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.

Biting Lollipops

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

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

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

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

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 For example, over the summer, one of my patients received weight loss advice from their doctor, guidance that is outdated and highly unlikely to achieve the doctor’s expected results.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

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

We are all going to die!

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

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

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

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

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

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

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

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

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

Cottage Cheese Is Having A Moment

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

 

Cottage cheese pancakes (A-)

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

 

Cottage cheese ranch/French onion dip (B-)

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

 

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

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

 

Adding cottage cheese to pasta dishes (A)

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

 

Cottage cheese ice cream (D)

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

 

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

Experimenting With Food

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

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

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

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

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

“Food Noise”

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

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

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

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

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

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

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

The Lingering Effect of Scarcity

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

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

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

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

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

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

A Con Or A Pro?

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At some point in my clinical training, I learned the basic guideline, “When the gut works, use it.” In other words, do not utilize TPN (intravenous feeding) if the gastrointestinal tract is healthy enough for at least enteral (tube) feeding. If the latter is called for, depositing into the stomach rather than the small intestine is better, if medically possible, in order to utilize as much of the gastrointestinal tract as possible. If the patient can eat by mouth, even better.

Working in an outpatient setting, I use meal plans similarly to how clinical dietitians utilize TPN. Both are treatment options that have their place, but better to avoid them if possible. Whereas clinical dietitians resort to TPN only when the patient’s gastrointestinal tract is not functioning well enough to rely on other options, I use meal plans only when a patient’s ability to make sound eating decisions on their own is significantly compromised, as can be the case when one is in the early stages of recovering from a restrictive eating disorder.

In these situations, meal plans can help in a multitude of ways. By making some of the decisions regarding what, when, and how much to eat, meal plans streamline the choices that patients have to make themselves. Rather than patients and their parents arguing over meal compositions and quantities, they can refer to the meal plan, thereby reducing the strain that eating disorders can place on families. When followed, meal plans provide enough nutrition for the body to rebuild itself and hopefully keep the patient out of a higher level of care.

Despite these upsides, meal plans also have their downsides, one of which is that they simplify nutrition to a fault. Rather than specifying what a patient is supposed to eat at a given time, meal plans typically utilize an exchange system that allows the patient to select the foods that fit the indicated criteria. For example, one patient’s meal plan might say to have one protein and one grain at snack time, so then the patient would survey the provided list of foods that qualify as proteins and their respective quantities and decide which one to have, and then they would make a similar decision about which grain to have.

The problem is the oversimplified rounding off necessary in order to force foods with complex nutrient profiles into these basic categories. For example, we classify chickpeas as a “protein” when in reality only approximately 23% of their calories come from protein and 10% and 67% come from fat and carbohydrate, respectively. How does that make sense? Cashews are 19% protein, 42% fat, and 39% carbohydrate, but our exchange list says a patient can count them as a protein or a fat. Huh? We treat all cooked vegetables the same even though spinach is significantly higher in protein than carrots are (48% versus 8%, respectively) and much lower in carbohydrate (41% versus 89%, respectively). What?

But is this oversimplification really a flaw? Consider that many (but certainly not all) patients with restrictive eating disorders are high achievers with perfectionist tendencies, and their disorder drives them to seek out and consume exactly what and how much they believe they are supposed to eat. Part of their recovery entails helping them to understand that a drive for perfection, which might be an asset in some realms of life, is unnecessary and counterproductive when applied to eating.

The human body is adaptable and can thrive under a variety of eating conditions. Some populations rely heavily upon starches, fruits, and vegetables, while others get by subsisting on fatty meats. Looking at our country’s own nutrition guidelines, the recommended ranges for protein, fat, and carbohydrate are quite wide. For example, the acceptable macronutrient distribution range for carbohydrate is 45% to 65% of one’s total energy intake, which is quite broad.

Barring certain medical conditions, we do not need to be exact in our eating in order to provide our bodies with the nutrients they need. In that sense, whether we classify chickpeas as a protein or a carbohydrate, or cashews as a protein or a fat, etc., really does not matter; the body will still receive the nutrition it needs regardless. So, while we could view such oversimplifications as cons, I see them as pros, as they teach and reinforce flexibility and freedom in eating, which are important aspects of recovery, rather than rigidity and precision.

“Why can’t I eat dessert all the time?”

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In our quest to find entertaining and educational television shows for our kindergartner, I stumbled across an animated show on Netflix called “Ask the StoryBots.” In each episode, a child asks a question of the StoryBots, and they try to answer it by traveling to different locations and talking with different “experts” or individuals who might have answers. Most of these questions are about the world we live in, such as “why is the sky blue?” and “how do ears hear?” and they are answered in an accessible way. My daughter and I have found most of the episodes funny, entertaining, and interesting, as the show uses lots of humor and catchy songs to educate its audience. The StoryBots themselves are cute and silly and full of boundless curiosity. And the show also has guest appearances from a number of recognizable celebrities, including Snoop Dogg, Zoe Saldana, and Jason Sudeikis, among others.

When I came across the title for episode 2 in Season 2, I automatically cringed a little bit: “Why Can’t I Eat Dessert All the Time?” Teaching kids, especially little ones, about nutrition can be a tricky thing to do. I remember when our daughter came home from preschool one day and told us that her teacher made her eat lunch in a certain way (i.e., sandwich and veggies first and then dessert), I knew that we would have to step in and explain our food philosophy. The teacher was open to our request to let Lorelai eat her lunch in any order she would like, thankfully. But as the days and weeks went by, we started hearing Lorelai talk about “good/healthy foods” and “bad/unhealthy foods,” phrases we never use in our home, and I knew that it was going to be an uphill battle to maintain her intuitive relationship with food and her body.

Lorelai and I immediately skipped over episode 2 of Season 2 because I was afraid that it would be just another fearmongering treatise on why sugar is bad for us. Later on, I watched the episode by myself, and while I did not find it as harmful as it could have been, it definitely was not ideal.

The StoryBots field a question from a young girl named Lilyn who asks them why she cannot just eat dessert all of the time, as she does not like other food. The StoryBots are stumped and tell Lilyn that they will find the answer to this question and get back to her. The first stop for the StoryBots is at a bakery to ask the baker (played by Christina Applegate) why we can’t eat dessert all of the time. In an attempt to answer the question, the baker rolls out a chalkboard filled with formulaic equations and organic chemistry and begins a very lengthy (and swiftly spoken) explanation, using complicated terms that a child most certainly could not understand. She tells them that “an excess of monosaccharides can have an inherently negative effect on everything from our teeth to our metabolism.” She also explains that given the standardized 2,000-calorie diet, “the ratio of calories to nutrients found within your average sugary sweets deviates significantly from what has come to be widely accepted healthy percentages for what one’s caloric intake should be derived from.” Not surprisingly, the StoryBots are confused and at a loss for words.

Obviously, there is a lot that I don’t love about this explanation, but I especially disliked the part about the standardized 2,000-calorie diet. As we know, the 2,000-calorie standardized diet was created as part of the Nutritional Labeling and Education Act in 1990 as a way of simplifying the nutrition label to make it easier to calculate percentages of daily values. 2,000 calories was settled on after the USDA surveyed men and women and asked them how many calories they ate in a day via self-report. Women reported eating between 1,600-2,200 calories per day while men reported taking in between 2,000-3,000 calories/day. So, using these calorie ranges, researchers decided on 2,000 as it was a “nice round number” that would be easy to use for calculations. That being said, 2,000 calories is an arbitrary amount as we truly do not know how many calories one “should” be eating each day. Some folks need much more and others need much less, and the factors that determine this are largely genetic.

As the StoryBots stare at the baker with utter confusion, Jake the Supreme Cupcake (a cupcake that is a “bad boy”) tells them that they can, in fact, eat dessert all of the time and invites them to join him on a journey. The group ends up at Tummy University, where Jake brings the StoryBots to the Alpha Kobbler Pie fraternity. There the partiers (sweets including cake, Twinkies, and gummy bears) are having a sugar rave and initiating new frat pledges, one of which is a piece of broccoli named Brock. Jake explains that the parties at this fraternity are the best because they are “packed with sugar, which gives you short bursts of energy.” All of the attendees are basically bouncing off the walls and acting “crazy,” which they attribute to being “full of sugar.” Brock finds himself at a ritual initiation called “The Dunk,” where pledges are dunked into chocolate, and he decides to bow out.

At the same time, one of the StoryBots, Bing, gets swept up in the rave and is goaded into chugging a two-liter bottle of soda. Brock warns the StoryBots that drinking a two- liter bottle of soda is bad as “it’s almost 100 times the amount of sugar you find in a carrot!” Terrified, the StoryBots try to stop Bing from drinking the soda, but they arrive too late and find him chugging away. Of course, directly after this, Bing starts acting “crazy” like the others, sliding down the stairs on a sled, doing a cannonball into a glass of soda, etc. The StoryBots look on in horror and ask Brock what they can do. He tells them that they will just have to wait as “sugar gives you lots of energy, but you crash and burn pretty quickly.” Almost immediately, the partiers run out of energy, and all of them have sugar hangovers.

The StoryBots end up leaving with Brock as they do not feel that they got their question answered. Brock also wants to find his place at Tummy University. The group runs into the campus police, who are “healthy fats” including avocado and fish. The police chastise Bing for eating too much sugar and are surprised to see Brock coming out of the rave. The police recommend that Brock speak with Dean Banana who is known to say “every food can make the body a better place.” The police then go on to explain that they are healthy fats that are good for protecting the cells in the body. On the way to finding Dean Banana, the group comes across the “Protein Gym,” where a large sweaty T-Bone steak runs over to the group. He has an Austrian accent (reminiscent of Arnold Schwarzenegger) and tells them that protein is needed for building big muscles, and he challenges them to lift heavy weights. Brock does not feel that this is a good fit for him either.

Next the group comes upon a group of foods (including a bowl of pasta, a loaf of bread, and a potato) lined up at the starting line of a track, getting ready to run a race. Brock tries racing with the group who explain that they are “packed with the good carbohydrates,” which give the body sustainable energy, unlike simple sugar. Brock is unable to keep up with the runners and ends up collapsing at the track and then waking up in a hospital bed at the campus medical center. The doctors are fruits and vegetables and introduce themselves as “vitamins and minerals” that “prevent people from getting sick, make the cells in the body strong, and strengthen the immune system.” The doctors share that Brock’s vitamin and mineral levels are “off the charts,” as he has tons of folate, vitamin C, potassium, and calcium, and they tell him that he would be a great fit at the medical center. Dean Banana shows up and confirms that Brock has found his place among the nutrients. He explains that “while a little bit of sugar tastes good,” it’s protein, healthy fats, complex carbohydrates, and vitamins and minerals that “make people strong, smart, and healthy.” The StoryBots believe that they have finally found the answer to their question and are excited to share it with Lilyn.

Overall, the episode is not completely terrible. It is amusing and interesting and provides some solid nutrition education. What I take issue with though is how the simple carbohydrates are portrayed as “naughty crazy partiers,” while the other nutrients are shows as the “good” ones. Young children have very binary thinking, and setting up this “good food/bad food” dichotomy is not necessarily helpful. The message that children will hear from this is that “good foods” such as protein, healthy fats, complex carbohydrates, and vitamins and minerals are to be put up on a pedestal while simple sugars make you sick. This also gives simple sugars the allure of the forbidden food and can result in children over-valuing these foods rather than just having a neutral place in the diet. Kids are naturally born with the ability to be intuitive eaters, and the more that we intervene and try to push them in the direction of “healthy” foods, away from “bad” foods and scare them about the consequences of eating said “bad” foods, the more likely that they will lose their ability to eat intuitively.

Aside from very general nutrition education, namely telling kids that eating a wide variety of foods will help their bodies grow and feel good, I don’t think that getting into the nitty-gritty of how protein, fat, and carbohydrates function is particularly helpful. In our diet-obsessed culture that demonizes sugar and is responsible for the “childhood obesity epidemic,” these types of messages around nutrition do more harm than good. If you do end up watching this episode with your child, please be sure to explain that sugar is not the enemy and that there is more to food than just the nutrients they contain. Food is about connection, tradition, history and pleasure, not just nutritional content.