black-and-white approaches that teach us to ignore our internal cues and rely instead on external constructs will in all likelihood ultimately backfire.

Real life exists in grays, so building healthy relationships with food means both listening to our bodies and being flexible to allow for the complexities and variables that come our way. A professional athlete may have incentive to sacrifice such a relationship and rely instead on external rules because the here-and-now upside is so great, but the rest of us are better off learning a lesson from the 99.92% of high school football players who will never play in the National Football League. In other words, think long and hard before deciding to sacrifice for the here and now, and instead focus on life’s big picture.

Health at EVERY Size

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In response to my recent post about the calories-in-versus-calories-out myth as seen through the lens of my surgical recovery, someone posted a typo-filled response along the lines of, “You would not have posted this if you had lost weight.” He continued with pretty offensive commentary about people of a certain size not having the right to exist, but I will put that aside for now, not because I condone that nonsense, but because I want to focus on what he said in the quote.

His comment seems to be implying that I had hoped to lose weight and therefore I found a scapegoat for my supposed failure. Not true. We must remember that not everybody wants to lose weight. Some people, whether they are large, small, medium, round, slender, or any other shape, actually like their bodies the way they are. Other people may wish for a different body shape, but they understand that purposely trying to manipulate their form is unlikely to work in the long run and comes with consequences.

The commenter also seems to be assuming that I am overweight based on the fact that I shared my blog on the Health at Every Size® (HAES) Facebook page. To be clear, the name of this approach to health is not Health at Some Sizes and Failing Weight Loss Endeavors and Shame For Everybody Else. It’s Health at Every Size, and people of all shapes and sizes understand its importance in healthcare.

Consider the counterexamples we have all heard before: “He is so skinny, he can eat whatever he wants” and “She is a twig already, she doesn’t need to work out.” These weight-centered opinions have nothing to do with health. Being lean does not guarantee good health, nor does obesity guarantee poor health; behaviors do matter at every size.

Consider doctors who make assumptions about patients based on their weights. Prior to my surgery, a handful of the doctors with whom I consulted made incorrect assumptions about my lifestyle based on my size. Some doctors will decline to run routine tests on lean people based on the assumption that the patients are healthy, and some doctors will similarly decline tests for larger people, blame existing symptoms on weight, and instead recommend weight loss. None of these behaviors are about health, either.

A long time ago, shortly after my first back surgery, my neurologist asked me, “Are you exercising at all?” At the time, I was really offended. I was running, lifting weights, and playing tennis. Didn’t I look like I worked out? However, as time went on and I became more educated, I realized his question was spot on. Some muscular people never lift weights, some lean people never do cardio, and some obese people are more active than all of them but happen to exist in bigger bodies. Making assumptions about one’s lifestyle based on his or her appearance is not about health either, and to my neurologist’s credit, he knew it.

HAES is about focusing on actual health no matter what size we are, hence the name. For more information on the the HAES approach to health, check out the Association for Size Diversity and Health, of which Joanne and I are proud members.

“Beauty Work”

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This morning I read an article on “beauty work,” the digital manipulation of actors and actresses in movies and television to alter their appearances. No matter how rampant this practice may or may not be, the larger point is that comparing ourselves to people we see in any form of media, or even in real life, is never a good idea.

Joanne and I love the town in which we practice. She grew up here while I grew up just one town over and used to work at a sporting goods store a block from where our practice now stands. One of the challenges of our town, however, is the widespread focus on appearance and the negative fallout that this behavior spawns. Because the latter often shows itself in the form of eating disorders and disordered eating, we set up shop here in order to fill the need for help.

Quite often, patients come into my office and compare themselves to others, but the points of comparison go beyond actors and actresses and more often focus on fellow residents they see in the community. No digital manipulation there, but still, what are they really seeing?

Unless someone is completely candid with us, we never really know what he or she does or does not do to look a certain way. How do you know that the person who just lost a tremendous amount of weight is not battling a serious disease? Are you really sure that the friend you admire for being supposedly naturally slender is not struggling with anorexia, or that the co-worker you praise for eating the perfect little lunch is not later secretly bingeing on pizza and cupcakes before purging? Do you ever consider that the super buff weight lifter might be on steroids, or that the gym rat who can seemingly go for hours on the stair climber might be ignoring a slew of overuse injuries?

How sure are you that the person whose body you wish you had is any more happy, satisfied, comfortable, or confident with his or her body than you are with your own? Do you recognize the very real possibility that he or she is looking back at you with envy as well?

We never really know what is going on with someone, whether they are on a movie screen or walking down the sidewalk. Given that someone’s appearance tells us nothing about the person other than what he or she looks like, and given the negative consequences that frequently arise from comparing ourselves to others, how is it ever a good idea to make such comparisons?