The Privilege of Intuitive Eating

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While my time working in food service was mostly limited to academic teaching restaurants and hospital cafeterias, I learned that some businesses monitor the food that customers leave on their plates and interpret the observations as feedback for what the patrons thought of their orders. The less food remaining, the more the customers enjoyed it, is the general theory. This summer, I thought about that each afternoon as we opened our daughter’s backpack to see what portions of her snacks and lunches returned home from camp unconsumed.

We packed her an array of snack options each day without any expectation that she would eat them all, but we wanted her to have choices so she could select something that sounded good to her. Sure enough, each day she ate at least one of the snacks, but lunches were a different story. Providing multiple snack options was easy because they were all shelf-stable items that required no preparation; if she did not feel like eating a particular snack one day, it could stay in her bag until a different day when she did. However, the lunch options she said she wanted were perishable and took time to prepare, so sending her off to camp each day with multiple lunch choices was impractical. Thus, when a lunch returned largely uneaten, that got our attention because it meant she did not have much of a meal. 

If she just was not hungry at lunchtime, that would be fine, but our concern was the possibility that she was hungry but did not want the packed food. So we tried a bunch of lunch options, all of which she said she wanted, only to see them return home virtually or literally untouched. Eventually, I realized and accepted that she simply was not very hungry come lunchtime, and it became sort of humorous that she would request a specific lunch option only to not eat it.

As I chuckled at her uneaten food, I reminded myself of our luck and good fortune, and how being able to practice intuitive eating is a privilege. We did not mind if food came back uneaten and went down the garbage disposal, but what if that was the extent of the food that we could afford, and the choice was either to eat it or go hungry? Over the years, I have met people in our community who experience food insecurity, kids who either eat their free school-supplied breakfasts and lunches or have nothing all day, and families who accept what the food pantries have to offer or deal with barren kitchens.

Intuitive eating is embedded with privilege. Going through the matching process to choose one food over others requires having options available. Choosing when to eat necessitates having enough autonomy to be able to make such a decision. Ceasing to eat when comfortably full demands confidence that another opportunity to eat will arise again soon. Any of these privileges go out the window, and so does intuitive eating, at least to an extent.

However, subtle opportunities might still exist to utilize our intuition even in times when privilege is sparse. Buying dried legumes in bulk can be a thrifty way of obtaining protein, and with the prices of each bean being so similar to each other, we could choose the one that we most enjoy. A small array of cheap spices can impart somewhat different flavors on the same food for more variety in tastes. Free school meals include choices, such as chocolate or unflavored milk, and possibly different entree options. Foods that are shelf stable or at least function well as leftovers can be finished later, thus reducing the pressure to eat past the point of comfortable fullness.

The extent to which each of us practices intuitive eating is based at least in part on our circumstances. The laugh I got out of seeing our daughter’s uneaten lunches come home each day was a privileged reaction, and someone in different shoes might understandably have a very different reaction.

Post-Exercise Vending Machine Options

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In early June, I passed by my gym’s vending machine as a woman in tennis attire was looking at its contents and commented, “There is nothing in here that someone would want to have after a workout,” a statement that I am going to challenge.

Before I get to that though, remember that the vending machine serves more than just the individuals who are done exercising. Administrators, trainers, lifeguards, daycare center staff, custodians, contractors, spectators, parents, children, and members (before, during, and after exercise) all utilize the vending machine. Offering a wide variety of options makes sense because of the wide variety of people making purchases and their wide variety of preferences, needs, and circumstances. 

Now, let’s consider the woman’s assertion, “There is nothing in here that someone would want to have after a workout,” which is factually incorrect. But I will go further than that and make the case for why each of the vending machine’s options could appeal to someone after a workout. 

The Concentrated Proteins

My clinical experience as well as conversations I have overheard in gyms suggest that when people think about post-exercise nutrition, protein is the nutrient that most commonly comes to mind, and legitimately so. Physical activity can break down soft tissue, and protein is important in the repair process. Our bodies are particularly efficient at utilizing protein if we ingest it within approximately 30-60 minutes of finishing an exercise bout.

Dedicating four slots to fairlife nutrition plan chocolate shakes hints at this drink’s popularity. Chocolate milk is one of those stereotypical recovery foods often mentioned in nutrition schools and locker rooms, so I can understand the demand for this beverage, which is essentially just fortified milk. In addition to providing 30 grams of protein, these shakes also help to replenish fluids lost during exercise.

As for some of the other options, Jack Link’s Beef Jerky Teriyaki delivers 14 grams of protein with a taste and texture profile that some might find more pleasing than a sweet protein shake. Those looking for protein in a sweet and solid food option might enjoy the Quest Soft & Chewy Peanut Butter Cookie or the Quest Chocolate Chip Cookie Dough Protein Bar, which provide 15 grams and 21 grams, respectively, of protein. The erythritol content in the latter two products might scare some people away, as it can have a laxative effect, but others might find it beneficial in maintaining their gastrointestinal regularity. Those looking for a salty and crunchy experience might like the Quest Nacho Cheese Tortilla Style Protein Chips.

Joanne thought I was joking when I told her about Protein2O, but protein-fortified water, as fake as it sounds, actually exists, and those who find clear liquids more appealing or agreeable might find this option helpful.

The Water

Speaking of water, we lose it not just through sweat, but also through evaporation from our skin and in the breath we expel, so we need to rehydrate. Many gyms have water fountains, and this particular gym also offers free cups and a water dispenser, but people who prefer bottled water for one reason or another can buy Poland Spring from this vending machine.

The Electrolyte Drinks

When we sweat, we also lose electrolytes, namely sodium, potassium, magnesium, and calcium. Some of us lose electrolytes more readily than others do, and if you find streaks of fine white crystals dried to your skin or clothing after a bout of exercise, you are probably among the former rather than the latter. Beverages that are fortified with electrolytes can be helpful replenishment tools, and this vending machine offers three of them: Vita Coco coconut water, Gatorade, and Gatorade Zero.

The “Energy” Drinks

Early in nutrition school, I had a professor who used to rail against the myth that “energy” drinks provide energy. Carbohydrate, protein, fat, and alcohol are the only nutrients that provide energy, whereas vitamins, minerals, and water do not. We see evidence of this by looking at nutrition labels. Calories are a measure of energy, so if a food contains very few or zero calories, then that food is going to provide very little or no energy, respectively. Regarding the “energy” drinks in this vending machine, the bottle of Gatorade Propel has no calories, thus provides no energy, and Celsius Kiwi Guava and Monster Energy Zero Ultra contain 10 calories per can, which means they provide the same energy as consuming a couple of peanuts. 

In fairness, these “energy” drinks do provide various B vitamins, which act as cofactors in various metabolic processes, and we might feel tired if we are deficient in one or more of these vitamins because said processes are not working properly, but the vitamins themselves are not actually providing any energy.

So, why might someone want to choose one of these drinks after a workout? Well, they do contain water, and as previously discussed, we do need to rehydrate after exercise. Beyond that, some also contain caffeine, and just as some people include coffee, black tea, or Mountain Dew in their mornings because of their caffeine content, they might want to grab one of these “energy” drinks for the same reason. 

The Other Sugar-Sweetened Drinks

Capri Sun Fruit Punch, Vitamin Water Energy Tropical Citrus, and BodyArmor Fruit Punch Super Drink are all sugar-sweetened beverages that provide carbohydrates (Hence, they are actual energy drinks!) and water. Just as protein is helpful for rebuilding tissue after an exercise bout, carbohydrates allow our bodies to replenish the glycogen – the storage form of carbohydrate that we stash away in our muscles and liver – which we deplete through physical activity.

Sugar is the simplest, and therefore the most quickly absorbed, form of carbohydrate, and someone feeling a bit hypoglycemic after a workout might find these drinks helpful.

The Fruits

Some people prefer to get their carbohydrates from fruits, and this vending machine provides three such options: Juicy Juice 100% Juice Fruit Punch, GoGo Squeez Apple Apple applesauce, and Once Upon A Farm Fruit & Veggie Blend puree. Even though the latter two are semi-solid foods that could be eaten with a spoon, they come in squeeze pouches that enable on-the-go consumption. The puree is the vending machine’s only organic option, which is an important factor for some people.

The Gummy Candies

Sometimes when I talk about intuitive eating with a patient, we talk about a hunger-fullness continuum that ranges from extreme hunger to extreme fullness. These two end points are generally similar in the sense that an individual in either state is feeling very unwell, but they are also more specifically similar in terms of some of their symptoms, including nausea and feeling too sick to eat. At the extreme end of fullness, the reason for these symptoms is probably obvious, while hypoglycemia is the driver at the opposite end of the spectrum.

As someone who has been hypoglycemic and totally depleted at the end of various marathons and training runs, I know how important it can be to rapidly raise blood sugar after exercise. Similar to sugar-sweetened beverages, the gummy candies – Nerds Gummy Clusters, Sour Patch Kids, Swedish Fish Mini, and Haribo Goldbears – found in the vending machine can quickly raise blood sugar due to the absence of nutrients like protein, fat, or fiber that could slow the absorption of simple sugar. 

The Chocolate Candies

Like the aforementioned gummy candies, Twix, Reese’s Peanut Butter Cups, and Peanut M&M’s contain plenty of simple sugar, but these chocolate candies also provide fat and a small amount of protein, which means they are less suited for hypoglycemia. Still, our bodies will digest and absorb these options fairly quickly, which means they could work well as post-workout snacks to tide someone over until they get to eat something more substantial. 

The Pastries

The Famous Amos Chocolate Chip Cookies and Oreo Chocolate Sandwich Cookies provide sweetness and recovery carbohydrates in a crunchy and easy-to-share format. The Duchess Jumbo Glazed Honey Bun contains more energy than perhaps anything else in the vending machine, which is neither a good nor a bad thing, but rather just a distinction. People looking for a sweet and substantial source of quick energy may find this fits the bill and hits the spot. We can think of the Hostess Cupcake as sort of a smaller version of the Honey Bun, but with a different taste profile. 

The Semi-Sweet Snacks

Still sugary but not quite as sweet as the pastries and candies, the Lance Toast Chee Peanut Butter Crackers, Goldfish Vanilla Cupcake Grahams, and Cinnamon Toast Crunch represent yet more recovery carbohydrate options. 

The Salty Snacks

Lastly, leaving sweetness behind, the vending machine provides several salty snacks: Lay’s Sour Cream & Onion Potato Chips, Snack Factory Deli Style Garlic Parmesan Pretzel Crisps, Cheez-It Original Baked Snack Crackers, Pirate’s Booty Aged White Cheddar Rice & Corn Puffs, Cheetos Crunchy Cheese Flavored Snacks, popchips BBQ Popped Potato Snack, Veggie Straws, and Pringles. The latter two are stocked in various flavors, so a potential buyer is at the mercy of whichever variety happens to be at the front of the row at any given time. In addition to providing recovery carbohydrates, these salty snacks also help to replenish sodium lost in sweat. Some of them, such as the Lay’s Potato Chips, also contain a substantial amount of potassium. The Rice & Corn Puffs represent a gluten-free option.

Summary

As you read about these foods and drinks, you probably noticed that the available options include quite a bit of nutritional redundancy. Yet, as similar as some of these products are to each other, they are all different. Each one provides a unique combination of nutrition, taste, texture, and color. Personal preference is always important, and those of us well-versed in intuitive eating know that our bodies are good at guiding us to the option that is going to hit the spot at any given time. 

With respect to the woman whose overheard comment inspired this piece, all of the vending machine’s items are valid as post-exercise options in their own ways, and when I look at the photo that I took of the choices, I see a machine filled with foods and drinks that someone would want to have after a workout.

“Salad is a girl food”

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Needham elementary school lunches have changed quite a bit in the decades since I was a student at Broadmeadow. Each morning, our teacher would collect cash from the kids who wanted to buy that day’s lunch, stuff it in a metal Band-Aid container, and send the money down to the cafeteria so the workers knew how many meals to prepare for lunch. My favorite days were when they served pizza rectangles or tuna salad sandwiches, but others – such as American Chop Suey day – I was very happy to have brought lunch from home.

Now 40 years later, the cash and Band-Aid container are long gone, as basic meals are free, and my daughter has a four-digit code she enters into a computer to pay for any supplemental food she wishes to purchase. The other significant change is that instead of offering just one meal choice as they did when I was a kid, the cafeteria now provides an array of options. The main meal varies day to day and includes chicken in various forms, cheese nachos, pastas, hot dogs, hamburgers, “breakfast” foods such as assorted cereals, and different styles of pizza. Students who are not psyched about a given day’s main meal can choose from alternative options, including bagels, soft pretzels, and sunflower seed butter and jelly sandwiches.

Our daughter says that over the course of the year, she had each of the alternative options at least once, except for one: the chicken Caesar salad. When I asked her if any of her classmates routinely got the salad, she rattled off five or six names, all of whom are girls. According to her, rarely would any male students get the salad. 

With this information in mind, I thought about cultural norms and how children learn expected gender roles and behaviors at such an early age. Since our daughter was in kindergarten, we have had to counter messages she has picked up, like science, math, and sports are for boys, but not girls. Add “salad is a girl food” to the list.

Then I remembered a lesson that I learned at the very beginning of my nutrition career: cultural norms vary between settings. My first job as a dietitian was a research position that had me traveling the country gathering data regarding elementary school lunches and eating behaviors. On a typical day, I left my hotel room early in the morning in order to get to the school as soon as it opened so I could observe the cafeteria staff’s process for preparing the day’s food from the very beginning. My job involved taking a detailed look at the foods and their nutrient profiles, documenting the school’s food environment – including photographing the cafeterias and any nutrition-related signage that may have existed – and observing the children as they ate their meals. 

The variations between locations were striking. In one Chicago suburb, eating vegetables was considered “uncool.” Because students were more likely to use veggies as ammunition for food fights rather than for consumption, cafeteria supervisors intercepted the kids exiting the lunch line and removed the vegetables from their trays before they sat down. I remember looking into a trash can and seeing thousands of peas that were served but never had a chance to be eaten. In contrast, I visited a Tennessee hill town where the school was trying to figure out what to do about students trying to eat too many vegetables from the self-serve salad bar. I watched the cashiers ring up students with one hand and pick vegetables off the trays with their other hand in order to keep portion sizes in line with system guidelines.  

Given the contrasts, one could reasonably argue that cultural norms regarding what, when, and how much to eat are not inherent to age or gender, but are rather externally created and imparted upon our children. “Salad is a girl food” – or at least it is here in Needham, where very young girls have already picked up said message – but the situation could be different. What would school lunch selections look like if we taught our children to base their eating decisions upon internal cues rather than external expectations?

Body Thoughts

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In terms of health, 2025 has not been kind to me so far. Earlier this year, my family had a bout of influenza that knocked us out for about two weeks, and even the weeks following that illness I found myself struggling to get back to my “normal.” Then, in March I had an accident on the tennis court when I ran forward for a ball, lost my balance and ended up “splatting” face down on the court, with my knees and my left shoulder taking the brunt of it. Ever since then, my left shoulder has been in pain whenever I reach behind me, so after an x-ray, physical exam and MRI, it was determined that I have shoulder tendinopathy and bursitis. On top of that, I took a step one day in April and felt sharp pain in my inner right ankle, which turned out to be posterior tibial tendonitis. And to put the cherry on top, I am in the midst of perimenopause, which is wreaking havoc on my sleep patterns. All in all, my body has not felt great this year.

This got me thinking about bodies in general and how injuries and illnesses can take a toll on them. When I was in my twenties, I rarely got sick or injured, and if I did, I recovered quickly. Nowadays, it takes me much longer to feel like my “normal” self again, whether it is the cough that just won’t go away for weeks after the flu or physical injuries that just seem to linger for weeks on end without improvement. The part that is most frustrating for me is how these illnesses and injuries limit what I am able to do, whether it is going to certain events, playing tennis, or even playing with my daughter.

For all of the injuries and illnesses I have incurred, I have sought medical treatment. For the flu, I was prescribed Tamiflu, which helped to lessen the severity and duration of the flu. I have been to the walk-in orthopedic clinic for both my ankle and my shoulder, and I have been given treatment plans for them. I met with a new OBGYN to address my perimenopausal concerns. It feels like it takes a village to keep our bodies feeling well!

With the discomfort and pain I have been experiencing in my body over the past couple of months, I have not been immune to having negative body thoughts. Living in a larger body is already challenging enough in this weight-obsessed world, but add on illness and injury and the internal and external fat phobia can make things even worse. While I have luckily not encountered fat phobia with any of my medical practitioners lately, I have had bad experiences in the past when a doctor has pathologized my fatness.

What I find that I am struggling with more is the negative body thoughts I have been having. I have been doing this body acceptance work for so long (over a decade), and even though I know that all bodies experience illness and injury and my fatness isn’t to blame, I still have the occasional thought of “well, maybe if I lost some weight, I would feel better in my body.” The idea that weight loss can cure fat people of injury or pain is not new and is still pushed by the medical community as a way to “solve” a myriad of issues. I often have to remind myself (as I do my clients in larger bodies) that thin bodies also get sick and injured and that losing weight is not curative. And as we all know by now, the majority of people who engage in intentional weight loss end up regaining the weight they lost within two to five years (with two thirds of them gaining even more weight).

So what can I do to help my body feel better? There are plenty of things, it turns out! Seeing the appropriate medical professionals and specialists was the first step, in most cases. My new OBGYN prescribed me hormone replacement therapy to address my perimenopausal symptoms. I have started physical therapy for both my ankle and my shoulder (with two separate physical therapists!), and I have been doing their prescribed exercises and stretches at home. I have rested my ankle and shoulder as best as I can, gotten acupuncture and massage for both, and have used ice/heat therapy as well. And I am making a concerted effort to pay attention to my body’s hunger and sleep cues to improve my energy levels as well. Most importantly, I have been (gently) reminding myself that all bodies age, get injured and sick sometime and that none of that is inherently about my body size.

To food journal, or not to food journal?

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Back in 1993, I was a high school runner with a warped understanding of nutrition, so much so that my parents sent me to a dietitian, who had me keep a brief food journal as part of our work. After analyzing my journal, she told me that I was not consuming enough fat (Hey, it was the 1990s, and being afraid of dietary fat was the in thing to do.), and we brainstormed ways in which I could increase my intake.

More than 30 years later, food journals remain commonplace in dietetic counseling, and tracking apps like MyFitnessPal have popularized and normalized the act of documenting one’s eating even outside of working with a dietitian. But just because we can does not mean we should. As with anything, keeping a food journal can offer benefits, as it did for 16-year-old me, but plenty of potential cons exist, which is why the vast majority of my patients never keep a food journal as part of our work.

For those of you who are unfamiliar with what food journals are, they typically involve the user recording what, when, and how much they have eaten. When I do suggest that a patient keep a food journal, it is usually for one of four reasons, the first of which is reassurance. Sometimes a patient wants to make sure their intake of a particular nutrient or food group is appropriate, and having objective data to point to – as opposed to solely my subjective opinion – helps to relieve their anxiety while also serving as a double check for me. Along those same lines, I have found that when people eat intuitively, their macronutrient intakes almost always fall within their estimated need ranges without them even trying to make that happen, and analyzing their food journals is a way to confirm this.

Other times, I might suggest a food journal in order to prove a point. The science of nutrition moves steadily at a glacial pace while the pop culture of nutrition is labile. Just as my predecessors spent a great deal of time teaching people like teenage me that dietary fat need not be feared, I am sometimes in the position of reeducating patients about what their nutrition needs actually are versus what social influencers have made them believe that they need. Some patients take my word for it when I tell them they are getting way more protein than they need, but other people need to see their food journal analysis showing that their protein intake is equivalent to what we would give to a third-degree burn victim fighting for survival in order for them to understand that TikTok and its ilk are questionable sources of nutrition information.

If someone’s medical condition makes us particularly interested in their intake of a particular nutrient or nutrients, a food journal can help us to take a focused look at their consumption. For example, if bone health is an issue, a food journal can enable us to better understand their calcium and vitamin D intakes.

The fourth reason that I might recommend a food journal is simply to get our foot in the door to discuss a particular subject. People have different communication and learning styles, which is totally fine. Some patients like to converse, ask questions, and share their own thoughts, while others do better with a data-driven approach. For the latter folks, sitting down together and looking at their food journal yields a more fruitful conversation than if we were just looking at each other.

Despite their upsides, food journals have their drawbacks, which is why I only end up recommending their usage to a small subset of my patients. One of my main concerns is the tendency for people to use food journals as a tool to be hard on themselves. Sometimes people rationalize that if they have to record an eating behavior of which they are ashamed, they will be motivated to change. The expectation, in other words, is that keeping a food journal will provide accountability, but in reality, I cannot remember a single instance of such an approach bringing about long-term behavior change or an improved relationship with food. The risk is that food journaling exacerbates feelings of shame and damages a relationship with food that is already fraught.

My second concern is that keeping a food journal can be a step in the wrong direction for people who are trying to redevelop their intuitive eating skills, which involves making decisions about what, when, and how much to eat based on one’s internal cues. In contrast to intuitive eating, tracking apps, points systems, and lists of foods to eat or avoid are all external systems that distance people from their intuitive eating cues. While food journaling has the potential to help with intuitive eating, as previously discussed, I have seen many instances in which they are more of a hindrance. Although I always explain to people that the estimated needs that I calculate for their intakes of various nutrients truly are merely estimates based on algorithms that are the best we have yet are still highly flawed, sometimes people have difficulty internalizing such nuance, especially if they have a history of an eating disorder or disordered eating. Put more simply, they view these estimated needs not as ballpark guidelines, but rather as rules of what they “should” be doing, and becoming an intuitive eater while holding onto such a belief is an uphill battle.

Related to my previous concern, keeping a food journal opens the door to getting too caught up in objective data. Numbers are cool – I have a degree in mathematics from Tufts, and I spent my first three years out of college working as an operations research analyst for the federal government – but we can lean on them too much. SMART goals have their place, but the further I get in my career as a dietitian, the less I believe that they belong in nutrition counseling, where subjective data carries more importance. The more that a given patient seems to care about numbers, the more cautious I am about recommending a food journal due to the risk of exacerbating what is already an overemphasis on the objective.

Lastly, keeping a food journal is hard work! The best practice is to record the foods eaten in real time, as trying to remember what one ate in the past increases the likelihood of mistakes, which means that the individual has to be willing to write down or input into a device the details of their eating at the time of consumption, which takes time and has the potential to be socially awkward. Recording the necessary level of detail – including product brands, produce varieties, quantities, and details of each component of a meal or snack – is tedious. Because of everything that goes into keeping a food journal, the most that I ever ask anybody to record is three days of eating, and even in this instance, the third day’s journal is typically sparser and vaguer than the preceding two. Food journaling is an exhausting endeavor, and if someone is unable and/or unwilling to put in the effort to go about it properly, the data could end up being virtually useless, meaning all their time and effort is for nothing.

Earlier, I briefly defined a food journal as one’s recording of what, when, and how much they have eaten because that is what they usually include, but sometimes they take on different forms. For example, a food journal could omit quantity but prompt the user to record data such as their hunger level at the start of the feeding, their fullness level at its conclusion, the environment in which they ate, their mental and/or physical state, and any noteworthy thoughts or feelings that arose before, during, or after the eating experience. Utilizing this latter type of food journal can sometimes – but not always – be a way of taking advantage of the upsides of food journaling while mitigating their downsides.

Looking back, I am grateful that my own dietitian suggested a food journal all those years ago, as it was a useful exercise for me to go through at that moment in time. Food journals have their place, but like any tool, sometimes they are better left in the toolbox.

Prediabetes

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

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

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

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

Misguided and Deplorable

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

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

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

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

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

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

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

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

The Potato Diet

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

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

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

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

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

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

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

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

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

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

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

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

Nutrition Counseling in the Age of AI

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Listening to my niece and nephew talk about the role that artificial intelligence (AI) is playing in their college academic experiences, I started thinking about AI’s impact on my profession, including what possible future human counselors will have in an age of machine learning.

Long before AI became part of our vernacular, technology had already eaten into the role of registered dietitians. Why bother seeing a dietitian when we have search engines, some would argue, and to an extent, these folks have a point. Some patients are only interested in information that is readily available online. Sure, online information can be of questionable quality, but we dietitians are wrong sometimes too, so accuracy is not guaranteed either way.

One of the issues with relying on online health information is applicability. At some point, I read a study that looked at people who self-diagnosed using WebMD and then got a formal diagnosis from a doctor, and the discrepancy between the two was quite high. So, sure, we can hop onto the internet and readily find the medical nutrition therapy protocol for treating various conditions, but what if the condition we believe ourselves to have is more nuanced than we realize or just plain incorrect? AI, of course, is more advanced than a simple search engine, and from my layman’s perspective, it seems to be continuously improving at a rapid rate. The interactive nature of AI has the potential to reduce self-diagnosis errors.

If all patients wanted was information, the future of nutrition counseling would look quite grim, but many people are looking for more than just knowledge and data; they want a human connection. They want to talk with someone who can relate to their own challenges – not because that someone is a something that has absorbed enough data about said challenges to have assembled appropriate responses and follow-up questions – but because that someone has lived experience and has felt scared, nervous, sad, excited, or however they are feeling in the midst of whatever situation has inspired them to find a dietitian. That human dietitian has genuine empathy.

An AI entity can spit out the right words and tone, can mimic empathy, but it remains – as the name suggests – artificial, and no matter how the technology evolves, this basic fact will never change.

Weight Loss Wagering

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

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

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

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

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

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

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

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