He Said, She Said: Celebrity Diets

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He Said

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

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

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

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

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

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

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

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

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

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

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

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

 

She Said

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

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

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

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

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

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

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

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

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

 

Background

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

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

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

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

 

Other Biases

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

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

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

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

 

Size-Based Biases

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

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

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

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

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

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

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

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

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

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

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

 

Discussion

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

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

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

 

Motivational Interviewing

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

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

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

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

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

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

 

Summary

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

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

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

 

Guarantees

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

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

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

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

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

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

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Day 458: Mount Washington

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In my mind’s eye, June 20, 2015 represented the end of an extensive journey back from a major operation. Long ago on the eleventh day of my recovery, I began keeping a log of the daily indicators of my progress, small steps all leading towards this late-springtime Saturday morning in New Hampshire when I would return to racing by competing in the Mount Washington Road Race and, upon reaching the summit, declare my recuperation complete.

Beginnings and endings make for nice stories, but they are sometimes just myths. Even as conditions improve and problems slip into the past, they still exist somewhere. Perhaps that is why alcoholics often still label themselves as such even after decades have past since their last drinks. My back will always demand my attention and vigilance, just as diabetics must continue to practice daily blood sugar management, as opposed to achieving their target A1C values and leaving their endocrinologists’ offices thinking they have wiped their hands clean of the disease. Not that I am complaining or feeling bad for myself; we all know that life could have dealt me a much worse hand.

Next week, I undergo a third back operation to correct what my surgeon terms an “extremely rare” complication related to last year’s procedure. Although I can run up the highest mountain in the northeastern United States, I cannot jog around the block or even go for a walk without significant pain. Go figure.

While this past Saturday was not the metaphorical finish line that I anticipated, the occasion still carried a significance. As I neared the summit, I remembered that exactly 15 months earlier I laid in a hospital bed unable to do anything more than slowly shuffle about the unit with my walker and a back brace. The days that I thought I would actually make it back to competitive racing were vastly outnumbered by the days I felt in my heart that I never would, but I always kept working and accumulating small daily indicators that I was inching back towards my old self.

Effort alone, however, is not enough, and I never would have gotten to this point without the help of many people, including my surgeon, Dr. Jean-Valery Coumans, my physical therapist, Sue Bloom, and most of all my wife, Joanne, who has experienced this saga from spending sleepless nights on a couch in my hospital room to waiting for me at the summit. Literally and figuratively, it was a long way back to the top of that mountain, and I could not have gotten there alone. We got this far, and will go even farther, together.

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

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

 

He Said

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

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

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

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

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

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

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

 

She Said

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

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

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

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

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

Will

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Yesterday, I received word that a childhood friend of mine died suddenly over the weekend from a brain aneurysm. After processing the news for a few hours, I decided to write a letter to his mother. Everybody deals with loss differently so I could be way off base here, but I imagine that after the immediacy of this tragedy passes, she might appreciate hearing some stories about her son and what he meant to the rest of us.

To all of the patients – children, adolescents, and adults alike – who show up in our office looking to manipulate their bodies in hopes of fitting in and gaining acceptance, and to all of our own family and friends who seek to do the same, it is important to keep in mind that in the end we are often not remembered, respected, and appreciated for what made us the same, but rather for what made us different.

He Said, She Said: Marathon Nutrition

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He Said

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

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

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

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

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

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

 

She Said

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

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

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

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

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

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

Yes, #repealtheseal, but not just in this case

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Much has been made of the Academy of Nutrition and Dietetics’ (AND) decision to place a “Kids Eat Right” seal on Kraft Singles. In the virtual world of Twitter, the #repealtheseal trend is off and running. Yesterday, a colleague of mine emailed me and asked that I sign a petition that would join me with thousands of other dietitians who object to the AND’s decision. After giving the matter some thought, ultimately I did sign, but I did so with hesitation.

When I was on my cross-country bike trip, food was often a source of debate. On one hand, riding our bicycles was essentially our full-time job, and as such our nutritional needs were so enormous that we needed a daily tsunami of protein, fat, and carbohydrate just to keep heading east. On the other hand, we were a charity group on a tight budget. Balancing these competing needs led to tension, arguments, and some questionable choices, many of which I begrudgingly tolerated. Unrefrigerated clam chowder and yellow tap water in Washington? Umm, okay, fine. Expired energy bars bought in bulk at a negotiated discount and fragments of broken glass in my PB&J in Montana? Definitely not thrilled.

But “pasteurized prepared cheese product” instead of real cheese slices in North Dakota? That ticked me off, as the difference in price was so slim that I felt our balance had tilted too far towards finances at the expense of respect for our needs as athletes. So while I am not a huge fan of Kraft Singles for myself, let’s get one thing straight: My objection to the AND’s use of their seal has nothing to do with this specific food.

My objection is not that the AND is endorsing Kraft Singles; my objection is that the AND is endorsing any foods at all. If I found an AND seal on broccoli, I would still take exception, which probably separates me from some of my colleagues and explains why I initially hesitated to sign the petition and risk lumping myself in with other dietitians with whom I disagree on the following point. Good/bad or healthy/unhealthy food dichotomies create more problems than they solve. They move people further away from balance and internal eating cues and push them towards external food regulation and feelings of guilt and self-depreciation. If you see one food on the shelf that has an AND seal, what does that say about the seal-less food next to it, and how do you feel about yourself and your behavior if you choose to eat the latter?

Kraft Singles might not have been my food of choice during long bicycle rides, but I can understand that we as a group made the decision to purchase them because of monetary constraints. Remember that people in our own neighborhoods struggle to afford food on a daily basis. Food pantries, the Supplemental Nutrition Assistance Program (SNAP), canned-food drives, and similar initiatives do not exist just for the heck of it. For some of our neighbors, affording Kraft Singles is the best they can do.

Joanne and I each have patients for whom getting enough nutrition is a challenge for medical reasons as well. A few months ago, I suggested to a father that he pack Starbursts with his daughter’s lunch and I make no apologies for that advice. While I of course understand that candy for a meal potentially has downsides, in the case of this patient and the struggles she was facing, the upsides won out. We have other patients with eating disorders for whom the highest nutritional priority is just eating – period – so they can continue their recoveries on an outpatient basis rather than ending up in a treatment facility due to medical necessity. If we as dietitians limit food choices for patients like these by making them shy away from foods that lack a seal, then we are not meeting them where they are at; we are failing to help them to the best of our abilities.

Furthermore, remember that virtually all of us make choices in life that do not prioritize health, and for many of us that extends to food. Cheese product may not be my personal cup of tea, but some people genuinely love it, and perhaps those same people might turn their heads at the sight of my favorite foods. Attempts to cut out favorites for reasons other than medical necessity often ultimately backfire by triggering overeating. For example, someone may eat slice after slice of cheddar in an attempt to satisfy a craving that one Kraft Single could have quenched at the outset. When we take all-or-nothing approaches and “nothing” proves to be unsustainable, the only alternative we have at our disposal is “all.” The floodgates open, and what could have just been one slice – if we were eating in response to internal cues – turns into the whole package.

Given all of these reasons, just as my colleagues and I stand up to the AND for inappropriate use of their seal, we have to be careful to avoid making this about the specific product at hand and remember that placing a seal on any food – any food at all – is the real issue.

Day 366

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Today marks the one-year anniversary of my surgery. Because my spirits were so dismal in the days immediately following the operation, on day 11 I began writing a log of the small daily victories that marked my healing and recovery. While I was initially unsure how long I would keep it up, I have maintained the log to this day and have no plans to stop, not when I still have so far to go.

One year ago tomorrow, I strapped on my back brace, leaned on a walker, and shuffled slowly from my hospital room to the nurse’s station and back, flanked by my wife and a physical therapist. Due less to pain and more to my fear that the operation had not worked, I cried the whole way.

Going into the operation, I was under the impression that I would not need a brace. When I found out the surgeon was prescribing one, I angrily and defiantly informed the nurse that I refused to wear the contraption. Over time though, I became attached to it. While the brace was at first just a literal support, over time it took on a figurative role as well, sort of like my version of Wilson the volleyball. During the first two months of healing, my brace and I walked for hours and hours together, and during long walks when I was otherwise alone, unsteady on my feet, unsure of my present, and scared of an uncertain future, my brace was always there to keep me upright and give me the courage to keep moving forward.

On day 67, we walked the entire Boston Marathon route together. Shortly thereafter, my surgeon told me it was time to stop wearing the brace. Truth be told, I was sad to jettison my sidekick. Finding the brace by surprise in the house triggers a similar fondness to randomly running into an old friend in the grocery store.

My surgeon was astonished by how quickly I progressed in the first few months after the operation. “You will be back to your crazy workouts in no time,” my physical therapist told me last summer. Turned out she was way off. As I wrote on day 197, we are only somewhat in control of our destiny and life does not always unfold the way we might expect or wish for ourselves.

Setbacks have been plentiful. Activities that my surgeon said should be fine at the time, like swimming, remained intolerable until seasons after his timetable indicated. Some of the bone grafts were unusually slow to heal and for a couple of months we faced the legitimate possibility that they might never fuse. Once I got the green light to resume weight training, I hurt one shoulder, then the other, and had to leave the weight room once again while I rehabbed them. Raking leaves in the November twilight and rushing to finish before darkness, I swiftly walked into my leaf blower, broke my big toe, and ended up in a walking boot. My most recent MRI showed a bulging disk at the surgical site, a highly unusual complication, and the radiating pain down my leg has returned. What can I say, Robert Smith taught me a long time ago that life is neither fair nor unfair.

Before the surgery, I expected that my healing would plot out a linear trajectory with each week being better than the previous one, but quickly I realized that was unrealistic and a setup for disappointment. Real life has its downs, but thanks to good fortune, hard work, and help from many people, it also has its ups.

Although my ultimate goal remains to resume playing competitive tennis and I am working hard in a physical sense to make that happen, simultaneously I am doing my best to prepare myself emotionally for the possibility that it may never come to fruition. Although I remain light-years away from returning to the court, accepting the latter feels much harder – and much less likely – than ever achieving the former. Past opponents and fictitious foes have contract court time in my dreams and we battle it out several nights most weeks, and my wife does not know that I often tear up when I watch her own matches from the sidelines.

Recovery does not end once the surgical site heals. Despite all that has happened in the past twelve months, in some ways I feel like I am still at the beginning of the journey with a long and unmapped future ahead of me. One year ago, I was bawling on a hospital gurney awaiting my turn in the operating room. Today, I went for my first run outside in 18 months. It was slow, short, uncomfortable, and really, really difficult. And it was totally and completely awesome.

He Said, She Said: Supplements

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He Said

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

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

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

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

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

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

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

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

 

She Said

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

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

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

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

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

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