“As long as you’re healthy . . .”

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“Health.” It’s a simple one-syllable word with a deceptively simple definition: “the state of being free from illness or injury.” What I have come to realize over the decade-plus that I have been practicing nutrition therapy as a registered dietitian is that health means many different things to different people. Health is not black or white, but a million shades of gray. But the wellness industry (diet culture’s shapeshifted cousin) would have us believe that health is not only easy to define and simple to identify, but also easy to achieve, if we just try hard enough. Well, sorry, it’s not that simple.

When I was a preteen, I remember feeling like my body was wrong, too big, taking up too much space. My mother and I would go to my pediatrician appointments, where my doctor would hem and haw about my weight. I had always trended on the 95th percentile on growth charts, and every year my pediatrician would comment on it in a concerned way. My mom would echo these concerns at home, gently reminding me that my doctor was worried for my health. When I would cry to my mom about being in a larger body than my peers, she would always come back to this statement: “You are a beautiful girl. We could make some changes to how you eat and exercise. I just want you to be healthy.”

“I just want you to be healthy.” These words ring in my ears as they have been spoken to me in different iterations throughout my life. From concerned college friends after I had gained a significant amount of weight during my freshman year (post diet, of course): “We are just worried about your health.” From my first adult PCP when I was 22 years old: “We just want to make sure you are healthy.” From my mom when I announced that I would be going on a low-carb diet at age 25: “as long as you’re healthy!”

Everyone seemed to say that my health was the most important thing and that being healthy meant being in a “healthy-looking” body. When I actively engaged in dieting, restricting, tracking every morsel, weighing myself multiple times a day, exercising even when I didn’t feel like it or was sick or injured, eschewing lunch outings with friends, losing my period – during these times, everyone marveled at how “healthy” I was. “It’s so nice to see that you are finally taking care of yourself!” my family would crow. “Keep going, get healthy!” my doctor cheered. Little did they know the personal hell I was living in. But at least I “looked” healthy. Or at least my body fit the social norm for what we collectively believe is healthy, i.e., it was no longer considered fat. But inevitably as the weight would come back on, the concerns for my health would resurface.

When I finally gave up on dieting and learned about Health at Every Size® and intuitive eating, I was ready to hear the message. At last, I didn’t need to micromanage my intake and output. I didn’t need to obsessively count and weigh and measure. I didn’t have to give lunch outings with friends a second thought. It was like a freedom I hadn’t felt since I was a child, before I was told that I had a body that was “wrong.” I began to realize that health is not one-size-fits-all and that it looks different for different people. With individuals who have chronic illnesses such as celiac disease or cystic fibrosis or those with physical disabilities such as paralysis or amputation, they would never be able to achieve a state of being “free from illness or injury.” How about the millions of people who deal with depression or anxiety? Are they unable to achieve health as well?

I feel that we need to change our beliefs and expectations around health. In my opinion, health is a multifaceted amorphous concept that is not always attainable. It is also something that changes during our lifespan for a multitude of reasons. Even if we engage in all of the “health-promoting behaviors” we have been told to do, there is no guarantee that we will be healthy. In addition, there is no moral requirement for us to engage in these behaviors. As the wise Ragen Chastain so eloquently states: “Health is not an obligation, a barometer of worthiness, completely within our control, or guaranteed.”

The wellness industry loves to prey on our fears of illness and death. It purports to give us the answers to living longer, healthier lives. All we need to do is buy their program, supplement, or detox, and we can unlock the secret to immortality. It’s a brilliant marketing scheme that swindles millions upon millions of people every year. What if we decided to care more about our mental health and wellbeing? What if we made healthcare accessible to everyone? What if we eradicated weight stigma from the medical field? What if we decided that health doesn’t look the same on every body and that this is okay? My guess is the wellness industry would lose billions of dollars. Worrying about and obsessing over our “health” is most definitely not good for us. I wonder when our society will figure this out.

“You have permission to not eat.”

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Some of my patients who are relearning how to eat intuitively find it helpful to utilize a mantra, a phrase they can say to themselves to help them through a challenging situation. Because we often discuss the concept of unconditional permission, “You have permission to eat” is a refrain that my patients commonly use. One of my patients though flipped it on its head and began to use “You have permission to not eat.” At first, I was a bit perplexed, but the more I listened to her and reflected on these words, the more I realized their power.

Having the freedom to allow ourselves to eat whatever we want, whenever we want, and however much we want – otherwise known as unconditional permission – is central to intuitive eating. Without this foundation, everything else we study can easily warp into dieting tools. Given that, I initially bristled at “You have permission to not eat” because I thought it might be a veiled attempt at restriction, but that is not the case at all. Rather, the power in these words comes from acknowledging the times when we feel obligated to eat even when our bodies are saying no and freeing ourselves from the burden of feeling powerless.

As a first example, consider the scenario that my patient told me about when she was explaining the power of her mantra. She was at dinner with her extended family, and all of the latter were leaning towards ordering dessert. While my patient did not feel like having dessert, she also felt a social obligation to order it since others were. Then she reminded herself, “You have permission to not eat,” which reaffirmed that whether or not to order dessert was her prerogative, and she could act in her own best interests regardless of how the rest of her family went about their eating.

Thinking about other possible applications, I realized how helpful this mantra can be for people who feel pressure to not “waste” food. We are familiar with guilt-inducing refrains to clean our plate, such as “There are starving children in the world,” as if whether or not we finish the food in front of us has any impact whatsoever on the global politics of food insecurity. In these moments, “You have permission to not eat” reminds us that we do not have to be human garbage disposals for the sake of some theoretical benefit to others.

My thoughts then went to how this phrase could be useful for people working through compulsive overeating. Recovery is, of course, more complex than simply reciting a mantra, but just as the concept of unconditional permission is essential for diet survivors who are building healthy relationships with food, “You have permission to not eat” reminds compulsive overeaters that they have the freedom to move away from the urges to overconsume that have felt so irresistible.

Lastly, I considered how “You have permission to not eat” can aid those who overconsume due to habit or tradition. Maybe we eat to the point of physical discomfort every Thanksgiving because we have come to accept that this is the norm on the holiday, or maybe we buy popcorn every time we go to the theater regardless of whether or not we are hungry or feel like popcorn just because eating the snack feels like an intertwined and essential component of movie watching. “You have permission to not eat” reminds us that even if we have long engaged in certain eating behaviors, we have the freedom to move away from them if we feel that they no longer serve us.

You may discover other applications in which “You have permission to not eat” is a helpful mantra, but guard against the temptation to use it as a tool to restrict because that would likely backfire and be counterproductive. If you feel yourself tempted to go down that road, remind yourself of the phrase from which this mantra came: “You have permission to eat.”

“What should I do for exercise?”

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When the topic of physical activity arises, a common question I get – especially if the patient knows I used to work as a personal trainer – is some version of, “What should I do for exercise?”

Before I get to my answer, a little history: Back when I was in nutrition school and working on the side as a trainer, I began my relationship with a new client by asking about their exercise-related goals. With their answer in hand, I researched the best (in theory, anyway) physical activity approach towards achieving said goals. Whether or not the client enjoyed my exercise prescription was largely immaterial. I offered a means to an end, and they were going to do what I suggested whether they liked it or not.

Furthermore, my clients hardly seemed to mind my approach. They expected trainers to have a no-pain-no-gain mentality, an element of an exercise-as-punishment culture that is so harmful yet prevalent, and I was giving them what they thought they deserved. Clients wanted clear and crisp answers, and I was providing them. Whether I was right, wrong, or somewhere in between seemed a distant consideration to the reassuring comfort that came with being told what to do.

At this point, I should add that I was a fairly horrible personal trainer. With hardly any experience, little oversight, and no mentors, I was on my own to take what I had learned in academia and apply it to the real world. Humans, it turns out, are way more complicated than straightforward case studies in a textbook. Clients became burnt out, got hurt, lost interest, or dropped off for other reasons, and they almost always blamed themselves instead of my flawed approach.

If that sounds similar to how dieters tend to place the blame for weight regain on themselves rather than on the diet, know that the parallel stands out to me too. Just as I cringe at the way I used to train clients, I am embarrassed and ashamed of how I practiced dietetics at the beginning of my career. The difference is that I have been a dietitian long enough to have outgrown those painful beginnings, whereas I worked as a trainer for such a short time that just when I was beginning to recognize my mistakes, it was time to move forward in my career.

When patients ask me about exercise, I now know that the straightforward answers they want and expect – the very kind of answers that I used to provide as a trainer – are not all that helpful even if they would be welcome. Just as is the case when it comes to our relationships with food, our relationships with physical activity are nuanced and unique. The answers come about through discussion and collaboration. Here are five factors that I encourage my patients to consider:

  1. Enjoyment: My decision to lead with a factor that is often shoved towards the end of the priority list or set aside entirely – yet in my eyes is so essential to consider – is a conscious one. If you do not like doing an activity, how likely are you to sustain it? If you repeatedly put yourself through an unpleasant experience, what kind of ripple effects will that have in the rest of your life, whether it be seeking out rewards, being in a bad mood, etc.?
  2. Risk: We can get hurt doing literally anything, but some activities are riskier than others. Injury risk also depends on the person in question. For example, some people can run their entire lives, whereas a friend of mine had to give it up due to a recurring injury that arose whenever he attempted to resume jogging. Risk extends beyond musculoskeletal concerns and includes other factors, such as a maximum heart rate that a cardiologist may suggest their patient not exceed.
  3. Access: If you enjoy swimming but cannot afford a pool membership, or you like walking but live in a mosquito-infested area without sidewalks, or you are into a team sport without a league in your area, you will face more challenges than someone with ready access to the facilities and opportunities they need.
  4. Goals: Choosing activities that advance us towards our goals increase our chances of achieving them. An aspiring strongman will get little benefit from participating in cycling brevets, whereas someone with osteopenia in their hips may be better off skipping both of those pursuits entirely and instead going for a walk.
  5. Options: Remember that physical activity is comprised of more than just “exercise” in that the latter typically conjures images of things like elliptical machines and dumbbells, whereas the former is broader and can include gardening, cleaning, shopping, dancing, hiking, chair yoga, isometric contractions, and anything else that engages the body.

So, what should you do for exercise? Look for a mode that you enjoy, have ready access to, makes you physically feel good, and helps you towards your goals. Whatever your answer is, that is what you should do for exercise.

An Open Letter to Daycares, Preschools, Nursery Schools, and Elementary Schools

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We so appreciate the care you take of our little ones. In fact, I am sure that most parents would agree being able to send our kiddos to daycare, preschool, and/or elementary school is a huge factor in maintaining our sanity. The way that you help our children learn, grow, and adapt is amazing, and we are grateful for you. Having said all this, we need to talk about the policing of our kids’ food in school.

Lately, I have begun hearing more and more from parents whose kids are being sent back home with notes about their packed lunch. One parent received a phone call from a daycare saying that they were not going to give her daughter the 10 M&Ms that she had packed in her daughter’s lunchbox because they were “unhealthy.” Keep in mind, this mom had the forethought to pack in her daughter’s lunch The Feeding Doctor’s lunch box card stating that she did not want the staff to interfere with her daughter’s eating of lunch and that her daughter is allowed to eat any or all (or none) of the foods packed in the lunch in any order she wants. The staff overruled these directions and said that candy is “frowned upon” in their program.

Listen, I get it. In our fatphobic, diet culture world, we’ve been taught that sugar is the enemy. That if we give it to our kids, they will turn into sweets-addicted, hyperactive lunatics who will be out of control, that their bodies will balloon up like Violet Beauregarde in Willy Wonka’s Chocolate Factory, and that their teeth will fall out due to cavities. As a registered dietitian who has a Master of Science in Nutrition and Health Promotion with over a decade of experience in the dietetic field, I’m here to tell you that all of this is false.

Kids are naturally born intuitive eaters. Newborn babies cry when they are hungry and drink breastmilk (or formula) provided by their caregivers until they are satiated. They are perfectly in tune with their bodies’ cues and eat in response to them.  As babies grow and they start eating solids, they continue to eat intuitively. If you’ve ever tried to get a baby to eat anything they don’t want to eat (I’m looking at you, strained peas.), you know they just won’t have it. As kids reach toddlerhood, often their eating habits become erratic. Some days, it seems like my daughter barely eats anything, but on other days, she appears to eat more than a grown adult. Despite this seeming chaos, our kids’ bodies know what they are doing. While meals might seem hit-or-miss during one day, it’s best to look at our kids’ eating over a period of days as things will usually average out.   

Kids usually remain intuitive eaters until the adults in their lives start interfering with their food. Whether it be pressuring kids to take “one more bite” at dinner even if they are no longer hungry, limiting their access to sweets and other highly palatable foods because they are “unhealthy”, or expressing concern about their eating “too much,” parents and other adults can really throw a monkey wrench into their kids’ relationship with food.  Many parents worry about their kids gravitating towards foods that are high in fat, sugar, and/or salt because they themselves have a complicated relationship with those foods. In reality, if we relax around these foods and include them regularly with more “nutrient-dense” foods, we can neutralize them and take the “shine” off of them as well. In my work with kids and families, it’s the kids who are the most restricted around highly palatable foods that end up bingeing on them when they get the chance, sneak eating them in their room, or being hyperfixated on them at their friends’ houses. If we teach our kids that food has no moral value (i.e., eating vegetables doesn’t make you a “good” person and cookies aren’t the devil’s food), they will be able to make choices about what and how much to eat based on their internal hunger and fullness cues.

In addition to being natural-born intuitive eaters, young kids have very binary thinking. That is, when we present them with the idea that there are “good” foods and “bad” foods, they take this information quite literally and are unable to see the gray. So many children feel guilt or shame for enjoying “bad” foods because they feel like they are bad for eating them. This is setting our kids up to have a very charged emotional experience around these foods which can continue on into adulthood for many of them.  If we teach kids that all foods fit and that the most important thing is getting a good variety of all sorts of foods, we can help foster their relationship with food and their bodies.

Another thing to consider is the concept of helping our kids become “competent eaters.” Coined by child feeding therapist and dietitian Ellyn Satter, competent eaters are those who eat in accordance with their hunger and fullness cues while taking into consideration their bodies’ needs and preferences. Parents’ (and caregivers’) role in this process is to be in charge of certain aspects of meals and snacks. Satter’s Division of Responsibility further clarifies that parents are in charge of what food is being served, when and where this food is offered. Meanwhile, kids are responsible for whether they choose to eat the food provided and how much they want to eat of said food. Ideally, parents offer their kids a variety of foods, including both highly palatable foods and foods that are more nutrient dense, and then let their kids eat in accordance with their bodies. This model posits that interfering with kids’ eating by cajoling them to eat more vegetables, discouraging them from eating other foods, or even praising them for eating more nutrient-dense foods will lead to power struggles at the dinner table.

So what can we adults do to help our kids develop a healthy relationship with food and their bodies? Here are some strategies:

  1. Avoid categorizing some foods as “junk” or “bad” and others as “good” or “healthy.” Food is just food and does not have moral value. Food is only “bad” if you are allergic to it or it is rotten or spoiled.
  2. Parents need to provide a wide variety of foods to their kids, including regular access to highly palatable foods in order to take these foods off the pedestal and make them morally equivalent to more nutrient-dense foods.
  3. Caregivers at school should refrain from pressuring kids to eat certain parts of their lunch before letting them eat other parts (e.g., “You need to finish your sandwich before you can have your cookies.”) If a child wants to eat their cookies first, please let them.
  4. Caregivers at school should also avoid confiscating food from kids’ lunchboxes unless those foods are an allergy or choking risk. If the parents packed the lunch, please respect that they know how to feed their kids.  
  5. Finally, school caregivers, please be mindful about sharing your own food anxiety with kids. Kids should not be hearing about your latest diet or how you don’t allow yourself to eat X, Y, or Z. Children are like sponges and absorb all of this information.

Again, thank you for everything you do for our little ones. We are so grateful to have you in our kids’ lives. Let’s help our children develop a healthy relationship with food and their bodies by setting a good example and not letting diet culture into the classroom.  

Weight Stigma in Healthcare Harms Us All

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The following is a guest blog written by Deirdre, who has given us permission to use her real name.

All my life, I’ve been sick. I can remember being five years old and waking up in the morning sobbing because my eyes were swollen shut, I could not breathe, I was always tired, and had severe skin conditions and rashes all the time. I had to go on nasal sprays, steroids, oral allergy medicines, and eye drops almost year-round from that age. Around the age of 14, I started to present with vomiting up bile every single solitary morning before proceeding with my day. Despite complaining to doctors all my life about all these things, I was ALWAYS considered healthy. The number one indicator for doctors? I was thin. I always had a “healthy” BMI, and all my bloodwork looked good, so nobody ever took me seriously.

Fast forward another decade. At this point, my body was so inflamed from consuming gluten – a protein which I later found out I was severely allergic to all along – that I had gained a significant amount of weight. I was 24 years old at this point, vomiting and having diarrhea after every single meal, suffering with mental illness (depression and anxiety, some from trauma but also largely because I *never* felt well and had no choice but to press on), smoking cigarettes constantly to suppress my appetite, abusing Adderall to suppress my appetite, exercising excessively (3-5 mile runs, 10 on weekends, and 2-hour workouts daily). Doctors still would not listen to me.

When I was thin, my health complaints were ignored because I was thin. When I was big, my health complaints were ignored because I was big. This is how weight stigma harms people of all sizes. When doctors are trained to view the BMI as such a strong indicator of our health, they tend to miss out on treating the whole patient and the concerns they are actually presenting. In this way, fatphobia continues to dominate our medical fields in the most insidious ways, regardless of a patient’s size.

When I was younger, I felt like my only sustainable solution was to put restrictions on my eating. I felt like I needed to do everything in my power to just not really eat. The only thing that ever felt good to me was mint chocolate chip ice cream. It was the one food that never made me sick. I ate a pint of it nightly, then would feel guilty, throw up the next morning involuntarily, feel good about that because I was disordered in my eating habits by then, and the cycle of “weight management” continued to wreak havoc on my life and destroy my gut health, self-esteem, and brain chemistry.

At 25, I was accepted to my dream graduate school for my health degree, and thus I was always in Boston. This meant finally seeking out primary care at Fenway Health and getting a fat-positive, conscious, and compassionate doctor for the first time in my life. Dr. Karen Kelly literally saved my life, as I know I would have attempted suicide that year if I had not met her. I was at my wit’s end.

Karen’s team allowed me to face away from the scale when they took my weight. I told Karen all the symptoms I’ve always had. She referred me to an incredible gastroenterologist who finally listened to me and tested me for a bunch of autoimmune gastroenterological diseases.

Notice that only now, because I finally was seeing a fat-positive doctor, was my weight looked past in order for me to receive the care I truly needed. My current health care team, including Karen, is amazing. It is a shame that all the doctors I ever saw prior assumed that being thin meant I was healthy. That mentality destroys a doctor’s ability to see clearly, and my chronic autoimmune disease was completely missed for 25 years as a result. If my celiac disease had been caught sooner, it could have meant avoiding severe damage to my organs, and possibly even reduced my chances of long-term health implications. Now I have to live with whatever damage has been done.

More and more public health research is finally showing that fat people can be healthier than thin people. More and more people are catching on that the BMI as a marker of health is a limited, archaic, outdated, weak, inaccurate, and frankly incredibly lazy way to approach medicine. It is a way for doctors to not do their jobs. All doctors should first and foremost be researchers and scientists listening, looking, and hypothesizing with open minds. I am almost the heaviest I have ever been now, yet my cholesterol, blood pressure, oxygen, etc., are all fantastic.

The concept of weight management is a barbaric and inhumane way for any doctor to practice. One hundred years from now, we will look back at the ways we tried to force mutilation on humans through diets and bariatric surgeries and see the oppressive reality of that kind of hatred of fatness. Doctors that focus on “weight management” and miss what is really going on need to start being held accountable – sued and fired by their patients.

I think that numbers are detrimental, and so is excessive monitoring of size and shape. We came here to live in these sacks of skin as vessels for our non-physical selves, our souls, and nothing more. The BMI is bullshit and was invented by an astronomer in the 1800s who only used white Anglo-Saxon males in his sample size. BMI does not account for muscle mass, bone density, or genetics. It does not leave room for all the boobs and butts and hips our bodies create to cushion us or to grow or feed our babies.

Someday I will have chapters in a book titled “the BMI is racist,” and “the BMI is sexist.” Once I am a doctor or nurse practitioner, I will create a new tool for epidemiologists to test that will actually be inclusive of all sexes, genders, races, etc., without poisoning our minds with self-doubt and self-mutilation.

If I had unbiased doctors all my life, I may have been diagnosed with celiac disease much earlier on and could have potentially saved myself from having cancer or infertility someday. I hope to live a long life and to have children and grandchildren, and I hope to leave them in a world with less weight stigma and more active listening, especially in the field of medicine.

Randomly Targeted

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One of the best books that I have read for professional purposes is Aubrey Gordon’s “What We Don’t Talk About When We Talk About Fat.” Although I have listened to countless patients detail what it is like to have a large body in our fatphobic society, Aubrey’s book helped me to grasp more deeply the contrast between weight stigma and thin privilege.

Some of Aubrey’s stories are wild enough to strain credulity, such as a stranger approaching her in a grocery store and taking food out of her shopping cart without permission due to supposed concern for the author’s health, yet I believe her. A couple of years ago, a Black friend of mine explained to me that Blacks have been complaining about police brutality for decades, but it took the widespread prevalence of cellphone cameras and their resulting videos to convince white folks that the problem is real. His words hit me hard, I learned from them, and I do not need to see video of someone stealing fruit from Aubrey’s cart to believe that this happened to her.

The crux of the book’s fourth chapter, “On Concern and Choice,” is that some people express concern about someone’s weight for supposed health reasons, in part because they believe body size to be a choice – which, for the most part, it is not – something that one can manipulate if convinced that their current size is a problem. Furthermore, their expressed concern is really not about the person to whom they are talking, but rather an indication of the fears they have about their own bodies. In other words, if we acknowledge that body size is largely out of our control, then we also have to face the reality that our own bodies might change in ways that we do not want them to despite our best efforts to keep them the same. That prospect scares the crap out of many people, who find it easier to pretend we have more control than we really do.

This chapter resonated because it hearkened back to the allegations people have directed at me upon learning that I used to have a spinal tumor. Surely you have a family history of such issues, they insist. No. You grew up under high-voltage transmission lines. Wrong again. You overdid it in the weight room. Eye roll. The list goes on. As each assertion is met with a negative response, the concern on their face grows. It took me a long time to figure out what that expression is about, but now I understand that when the ideas that the tumor’s cause was my own doing or something unique to my circumstances are struck down, people then realize that the condition can develop in anyone’s body – most notably their own.

Humans, we are a funny bunch. Our antennae go up a bit higher when we feel like something might affect us rather than just other people, do they not? Think about horrible stories we read about violent home invasions in our community. While the crimes and our thoughts for the victims may be similar either way, contrast how you feel when an article concludes, “The police say the parties were known to each other,” versus, “The police believe the victims were randomly targeted.”

Outer Limits

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A little over six years ago, I wrote a blog entry in which I attempted to rebut the notion that discussing topics other than food in our sessions somehow qualifies as psychology. In reference to intuitive eating, I wrote, “What does it say about how disconnected our culture teaches us to be from our internal signals regarding eating that an approach that encourages us to pay attention to said signals triggers connotations of therapy?”

After reading the blog, a friend of mine – a clinical psychologist himself – offered something along the lines of, “Maybe the reason your work is effective is because you include some psychology.” No, I bristled. Staying within my scope of practice is important to me, and certainly anything that qualifies as psychology is beyond what a dietitian can offer, I reasoned.

Given that, I have occasionally second-guessed myself when conversations with patients have strayed into more distant orbits around food. On one hand, I have tended to listen to my instinct to prioritize what my patients want to discuss and to follow the natural flow of conversation so long as what we are talking about ultimately relates to their eating. On the other hand, when conversations become less about nutrition and more about things like body image, weight stigma, or even happenings in someone’s life that are tangential to their eating, I have worried that perhaps I have inadvertently crossed the line from where a dietitian’s work ends and that of a therapist begins.

Then along came a session at the 2021 Multi-Service Eating Disorders Association (MEDA) conference that alleviated my worry and helped me to see the matter in a different light. In their talk, entitled “Staying in Your Lane – Until You Can’t: Balancing Scope of Practice and Competent Client Care,” Anna Lutz and Sandra Wartski, a dietitian and psychologist, respectively, delved into the issue of professional bounds.

One of the most validating concepts that I took away from their talk is that there is no crisp line separating the work of the two professions, but rather there is an overlap, a gradient that bleeds from one realm of expertise into the other. In other words, some topics, such as weight stigma, are appropriate for discussion with both a dietitian and therapist, and each practitioner can bring different perspectives that hopefully complement one another.

Furthermore, scope of practice is amorphous, fluid, and depends on context, such as an individual patient’s needs at a specific moment in time and the practitioner’s own comfort level. Sometimes a patient is unable to address the work at hand, and simply having a human connection is more constructive. Anna gave an example of a time when a patient was too preoccupied with other matters to discuss food, something I have experienced with patients of mine on occasion, so they spent the entirety of their appointment talking without ever discussing the patient’s eating.

Having said all that, scopes of practice can only stretch so far. If a patient raises an issue that is beyond my ability to expertly handle, such as a disclosure of trauma that they are hoping we can process together, I am responsible for making my limitations known. Similarly, a good therapist knows better than to delve into the specifics of nutrition. Part of the reason why collaboration between treatment team members is so important is because we can let each other know when something comes up that is better handled by the other practitioner.

For me, their talk validated my intuition and reassured me that the way I approach my work is well within my professional bounds. For our patients who are reading this, I hope hearing about their session resolves any lingering questions you may carry about possibly having overshared and similarly serves as encouragement to remain open going forward.

 

Reentry

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It’s hard to believe that we have been living in this pandemic for over a year. In some ways, it feels like the year flew by, but in other ways, it feels like 10 years have passed. Jonah and I have been lucky that we have been able to continue seeing patients remotely during this time. And we are fortunate that no one in our immediate family has gotten COVID. We’ve spent the past year plus ordering our groceries online to avoid going to the store, drastically cutting back on getting together with friends, and playing little to no tennis (only outdoors). Our daughter, who is nearly three years old, has not had that much disruption in her life, unlike school-age kiddos. While we had planned to put her into a nursery school in March of last year, we decided to hold off until we felt it was safe. Our tentative plans are to send her to preschool in the fall. Aside from having to wear masks outside, she has been blissfully ignorant of the pandemic.

Jonah and I were also lucky in the fact that we were able to get our COVID vaccinations back in February because we are healthcare providers. This has been a huge relief, although it hasn’t changed our behavior that much. We still get most of our groceries delivered, aren’t eating indoors at any restaurants, and are limiting our socializing to outdoors. But we know that as the summer approaches, things will likely start to loosen up. More and more people will become vaccinated, outdoor activities will be more prevalent, and we will have more opportunities to socialize with friends and family.

While part of me is excited to start getting back to “normal,” I also have some anxiety about it. Like many people, I know that my body has changed over the past year. My pants are fitting a bit snugger, and my body just feels different. I’ve had to buy some new clothes to accommodate the changes, which has felt hard. And sometimes I feel my internalized fatphobia bubble to the surface. I worry what people will think of me when they see my larger body. I worry that others will judge me for weight gain over the past year. I worry that I won’t be good at playing tennis anymore. I worry that this body won’t be able to do the things it was able to do previously. I worry that I won’t be able to fit into different spaces.

I know that I am not alone in this anxiety around resurfacing post pandemic. Many of my patients have experienced changes in their bodies over the past year. We have all gotten used to seeing our friends, family, and co-workers via computer, with our views limited to the shoulders and up. It’s been a while since we have been fully visible to people other than family. In some ways, it has been nice not to worry about how our body might look to others. I know that I have seriously gotten used to wearing leggings and sweatpants to work every day, and it will be difficult to go back to office attire once we start seeing patients in person again! Telehealth has also made it easier for me to really focus on my patients, rather than being distracted by my own body.

One thing that I also have had to remind myself about is stress and its effects on weight. Our bodies are unbelievably smart, and when they are under stress (whether being chased by a sabretooth tiger or, you know, dealing with the uncertainty and fear of a pandemic), certain chemical processes are put in motion. One of these chemical processes is an increase in the stress hormone cortisol. When we are stressed, our adrenal glands release adrenaline and cortisol. Cortisol kicks off a release of glucose (our bodies’ primary source of energy) into the bloodstream in order to provide us more energy as part of the “fight or flight” response to dangerous situations. Increased levels of cortisol also cause an uptick in insulin levels, which results in our blood sugar dropping. As a result of this drop, we tend to find ourselves gravitating towards more energy-dense foods (i.e., foods high in carbohydrates and fat). This process also slows down our metabolism and increases our propensity to store fat in preparation for the next threat. All of these mechanisms have been in place in the human body since the beginning of time as a way of helping us survive. So it should be no surprise that many people have experienced weight gain over the past year as a result of living through an unprecedented pandemic. It’s our bodies’ way of trying to survive.

When I find myself perseverating on my body changing, I try to remind myself to breathe. Bodies change. That is what they do. Our bodies will change throughout our lifespan. It doesn’t need to signify something negative. My body has gotten me through this past year – it has survived a freakin’ pandemic! That, in and of itself, is an amazing feat. My body changed for myriad reasons, many of which I don’t know. Maybe it was ordering more takeout, playing less tennis, not leaving the house as much, feeling more stressed and anxious, or maybe it is just plain old middle age. In the end, it doesn’t matter. There doesn’t need to be a reason for my body changing, and there really isn’t anything I can (or should) do about it. I will continue to take care of myself and my body the best ways I know how, to give myself some compassion around reentering the world and remember that this amazing body has gotten me this far. I hope that your reentries go well too.

Exercise Checklist

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Exercise. The word alone carries a lot of meaning for many of my patients. For some of them, exercise is something that feels compulsive, that if they did not do it every day, they would feel panic. For other patients, exercise brings up old memories from childhood, such as when their parents forced them to exercise. One patient told me that when she was just eight years old, her father made her go for a run every weekday for 30 minutes to “help” her lose weight and be “healthy.” Not surprisingly, this patient has an utter hatred for running now. The word “exercise” itself can be triggering for some people as it feels intrinsically linked to diet culture. As we all know (insert sarcasm), exercise is “good for you” and therefore the more the better. “No pain, no gain” is another message that diet culture tells us about exercise. In other words, if it doesn’t hurt, you aren’t doing it right.

In my work with patients who struggle with compulsive dieting, disordered eating, and eating disorders, the question of exercise often will come up after much progress has been made with eating. A great number of my patients feel afraid to start exercising again for fear that they will get sucked back into diet culture. These patients worry that they will not be able to view exercise as something enjoyable and not required. They have concerns that their old thoughts about weight loss will start popping up again as they have associated exercise with changing their body. Some feel just completely overwhelmed at the idea of moving their body in a way that feels good because they had been so used to suffering through boring, pain-inducing workouts. And still other patients are at a loss as to what physical activity they actually enjoy.

One tool that many of my patients have found helpful is a “checklist.” It is a list of questions to consider before engaging in physical activity. The goal of this list is to help the patient check in with their body and decide whether or not they want to be physically active, and if so, what kind of activity would they like to engage in. Here is a basic checklist:

  • Am I injured or sick? If the answer is yes, then it is likely that you should be resting and not pushing yourself to be active.
  • Have I eaten enough in order to do this physical activity? Am I hungry right now? If you have not been consistently feeding yourself, exercising would be contraindicated as doing so could put a lot of stress on the body. If you are hungry, then you should eat.
  • Am I well-rested? If not, you might be too tired to be physically active right now. Perhaps your body needs a nap.
  • What am I looking to get out of this physical activity? Different forms of exercise can help our body improve endurance, strength, or flexibility. And sometimes physical activity can boost one’s mood via stress relief.
  • Do I feel like I have to do this physical activity in order to deserve food today? If you feel the answer is yes, try to reframe this thought. You deserve to eat no matter how much or how little you exercise. You do not have to “burn it to earn it.”
  • Am I using this activity as a way to try to lose weight or change how my body looks? Again, if the answer is yes, then some body image work could be indicated. Instead of asking yourself “how will this activity change my body?” try asking yourself “how will this activity make my body feel?”
  • What kind of activity would I like to engage in right now? Do I want something high intensity like spinning, something low impact like walking, or something very relaxing like yoga nidra?
  • If I don’t feel like moving my body right now, what else can I do? Maybe taking a nap or talking to a friend would feel best right now.

The checklist looks different for each patient, but at its core, it is about checking in with your body and trying to listen to what it is telling you. The more that we can practice checking in with our body around its needs – including but not limited to food, physical activity, sleep, and stress relief – we will be able to develop and foster body trust.

Here Comes Mr. Greedy

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When I ask my patients to look into their pasts and tell me about the origins of their weight stigma, they can sometimes trace back and point to influential entities, such as a parent, teacher, doctor, or coach. In relatively rare cases, they can recall specific interactions, such as Joanne’s doctor telling her to “get skinny,” or my neurologist cautioning me that if I ever thought about “slacking off” in my exercise routine, I should remember the conversation we were having right then.

Most typically though, patients cannot point to anything. They look at me befuddled, as if I asked a Red Sox fan how they came to know that the Yankees suck. Like, aren’t Bostonians just born knowing that? No, they are not; nor are we born prejudiced against fat people. Both mindsets are learned.

Just as dislike of the Red Sox’s longtime rival is ubiquitous throughout the metropolitan area, so is weight stigma in our culture at large. We develop sports team allegiances from a young age via various sources – jerseys in elementary school, endorsements, televised games, familial preferences passed down – and the biases that we hold against people of higher weights were shaped from so many sources that no singular one tends to stand out in our memories.

And these sources get to us when we are young. Our daughter loves books and has an extensive library of reading material geared towards toddlers her age. In a boxed set of children’s books from the late Roger Hargreaves, Joanne intercepted one entitled Here Comes Mr. Greedy, which shows a cartoon of a fat man on the cover. Subsequent pages describe this rotund individual as “the greediest person I’ve ever met,” that he constantly thinks about food, and he is so “greedy” that he throws a birthday party for himself every week so he can regularly have his favorite food: birthday cake.

This is just one book that Mr. Hargreaves wrote that features his Mr. Greedy character. Another one reads in part, “In fact, Mr. Greedy loved to eat, and the more he ate, the fatter he became. And the trouble was, the fatter he became the more hungry he became. And the more hungry he became the more he ate. And the more he ate the fatter he became. And so it went on.”

Nothing against Mr. Hargreaves, who seemingly dedicated his professional life to creating content for children. Like most of us, he was an apparent victim of a fatphobic culture. Mr. Hargreaves presumably absorbed erroneous stereotypes about eating behavior and body size and repackaged them for preschoolers, thereby perpetuating the generational cycle of fat hate.

Sparing our offspring from weight stigma is certainly an uphill battle, but parents have the ability to take mitigating actions.

For starters, parents can minimize exposure. Just as Joanne spotted Mr. Greedy in our daughter’s new book collection and removed it, we can be vigilant in other ways. Change the channel when ads for weight loss programs and products come on, set appropriate boundaries with those who talk about their diets on family Zoom calls, and find a pediatrician who provides weight-neutral healthcare.

When children inevitably encounter weight stigma, address it head-on and help them process it. Teach them that bias against body size is as erroneous and problematic as any of the other stereotypes and prejudices that infect our world.

Most importantly, even though what happens out of the house is largely out of our control, make sure to keep a body positive environment at home. Avoid leaving problematic magazines on the coffee table (or better yet, do not keep them in the house at all), get rid of the scale, do not go on diets (or embark on “lifestyle changes” that are diets in disguise), and refrain from offering disparaging comments regarding anyone’s bodies, including our own.