Pinkalicious

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Mondays are our kindergartener’s “media day,” which means she and her classmates visit her elementary school’s library and have an opportunity to borrow a book for the upcoming week. During one Monday afternoon walk home from school, she gave me a synopsis of the book she was taking home, something along the lines of, “She [the main character] eats a lot of pink foods and turns pink, then she eats more pink food and turns red, and then she eats green foods and her color turns back to normal.”

Uh-oh.

Right off the bat, I had a feeling where this was going. My intuition proved correct once I read the book myself. Pinkalicious is a funny and cute book, but it is problematic in certain ways. If your child is going to read it, an accompanying and clarifying conversation will be important in order to mitigate harm.

The story begins with the main character, a young girl named Pinkalicious, baking pink cupcakes on a rainy day. She disregards her parents’ commands and eats so many of them that she wakes up in the morning and discovers that she has turned pink. Her doctor diagnoses her with a case of “Pinkititis” and advises her, “For the next week, no more pink cupcakes, pink bubble gum, or pink cotton candy.” The doctor continues, “To return to normal, you must eat a steady diet of green food.” Immediately thereafter, the book reads, “(YUCK!)”

The accompanying illustration shows several pink foods crossed out, indicating that Pinkalicious is to abstain from them. While the picture does include strawberries, grapefruit, and watermelon, the vast majority of the foods are desserts: lollipops, jelly beans, cotton candy, ice cream, donuts, milk shakes, jello, and cupcakes.

Following her trip to the doctor, Pinkalicious suffers various consequences as a result of her altered color: Her friend cannot spot her because she is camouflaged among the pink peonies, a bee mistakes her for a flower and lands on her nose, and she cries for her mother to take her home after bees, butterflies, and birds surround her.

Back at home, Pinkalicious requests and is denied another pink cupcake. After pretending to eat her dinner of “mushy, dark vegetables,” she sneaks back into the kitchen in the middle of the night and devours a cupcake that her mother had hidden. In the morning, a horrified Pinkalicious awakens to discover that her condition has worsened: She is now red.

Desperate to return to her normal self, Pinkalicious says, “I opened the fridge, held my nose, and squeezed a bottle of icky green relish onto my tongue. I ate pickles and spinach, olives and okra. I choked down artichokes, gagged on grapes, and burped up Brussels sprouts.” The accompanying illustration shows a few fruits – limes, honeydew, green apple, and grapes – and a bunch of vegetables, including broccoli, cucumber, celery, asparagus, cabbage, and peas. After ingesting these green foods, Pinkalicious loses her discoloration and becomes “beautiful.”

Left to their own devices to interpret this story, a child has likely internalized the following messages: (1) Pink foods are almost exclusively sweets. (2) Too many sweets will make them sick. (3) Sweets have an addictive-like quality. (4) The way to get healthy is to completely avoid sweets and to instead eat green foods. (5) Green foods are almost exclusively vegetables. (6) Vegetables are yucky. (7) Vegetables make them pretty.

Unfortunately, all of these messages are problematic. Let’s take a look.

Problematic Message 1: Pink foods are almost exclusively sweets.

Plenty of pink foods exist that have zero to mild sweetness, including corned beef, edible flowers, beets, dragon fruit, rare steak, and Himalayan salt, yet the only examples of pink foods that the authors cite are sweets because the former is really just code for the latter.

Problematic Message 2: Too many sweets will make them sick.

Sure, too many sweets can make someone sick, a lesson that I learned on Halloween many years ago. However, we tend to single out and villainize sweets, as if they are somehow the only food group that can sicken us in excess, while ignoring the reality that too much of anything can be detrimental to our health. Remember that even water, when consumed excessively, can kill someone.

Problematic Message 3: Sweets have an addictive-like quality.

Admittedly, this message is more subtle than the others, and I can imagine that it will go over the heads of some children. However, for those of us familiar with the apparent fallacy of sugar “addiction,” we can see its theme in the way that Pinkalicious eats another cupcake despite already having turned pink and gone to the doctor as well as in the lengths that she goes to – deceiving her family, waking up in the middle of the night, and sneaking around – in order to obtain the cupcake. Nevertheless, research suggests that sugar “addiction” is not a true addiction, but rather a byproduct of how we tend to demonize and restrict sugary foods.

Problematic Message 4: The way to get healthy is to completely avoid sweets and to instead eat green foods.

If this general sentiment sounds familiar, maybe that is because our culture oftentimes splits foods into dichotomies and presents one side as sin and the other as salvation. Whole30®, detoxes, “clean eating,” etc., are all based on this basic – and flawed – premise.

Alan Levinovitz, a religion professor who has taken to writing about nutrition because of the intersectionality of spirituality and food, sums up the situation very well, “It’s terrifying to live in a place where the causes of diseases like Alzheimer’s, autism, or ADHD, or the causes of weight gain, are mysterious. So what we do is come up with certain causes for the things that we fear. If we’re trying to avoid things that we fear, why would we invent a world full of toxins that don’t really exist? Again, it’s about control. After all, if there are things that we’re scared of, then at least we know what to avoid. If there is a sacred diet, and if there are foods that are really taboo, yeah, it’s scary, but it’s also empowering, because we can readily identify culinary good and evil, and then we have a path that we can follow that’s salvific.”

Sickness and health are never entirely within our control and are certainly way more complex than eat this, not that.

Problematic Message 5: Green foods are almost exclusively vegetables.

To acknowledge the obvious, yes, many vegetables are green. However, for all the green veggies in the world, we also have pistachios, pumpkin seeds, avocados, and other fruits that the book excludes.

Problematic Message 6: Vegetables are yucky.

The attitude that we have towards various foods shapes how our children come to see them. In our culture, adults often teach children to view eating vegetables as a chore. For example, earning dessert by first eating vegetables teaches the child that consuming vegetables is the suffering that one must endure in order to be able to eat what they really want.

My first job as a dietitian was a traveling research position that sent me all over the country examining the foods and eating behaviors in elementary school cafeterias. All these years later, I still remember two specific schools. In one suburban Chicago school, the kids saw eating vegetables as uncool and would not eat them, so the cafeteria monitors would proactively remove the vegetables from the trays for fear that the uneaten veggies would be ammunition for a food fight. Peas were on the menu the day I was there, and I remember seeing the bottom of the trash bin lined with confiscated peas. Meanwhile, eating vegetables was the in thing to do in one northern Tennessee school. The problem the cafeteria workers faced there was that kids were taking too many vegetables from the self-serve salad bar, thereby exceeding the allowed serving sizes. The contrast between these two schools stuck with me because it illustrates how cultural views of a food shape its consumption.

Of course we all have our own unique food preferences and aversions, and some people genuinely just do not care for vegetables, but teaching kids that they are “yucky” is mostly a self-fulfilling prophecy.

Problematic Message 7: Vegetables make them pretty.

“I was me, and I was beautiful,” says Pinkalicious after eating green foods and returning to her normal hue. With beauty being the subjective entity that it is, the use of the first-person perspective is significant and raises questions to which we will never know the answers.

On the surface, this quote reads as a self-affirming statement, but does Pinkalicious – who loves the color pink – really think she looks better now than she did when she was pink, or is she rather expressing relief that her color now matches the necessary criteria for societal beauty standards? In other words, does she really think she is beautiful in her own eyes, or because others – her parents, her doctor, and society as a whole – have taught her that being pink was wrong?

Unsaid but certainly implied is the message that if Pinkalicious returned to her beauty after eating green foods, then she must have been less than beautiful when she was eating pink foods, which tells kids that eating sweets makes them less attractive. If that sounds like too much of a stretch, consider the multitude of my adolescent patients (and sometimes their parents, too) who scapegoat sweets for their acne.

Given how many people – including kids – learn to dislike their bodies and yearn to conform to whatever media, peers, doctors, family, friends, etc., say they should look like, the notion that vegetables can make someone beautiful is surely enticing. The problem is that this message is false. Regardless of what one considers beautiful, no food group has the power to dramatically alter appearance.

Do you really want to indoctrinate your kindergartener into diet culture? If not, make sure that enjoying a reading of Pinkalicious is accompanied with a conversation discussing these messages.

Prep

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At the beginning of this month, I had my very first preventive colonoscopy. For those of you in your mid-40s and over, you may know that the procedure is now being recommended at the age of 45 (previously it was age 50) to screen for colon cancer and other bowel issues. So when I turned 45 earlier this year, I booked my colonoscopy for this fall and thought it would be “no big deal.” But as the months went by and the procedure day drew nearer, I found myself getting more and more stressed about it.

I was not feeling anxious about the actual procedure itself because people I had spoken to who had had one told me that it is the easiest part. I was more distressed about the prep for the procedure. I knew that for several days prior, I would need to be on a “low residue” diet (basically low fiber), and then on the day before, I could only have clear liquids (but no red, purple, or blue).

I’ve been eating intuitively for over a decade and have not restricted or changed what I have eaten during that time other than while fasting for blood labs. Even though I knew the low residue diet was important for the procedure, it still filled me with dread, and honestly, I felt quite depressed. I found myself becoming preoccupied with what I “could” or “could not” eat. I obsessively looked at the lists of foods to avoid, and I felt such sadness. Despite the fact that now I was supposed to be eating foods lower in fiber (no seeds, nuts, beans, whole grains, or high fiber fruits and vegetables), it felt reminiscent of my dieting days.

Interestingly, I also found myself eating past the point of fullness more often during this time. It felt like I was having my “last supper” before the prep day, as I knew I would not have solid food for over 24 hours. Even though I rationally knew that food deprivation almost always leads to food preoccupation, I was still surprised at how difficult it felt.

The day of the “prep” was the worst day by far. I had stocked up on Jell-O, tea, apple juice, and vegetable broth, but it was (not surprisingly) completely unsatisfying. On the tip of a friend, I learned that I could also have gummy bears and Jolly Ranchers (just not the red, purple, or blue ones) as they liquify at body temperature, so I had some of those as well. Overall, I was a cranky, hangry person, and all I wanted to do was isolate.

By the time I started drinking the liquid laxative that early evening, I was pretty miserable. I will not go into the details of this part other than to say that I spent a lot of time in the bathroom that night and in the wee hours of the morning.

Luckily, I had booked the colonoscopy for first thing in the morning, which meant that I would be done with it all sooner. And, as advertised, the procedure itself was quick, easy, and painless (I was thankfully asleep for it all.) Of course, I was thrilled to hear that my colonoscopy results were excellent, with no areas of concern, and I will not need to get another one for 10 years.

Once I was able to eat normally again, I quickly noticed that my food preoccupation subsided, and I started feeling more relaxed around food. I was no longer a cranky, hangry mess and was able to eat in tune with my body’s cues.

I am very grateful that my procedure went well. And despite the discomfort, stress, and anxiety I felt during the days prior, I am glad that I had this experience. It reminded me that I never want to go through the restriction/food obsession cycle of dieting again. And it also reminded me that my body is amazing and always trying to protect me – that survival instinct is no joke! My advice to those of you who will be getting a colonoscopy? Take off the day before, make sure you have plenty of supplies at the ready, and remember that this too shall pass.

Thoughts on the New Weight Loss Drugs

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I’ve been meaning to write a blog about the new weight loss drugs for months now, but every time I start, I find myself having trouble with what I want to say, especially since so many of the anti-diet and fat-positive activists I admire have already written such important and insightful pieces on these drugs. For anyone looking for some in-depth research study analysis, I want to point you towards Ragen Chastain, a speaker, writer, and amazing fat activist, in addition to being a certified “statistics nerd” (her words, not mine!). Her Weight and Healthcare Substack is an invaluable resource that takes a hard look at “weight science, weight stigma and what evidence, ethics, and lived experience teach us about best healthcare practices and public health for higher weight people.” Ragen is adept at sifting through the research studies that the drug companies publish to sell the efficacy of these drugs and finding the myriad issues, conflicts of interest, and straight-up bad statistics that these studies exhibit. So please read what she has written on the topic of GLP-1 agonists.

In this piece, I am not going to get into the science behind how GLP-1 agonists such as Ozempic and Wegovy actually work. Instead, I want to talk about how these drugs (and the weight loss drugs that came before them) have become such a lightning rod in the discussion of weight. I was a teenager in the 90s, and I clearly remember when the drug Fenfluramine/Phentermine (Fen-Phen) entered the weight loss scene. There was such a fervor about it on the nightly news, and the marketing by the drug companies was intense. It was touted as a “miracle drug” that could “cure” o*esity, and everyone was going to their doctor to get a prescription. I also remember the news stories that came out. Famously, there was one in the Boston Herald about how Fen-Phen was linked to mitral valve dysfunction, pulmonary hypertension, and other cardiac abnormalities. Subsequently, it was removed from the market due to these risks. It took years before people were convinced that the harms that these medications caused outweighed the “benefits” of weight loss for higher weight people.

There has been a seemingly significant theoretical shift in the medical community over the past few years regarding higher weight (the “o” words”) and weight loss. Unlike previous decades, when people were told that their high weight was their “fault” and was caused by their “unhealthy lifestyle behaviors,” many medical professionals are now putting forth the message that one’s weight is largely out of one’s control (true) and is not necessarily due to “unhealthy lifestyle behaviors” (also true). Most physicians acknowledge that the BMI is a flawed measurement and that there are many factors that play into health other than weight (true again). But instead of pivoting away from using weight as an indicator of health, there has been a push by the medical community to classify o*esity and o*erweight as “chronic health conditions” that must be managed over one’s lifetime. In essence, the medical community is saying that while being fat isn’t your “fault,” it is still a problem and one that needs to be managed.

In our fat-phobic, image-obsessed culture, it makes sense why these new “miracle weight loss drugs” are creating such a stir. Higher weight people are being told, “Hey, we know that your weight is out of your control, but we can help you manage your ‘condition’ with these medications!” In addition, there is a lot of pressure on higher weight people to “get healthy” (even if many of them are healthy by every measure other than weight), and losing weight is still seen as something that will improve people’s health. The marketing that the drug companies have put forth is simply astounding. I feel like I can’t watch a TV show, peruse social media, or even read the New York Times without sponsored content popping up about these drugs. Add to this all of the celebrities and influencers who have been publicizing their weight loss “success,” I would be surprised if any person in a larger body wouldn’t be affected. Currently, I am in a small-mid fat, abled body, and I’d be lying if I said that I hadn’t thought about turning to these drugs. I can only imagine how those who are in much larger bodies than mine and/or in disabled bodies are tempted to try them.

The studies that have been put forth by Novo Nordisk (the drug company who makes Wegovy and Ozempic) have shown that while participants lost about two pounds per month over a 68-week time period (during which they were also dieting and exercising 30 minutes per day, six days per week), at 60 weeks, those who were still taking the medication experienced a plateau in their weight loss, and in a follow-up study the following year, two thirds of the weight they had lost was regained. Conveniently, the studies all concluded at the second year of testing, as we know that the majority of weight regain occurs between two to five years post weight loss attempt. Novo Nordisk also reported that taking their medication leads to positive health outcomes, but a closer look at their studies shows that there were no statistically significant improvements in HBA1C (a measure of diabetes), triglycerides, cholesterol, or inflammation markers.

I don’t blame anyone who feels like they need to try these drugs. For some folks, losing 10-15% of their body weight (the average weight loss reported by researchers) could feel like it makes a huge difference in their quality of life. What I find distressing about these drugs is how hard they are being pushed by the media and medical community despite the long list of side effects and potentially harmful health outcomes that can occur. Wegovy has a Boxed Warning (the FDA’s most serious warning) due to it increasing one’s risk for thyroid cancer, acute pancreatitis, acute gallbladder disease, stomach paralysis, as well as an increase in suicidal ideation, among other risks. But it seems that the medical community feels that losing weight is worth the risk to fat people’s lives. That even though folks report nausea, diarrhea, vomiting, constipation, and stomach pain while on these drugs, it’s okay as it is just the price to pay for one to become “healthy.”

I wish that instead of telling higher weight people that their weight is a problem that can be “solved” by taking these medications, the medical community could instead focus its energy on reducing weight stigma in healthcare, as this (along with weight cycling or yo-yo dieting and healthcare inequalities) has been found to have much more of a profoundly negative effect than weight on one’s health. I wish that we lived in a society that didn’t prize thinness so much. And I wish that everyone could see that weight is just another human characteristic that exists on a continuum and that bodily diversity is a real thing, not something that has to be “managed” or “controlled.”

The End Is Near!

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Seven years ago, when I saw Chic in concert for the first time, Nile Rodgers used the interlude in one of their songs as an opportunity to tell the crowd about his recent cancer battle, which he ultimately won. The songwriter and producer explained that receiving the news inspired him to go on a music-making binge, as he figured he only had a short window of time left to express his art.

Earlier today, as I was driving home from the beach with our daughter, that memory crossed my mind. Since she will soon be restarting school, we have been trying to cram in as many daddy-daughter activities and outings – the Museum of Science, the Butterfly Place, farms, the zoo, fruit picking, restaurants, train rides, the aforementioned beach, etc. – as we can before the start of the school year interferes and forces these bonding experiences from frequent occasions to relative rarities. Before we have even left the parking lot of one activity, I am already thinking about the next one and all of the others that I hope to shove into our remaining time before it runs out. We have fun, but part of me is distracted, anxious, and sad as I think about the end.

Deadlines have their upsides because they can push us to accomplish tasks and achieve goals that might otherwise remain unfulfilled, but they bring with them stress and general feelings of unease that detract from the experience.

Life-threatening illnesses and the school calendar are examples of deadlines imposed upon us, realities that we just have to do our best to roll with, but sometimes we needlessly impose deadlines upon ourselves. A person who wants to get married by a certain age may settle because the timing is right even though the partner is wrong. Someone I know recently spent a hot summer evening in the emergency room with heat exhaustion and dehydration because they stubbornly kept hacking away at a tree they really wanted to cut down before dinnertime rather than conceding they should take an additional day to complete the project. When we were adolescents, a friend of mine wanted to bench press a particular weight before a school dance, and he ended up having to fight to free himself as the much-too-heavy bar laid across his chest.

Because this is a nutrition blog, I am of course thinking about the predicaments we can put ourselves and our relationships with food in due to self-imposed deadlines. An obvious example is the melancholy and frantic overconsumption that precedes a scheduled diet. Trying to lose weight before a wedding or another similar function is a common – yet problematic – behavior that is most likely to result in eventual weight gain and increased risk for developing a wide range of health woes. Someone I know severely dehydrated himself on his birthday and spent much of it at the gym because he had set a goal to be at a particular weight by his new age, and while he did survive and recover, he put himself in a dangerous situation for the sake of an arbitrary goal.

Imagine what these scenarios could look like instead without the needless deadlines. No diet on the horizon could mean more peaceful and intuitive eating without the threat of self-imposed food insecurity looming. Foregoing an attempt to lose weight before an event reduces the chances of harmful and discouraging weight cycling and creates space for the person to focus their time and attention on the big day itself and to go into it full of energy instead of depleted. Personally, I can think of more fun ways to spend a birthday than sweating out as much fluid as possible on an elliptical machine.

Time and opportunities are finite resources, and while we never know when they will run out, we can make life easier for ourselves by leaving self-imposed deadlines in the past.

What We Can Learn From Eating While Sick

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We managed to avoid it for over three years, but COVID finally got us. Joanne and I developed strange sensations in our throats virtually simultaneously and then tested positive a couple of days later. Whether due to the disease itself or as a side effect of Paxlovid, we developed terrible tastes in our mouths. Joanne described it as tasting like gasoline, while to me it seemed more a combination of cheese, bad breath, and metal. Additionally, I experienced waves of queasiness and a drastically reduced appetite.

Some of my patients talk about how much easier it is for them to eat intuitively when they are sick versus when they are fully healthy, and my experiences were somewhat similar to their own. When our appetites are diminished and food seems off-putting, our range of tolerable eating options shrinks considerably, which ironically makes food selection easier because foods we are willing and able to eat stand out in greater contrast to the rest.

Sometimes my patients, when they are ill, have an easier time practicing unconditional permission for a couple of reasons. First, because their array of appealing foods is so small, their only realistic option is to go with these foods. Second, because they are sick, they feel they are more deserving of self-care than when they are healthy, so they worry less about their perceived nutritional quality of food or about what they “should” be eating.

Being sick is so unpleasant and disruptive that at least making food choices can be easier for the aforementioned reasons, yet we can learn lessons from eating while sick that we can apply when we are healthy.

Choosing from a vast sea of eating options can be difficult and overwhelming, which is why deciding what to order from the Cheesecake Factory’s massive menu can be challenging. It is why, when our daughter demands “Choices!” when I ask her what she wants for a given meal, I offer her a small selection of different foods. We do advocate for having a wide variety of foods on hand at home so we have a reasonable shot at being able to satisfy whatever criteria our intuitive eating questions lead us to, but selection can nevertheless be hard if every option feels appealing. As when we are sick, having a smaller range of options that sounds good can make the process easier, but we can accomplish the same objective without being ill by eating before the magnitude of our hunger grows to unwieldy levels.

Only some of my patients utilize a hunger/fullness continuum, as it can sometimes be counterproductive if misused, but those who do know that we define a “3” as a comfortable hunger where we are ready for a meal and we are able to discern which foods sound like they will best hit the spot. In contrast, we define a “2” as a hunger that has grown uncomfortable, where we may feel irritable and stressed, and choosing what to eat can be especially challenging because our bodies are essentially telling us, “I don’t care what you feed me, just give me food!”

By eating before we get to a “2,” we give ourselves an opportunity to separate the most appealing foods more easily from the rest of our options. The practicalities of real life sometimes preclude us from being able to have our meals and snacks exactly when our body’s hunger cues suggest we are best off eating, but through experience, we can learn how to incorporate well-timed snacks that have us arriving at mealtime comfortably hungry rather than ravenous.

In terms of unconditional permission and the relative ease with which we can practice it when we are sick, remember that we are always deserving of self-care – including having the freedom to eat what, when, and how much we want without justification – regardless of our state of health. Think of self-care as something to be practiced not just when we are ill and need to get better, but also when we are already well and hope to stay that way. Personally, I can remember many times over the last few decades when I put self-care to the side, disregarded what my body was asking for, and ended up in a state of illness that was arguably avoidable if I had taken better care of myself.

Next time you are sick, consider the lessons about your eating that you can take with you as you leave the illness behind.

When Family and Friends Lose Weight

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It’s the beginning of summer, and one theme in particular has been popping up a lot lately in my appointments with patients. It seems like everyone’s mother/uncle/friend from college/cousin has gone on a “weight loss journey” since the winter. As you might expect, witnessing your loved ones and/or friends and acquaintances engage in intentional weight loss can stir up a lot of feelings in those of us who are trying to embrace the bodies that we have. Research on intentional weight loss has found “almost complete relapse” after three to five years. Other data are more specific and suggest 90% to 95% of dieters regain all or most of the weight within five years, while other research has found that between one third and two thirds of people end up heavier than they were at baseline. It can be hard to watch others receive the praise and acceptance that often comes along with these “weight loss journeys.” It’s difficult to watch these folks gain more and more privilege while we remain in bodies that often put us at a disadvantage in our fatphobic society. So what are we supposed to do with all of these feelings?

First off, I try to remind my patients that their mother’s/uncle’s/friend’s/cousin’s bodies are not our business. I firmly believe in body autonomy, or as Ragen Chastain calls it, “The Underpants Rule.” In essence, what someone chooses to do with their body is up to them (as long as it is not harming others). Our family and friends will often make choices that we don’t agree with. And those of us who are trying to fight the near-constant onslaught of fatphobia we are fed on a daily basis feel strongly that these friends/family members are doing harm to themselves and perpetuating diet culture. But at the end of the day, we aren’t in charge of others’ bodies. Just like we wouldn’t want someone telling us how to live in our own bodies, we can’t police others.

That being said, I think there is nothing wrong with protecting oneself and setting boundaries around diet and weight loss talk. If you are active on social media and the friend/family member is an active poster of weight loss updates, befores and afters, or touting their new “healthy lifestyle,” it might be time to either snooze them for a short while or hide them from your timeline indefinitely. This can be done by clicking the “unfollow” button on someone’s Facebook profile or clicking the “mute” button on Instagram. By doing this, you are removing the element of surprise from seeing these things popping up on your timeline. It’s hard to look away or unsee some of these posts, so preventing them from appearing on your social media from the start can be helpful.

Another way that you can set a boundary is by being up front with the friend/family member about how their diet/weight loss talk is affecting you. Sometimes I will help my patients role play what they would like to say to the friend/family member who brings up their diet/weight loss. In these types of situations, I encourage patients to try to give their friend/family member the benefit of the doubt. That is, it is very unlikely that they are intentionally causing you harm or distress; they just are unaware of how this kind of talk can be triggering. Here’s an example of how these conversations can be broached: “Hey, I know that you aren’t intending to, but when you talk about your diet/lifestyle/weight loss journey with me, it makes me feel uncomfortable. I am happy that you are happy with what you are doing, but hearing about it is unhelpful for me as I’m working on accepting my body and letting go of diet culture.” If you are struggling with an eating disorder (and this person knows about it), it could be helpful to also say, “Part of my eating disorder recovery is not engaging in diet/weight loss talk as it can make my symptoms worse.”

If after these tactics, the message is still not getting through, it is within your right to limit your exposure to these individuals. This might mean doing shorter meet-ups rather than long, drawn-out hangouts, limiting your time spent at family gatherings, or getting together less often. If this is not an option, you can take space when you need to at these events, excusing yourself from the room or going for a walk by yourself, for example. I also highly recommend cultivating your own “anti-diet” community either online or in person if you are able to. There are many fat-positive folks all over the world, and it can feel less lonely when you are around those who “get it.” Instagram and Facebook can be helpful in finding these people and connecting with them.

At the end of the day, I hope that the one thing you will remember is that just because your
friend/family member is actively engaging in diet culture, you do not have to go that route. You deserve to embrace and live in the body you have, and you do not have to change it. Your body has never been the problem – our fatphobic culture is.

The Problem With Fat Shaming Professional Athletes

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Felger: If we ever get to the point where we can’t fat shame athletes, I quit.

Massarotti: It’s coming.

Felger: It is coming.

Massarotti: It might already be here already.

Felger: It’s not. We’re not talking about a teenage girl. We’re talking about professional athletes whose job it is is to be in shape. We are allowed to call them fat and tease them for being fat. If that becomes off limits, I’m done.

The aforementioned exchange, which took place in the context of discussing Kyle Lowry of the Miami Heat, occurred between co-hosts Michael Felger and Tony Massarotti near the end of their Felger & Mazz sports talk show on May 17, 2023. Much like the fat shaming directed at Pablo Sandoval seven years ago, this problematic dialogue misses the mark and causes harm.

Felger asserted that part of a professional athlete’s job is to be in shape, but what constitutes “in shape” should not be defined by anthropometrics, such as weight or body fat percentage, but rather by an athlete’s readiness to perform their given sport at the level their employers expect of them. If an athlete lacks the strength, endurance, or flexibility to perform, the deficiency in their fitness is the real issue regardless of how their body is built; otherwise, teams would just fill their rosters with bodybuilders and models and call it a day.

“In shape” is also context dependent, as the physical abilities necessary to perform at a high level vary from sport to sport. A gymnast who lifts weights and runs but never stretches, a shot putter who stretches and runs but never lifts, and a marathoner who stretches and lifts but never runs would all have serious issues with their performance regardless of how their bodies look.

Besides, Kyle Lowry is actually quite a good basketball player. Lowry is in the midst of finishing his 17th season in the NBA, he earned spots in six straight All-Star games from 2015 to 2020, he started all 65 regular season and 24 playoff games that his team played on their way to winning the 2019 championship, and he was a member of the USA Olympic team that won the gold medal in 2016. Sure, his statistics dropped off a bit this season, but blaming the dip on his physique – which looks to be the same now as it did four years ago – is a bit of a head-scratcher considering the 37-year-old is the seventh oldest player (out of approximately 450) in a league where the average player is 26.01 years old. According to basketball-reference.com, Lowry’s career performance arc is thus far most similar to those of Terry Porter, Vince Carter, and Allen Iverson, the latter of whom is already enshrined in the Hall of Fame, and another – Carter – will likely get in too once he is eligible.

Lowry is far from the only “fat” athlete to outperform many of his leaner peers. The aforementioned Sandoval made over $73 million during his 14 years in the major leagues, and the two-time All-Star was named Most Valuable Player in one of the three World Series that his teams won. Pat Maroon was fat shamed despite winning three straight Stanley Cups. Back in Lowry’s realm of basketball, Luka Doncic’s own boss criticized him for his weight despite winning Rookie of the Year, then being named an All-Star and making the All-NBA first team in the four seasons he has played since then.

However, the most concerning part of Felger’s opinion is that he seems ignorant of the impact that his sentiments have on people other than professional athletes. “We’re not talking about a teenage girl,” he said, but the reality is that fat shaming anybody breeds fat shaming in general. Discussing the reasons why criticizing Donald Trump for his weight is harmful, Ragen Chastain explained, “And make no mistake, when you engage in fat-shaming, your victim is every single fat person.” The ramifications of fat shaming athletes are clear, as I discussed in the Boston Baseball article I wrote about Sandoval back in 2016.

“Fans and media have labeled Sandoval ‘disgusting,’ ‘lazy,’ and ‘pathetic,’ implying that those same terms apply to everyone who has a body type similar to his.

The message is that fat is to be loathed, that larger individuals are not worthy of the respect enjoyed by the rest of us. We reject stereotypes based on race, religion, ethnicity, or sexual orientation but we inexplicably tolerate those based on body size.

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

As we all know, pressure to be thin leads to dieting, which can lead to a variety of problems, including eating disorders. These life-threatening illnesses are so common in Massachusetts that if the crowd at a sold-out Fenway Park represented a random sample of the state’s population, those in attendance with a diagnosed eating disorder would fill section 41.”

Sounds like Felger’s intent was to focus his fat shame on professional athletes while sparing others – and good thing it was, for his behavior would be even more problematic if his intent was otherwise – but we all know that intent and impact are two different entities. Felger certainly should know this, as his co-host was suspended just three months ago for making a poor attempt at humor that came off as racially insensitive. Like Massarotti, Felger should have known better.

If Felger is unwilling to forego fat shaming professional athletes, then the time for him to quit truly has arrived.

Gentle Nutrition

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What is gentle nutrition? Imagine a Venn diagram. In one circle, we have intuitive eating, which is an approach to making decisions about what, when, and how much to eat centered around our body’s internal cues. In the other circle, we have medical nutrition therapy, which is the use of nutrition to treat various health problems. In the area in the middle where the two circles overlap lives a concept that we call gentle nutrition.

For my patients who are working to rebuild their intuitive eating skills, getting a firm handle on what gentle nutrition means and how to implement it in their lives are often two of the trickiest steps they face. The most common reason is that people oftentimes do not trust that their body’s internal cues will steer them in the direction of eating in a way that is conducive to their health. This fear, which I otherwise think of as the “If I allow myself to eat whatever I want, all I will do is have [insert the name of your taboo food] all the time” expectation, implies that eating for health means overriding intuitive eating cues.

My counter to that concern is to cite the food journal analyses that I perform on some of my patients. When I look at the intakes of my seasoned intuitive eaters, their nutrient consumption almost always falls within their estimated needs because their body naturally guides them towards the food it requires. In other words, my clinical experience suggests that when we eat intuitively, the eating-for-health part largely takes care of itself.

But what if our body is an imperfect guide? What if we face a gap between how far our intuitive eating takes us and where medical nutrition therapy suggests we should be?

For starters, take a step back and remember that our behaviors have limited influence on our health. One of my patients recently told me about a colleague who was diagnosed with cancer, and as word spread around the office, her co-workers reacted with surprise because the woman is so “thin and healthy.” (And as my patient astutely pointed out, if her colleague was fat rather than thin, people likely would have felt that she brought her health woes upon herself, which is a whole other problem.) Hearing the story reminded me of a fellow healthcare practitioner who was diagnosed with cancer herself despite being clearly orthorexic. For people who erroneously believe that they can control their medical fates if only they engage in certain behaviors, counter examples like these can rock their world.

Given that we may suffer whatever ailment we hope to avoid regardless of our best efforts to steer clear of it, we have to consider the lengths that we are willing to go to – and what we are willing to sacrifice – in hopes of reducing our risk. Focusing on medical nutrition therapy may sound sensible in theory, but doing so can come at the expense of our relationship with food. Consider the following scenarios that someone with hypertension might face.

  • What if you feel like you should never have salty food because of your high blood pressure, or when you do allow yourself to have it, you feel like you are being “bad”?
  • What if you have a history of restriction and the mere thought of cutting down on salt feels traumatic?
  • What if you are a recovering binge eater and stocking salty foods is an important step in your treatment?
  • What if you are on the road and happen upon a restaurant famous for a high-salt dish you really want to try, but you feel like if you do, you are asking for a cardiac event?

Who wants this level of angst interwoven with their eating when the fact of the matter is they could die of a heart attack no matter how much or how little sodium they consume? Unfortunately, stress, guilt, second-guessing, and inner turmoil can be significant issues when we practice not-so-gentle nutrition.

We advocate for gentle nutrition because of the downsides that come with focusing too hard on medical nutrition therapy and because of the upsides of taking a more moderate approach that still respects intuitive eating. Consider how someone practicing gentle nutrition would approach the same scenarios that I listed earlier.

  • What if you feel like you should never have salty food because of your high blood pressure, or when you do allow yourself to have it, you feel like you are being “bad”? They understand that complete abstinence of salty food is neither necessary nor practical, and they can enjoy such foods without guilt.
  • What if you have a history of restriction and the mere thought of cutting down on salt feels traumatic? Before even tackling gentle nutrition for their blood pressure concerns, they first do the necessary work to heal their relationship with food, thereby making medical nutrition therapy feel less triggering.
  • What if you are a recovering binge eater and stocking salty foods is an important step in your treatment? They recognize that in order to make peace with salty foods and get to a place where “a little” does not automatically turn into “a lot,” they have to practice unconditional permission and abundance, which entails exposure, continuous access, and predictable overconsumption for a period of time.
  • What if you are on the road and happen upon a restaurant famous for a high-salt dish you really want to try, but you feel like if you do, you are asking for a cardiac event? They understand that no single eating experience is going to save nor doom their health, that food is part of culture and travel, and that they would probably regret forgoing a rare opportunity.*

How then is the nutrition part of gentle nutrition implemented? That same person with hypertension may use their intuitive eating cues to determine that they feel like having a piece of fruit for a snack, but both the apple and the banana sound equally appealing, so they opt for the latter since it has more potassium than the former. On the other hand, if they feel like solely the apple would hit the spot, they eat it, enjoy it, and look for other places in their day to get their potassium. If the whole day goes by without consuming much potassium, they do not worry, but rather trust that their intuitive eating cues guide them in different directions day to day, and tomorrow they could very well find themselves taking in a high amount of potassium.

After reading all this, you might be thinking to yourself, “Yeah, okay, I get that my health is not entirely within my control, but I want to do everything I can to minimize my risk.” If so, that is entirely your right. You are the expert in your own life, nobody is in a better position to decide your path forward than you are, and I commend you for weighing the pros and cons and making an informed decision that feels right for you.

However, that same autonomy applies to each of us, and many people conclude that not-so-gentle nutrition is just not worth its cons and that gentle nutrition is the way to go.

* Speaking from personal experience, I remember spending a night at a church on a Native American reservation in Montana during my Seattle-to-Boston bicycle trip. My hosts offered me one of their traditional dishes – something that I can only describe as a French-fried donut, although I am sure that is not at all what it was – and it turned out to be literally the best tasting food I have ever had in my life. Sometimes I think about what I would have missed had I turned down the food due to nutrition concerns.

Being Your Own Advocate at the Doctor’s Office

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Going to the doctor has always been a fraught experience for me. As a child, I was consistently in the highest percentile for weight-for-height, and my pediatrician expressed concern from the get-go. He would talk to my mom about my weight in front of me, and it is probably one of my earliest experiences with the feeling of shame.

As the years went by, my experience with doctors didn’t improve. I would fear going to get check-ups, bracing myself for comments about my weight and how I would need to “do something about it.” Even on the occasions when I would go to the doctor having lost weight, I would be anxious and fearful that my doctor would congratulate me and tell me to “keep doing what you’re doing,” as that meant I would have to continue to restrict, over-exercise, and obsess about my weight.

When my PCP retired about six years ago, I made the conscious decision to try and find a weight-neutral doctor. A fellow non-diet dietitian recommended a concierge doctor as someone who did not push back when she was told that discussions of weight would be off the table. I met with this PCP and explained to her my concerns and my desire to be treated through a weight-neutral lens. While it was clear that she typically practiced from a weight-normative perspective, she said that she understood and would not push back on me regarding weight matters.

Despite having this conversation with her at the outset, I still felt anxiety and dread for my doctor’s appointments going forward. Even though I knew she would not bring up my weight in a negative way or push me to lose weight, the 35+ years of fatphobia I had experienced in the medical space up until then was not so easily erased. After many years of therapy, I’ve come to understand that all of those negative experiences I had with my doctors were traumatic events and that these types of experiences have led to my profound distrust and anxiety regarding physicians.

It wasn’t until about a year ago that I was able to find a doctor who expressly practices Health at Every Size®(HAES), and this has made a huge difference for me. The fact that she truly “gets it” and treats me as a whole person (i.e., not just a number on a scale) has greatly reduced my medical anxiety. I don’t hesitate to reach out to her with my health concerns as I know she will give me sound medical advice that is not tinged with weight stigma. In the event that I need to see a specialist, however, my old fears return, and I have to figure out a way to ensure that I get good medical care.

Many of my patients in larger bodies can relate to my feelings around going to the doctor. Most of them dread going to see doctors because they know that the topic of their weight will inevitably come up. In many cases, these patients have put off getting help for health concerns for fear that they will be weight-shamed. One of my patients struggled with indigestion for months before finally seeing her doctor only to find out she had multiple ulcers. Unfortunately, this experience is not unusual for fat patients. These kinds of instances are often noted as “noncompliance” in medical charts, further promoting the false idea that fat patients are to blame for their health issues when it is really weight stigma at play.

Over the years, I have worked with a number of patients on advocating for themselves in medical settings. In most cases, these strategies are successful, leading to the patient receiving respectful, weight-neutral care. I thought it could be helpful to share these strategies with our readers.

One strategy that has proven to be quite successful for my patients is reaching out to the new provider via email or the patient portal before their initial appointment. I have a template email that I recommend for my patients, but of course it’s best to tailor it to one’s own particular circumstances. In this initial message, I recommend telling the doctor that you are looking for weight-neutral care and providing examples of what that looks like. Some examples are not prescribing weight loss as a health intervention, not weighing the patient unless it is medically necessary (e.g., for proper dosage of certain medications), and not telling the patient the number if they do need to get weighed. In addition, it can be helpful to tell the physician that you have been practicing the concepts of HAES and intuitive eating and that you are happy to provide them with resources if they are interested in learning more.

Sometimes even if you have messaged your physician directly, that message does not get relayed to the rest of the medical staff. This can result in the staff being unaware of your no-weighing preference and lead to an uncomfortable situation at the first appointment. To lessen the chances of this happening, some of my patients have reached out to the medical office manager or the primary care nurse at the doctor’s practice ahead of time to specify that they do not want to be weighed at their appointments. You can also ask them to note it in your chart that you do not want to be weighed so that the staff is aware.

In the event that you are unable to reach the physician or medical office manager before your appointment, many of my patients have found it helpful to bring “Don’t Weigh Me” cards with them to their appointments. These cards were created by Ginny Jones, the founder of more-love.org, an online resource for parents who have kids with eating disorders. Ginny explains that in her own recovery from an eating disorder, getting weighed at the doctor’s office was always a major stressor for her. After investigating whether one needs to be weighed at every doctor’s appointment (hint: you don’t), she found that not being weighed at the doctor’s office greatly reduced her stress when going to these appointments. Ginny created small, wallet-friendly cards that you can use to facilitate the conversation with healthcare providers about not being weighed. Even if you don’t end up giving the card to your doctor, it can be helpful and empowering to look over it while in the waiting room prior to your appointment.

For some patients, even doing the above is not sufficient to allay their fears. In these cases, I recommend bringing a supportive family member or friend to the appointment as an ally. Ideally, this person should be someone who understands HAES and will help you advocate for yourself if you face weight stigma. Even if this person does not end up needing to intervene in any way, just having them next you can be an enormous help. When our bodies are flooded with anxiety, it’s often hard to remember all of the details relayed to us by our physician, so having someone there with you to take notes or ask follow-up questions is a helpful strategy.

Sometimes even doing all of the above does not work, and patients are still subjected to weight stigma at the doctor’s office. In these cases, I remind my patients that they have the right to find a different doctor who will respect their wishes regarding weight-neutral care. Though weight-neutral providers are few and far between, if you can find a fat-positive network in your area, often there will be a referral list of recommended providers (and ones to avoid). For instance, I am a member of the “Boston Area Fatties Meetup” Facebook group (a fat-positive group in Massachusetts), where members can ask for recommendations for fat-friendly doctors and other providers. This group also has an excel spreadsheet of fat-friendly providers in Massachusetts which can be searched by type of provider and location.

Currently, the Association for Size Diversity and Health (ASDAH) is working on compiling a list of fat-friendly providers into a database called the Health at Every Size® Provider Listing Project. According to the ASDAH website, they are working to create a better and more comprehensive listing of healthcare providers who are especially sensitive to the needs of marginalized groups including “Black people, trans people and superfat and larger people.” ASDAH has also provided a timeline of the different phases of this project, and currently (March 2023) they state that they will be launching their “new and improved” listing beta. We will be sure to keep you posted when the HAES Provider Listing is available for use.

Pancakes

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Some months, coming up with a newsletter topic is unusually challenging. For the last few weeks, Joanne and I were both scratching our heads, as the ideas we had were for research pieces that would demand more time than either of us is able to dedicate at this point in time. Being silly, I facetiously asked our four-year-old daughter what I should write about this month. “Pancakes,” she responded, “Pancakes and maple syrup.” Joanne and I laughed, and I walked out of the room, but I quickly returned and told them I was going to use her idea.

Our daughter’s suggestion reminded me of a quote from one of my earliest patients many years ago, and what the latter said to me felt significant enough that I wrote it down as soon as she left my office. “One day, you will have a baby boy who will love you,” my patient said, “and then he will grow up to hate you. But then one day he will love you again and say, ‘Hey, Dad, let’s go out to breakfast, just us guys,’ and then you will go to Bickford’s, and you will have an apple pancake, too.”

At that point in my career, I was still doing the kind of work that most people figure dietitians do: putting people on diets in the pursuit of weight loss. My prescribed diets were low in carbohydrates, especially grains, and so restrictive of calories that if my patients were living in a different region of the world, the United Nations would have sent cargo ships full of food to help them. While I did not author these diet plans, which seemed concerning to me at the time because of their restrictive nature and the good/bad food dichotomy they established, I did dole them out as instructed, and for that I have nobody to blame but myself.

These diet plans typically “worked” in the sense that my patients lost weight, but rarely – if ever – did the weight suppression last long term. At the time that I left the medical center where I was working and stopped doing that kind of work, I did have some patients who had maintained their weight loss thus far, but I have no idea what happened to them later. Given that most weight regain happens two to five years after baseline, I can only assume that at least some of these patients, if not all of them, regained weight after I was out of the picture.

Diets fail for a number of reasons. Most significantly, the physiological mechanisms that kept our ancestors alive through periods of starvation kick in when we restrict and promote weight regain. Another factor, the one that my patient was trying to make me aware of via her aforementioned quote, is that diets are incompatible with real life. After all, if I were following the low-carb, low-grain, low-calorie diet that I had put her on, I would be unable to both remain on the plan and partake in her breakfast scenario. The dietary expectations I had set out for her were unrealistic, which was exactly the point she was trying to get me to see. Point taken.

Now that I am a dad myself, I have greater first-hand life experience to reinforce my theoretical understanding. Numerous times over the last few years, I have eaten foods I was not in the mood for because sharing an eating experience with my daughter was more important to me than eating exactly what I wanted. For example, the food at Chick-fil-A rarely sounds good to me, and I certainly would have preferred something else for dinner last Tuesday night, but I took her there because she loves it, she asked me if I would take her, and I prioritized making her happy and sharing one of her favorite meals over eating what I really wanted.

If I was on some diet plan that restricted foods like Chick-fil-A, such as the plan I had given to the patient in question, I would have had to choose between breaking the diet or missing out on a family bonding experience. When I was a young adult and somewhat orthorexic, I prioritized “healthy behaviors” to the detriment of other important areas of my life. After turning down plans with friends so I could exercise after work and go to bed early, some of them began to distance themselves from me and stopped extending invitations. My insistence on only eating food I had brought from home kept me from joining co-workers for lunch, and my rapport with them weakened. If you have ever been on a diet yourself, consider the ways in which sticking to the plan came at the expense of other facets of your life. My guess is that if you look back, you will find examples in your own life similar to the ones I just described.

Furthermore, remember how you felt when you inevitably deviated from your diet. In Reclaiming Body Trust, authors Hilary Kinavey and Dana Sturtevant succinctly describe the pattern of dieting with a diagram that they entitle “The Cycle.” At the 12 o’clock position, the circular diagram begins with “The Problem,” which then leads to “The Shame Shitstorm” at three o’clock, followed by “The Plan” at six o’clock, then “Life” at nine o’clock, and then back to “The Problem” as the pattern indefinitely repeats. Delving into the particulars of these positions is beyond the scope of this blog, but the overall pattern is one to which many of us can relate: We identify a problematic eating behavior, feel bad about it, desperately grab for a plan that will supposedly rescue us from ourselves, abandon the plan when it proves itself to be incompatible with life, and the cycle repeats.

If a diet puts us in a position to choose between (A) sacrificing important parts of life, such as sharing a bonding experience with our kids, in order to remain on the plan, or (B) breaking the diet and perpetuating a cycle of shame and unsustainable attempts to deal with our problems, then perhaps dieting and living a full life are simply incompatible.