What I’m saying, and what I’m not saying.

Since people seem to be awfully confused.

What I am saying: “Weight loss interventions have very low permanent success rates for most people.”
What I’m not saying: “No one in history has ever lost weight permanently in a healthy manner.”

Health At Every Size is, fundamentally, a weight-neutral approach, which means it focuses directly on health-supporting behaviours, and allows weight to adjust as it will. Sometimes it will adjust up, sometimes down, and sometimes it will stabilize. It is true that only a small percentage of people seem to lose weight permanently, according to research, but I do not deny that those people exist. Some of them may have even lost weight by using a HAES approach.

What I am saying: “People have the literal, legal right to eat any food they like, because human beings are condemned to be free. Food choices cannot make you a better or worse person, and food choices are only one factor among many that influence health.”
What I’m not saying: “No food choice ever has an impact on health, and you can eat anything you like without having it impact your health in any way.”

Food choices do impact health, but food choices have also been spun up in the media as the only or the most important thing that influences health, which is not accurate. (The largest impact on health actually comes from living conditions and other social determinants of health.) You are allowed, as an autonomous human being, to choose to eat any food that’s available to you – but, as an autonomous human being, you will also be the one to bear the brunt of the consequences of those choices. Health at Every Size includes a focus on intuitive eating and getting good nutrition because we believe a healthy relationship with food, and a good quality diet, can help improve people’s health. Eating well, in the HAES philosophy, is not the same as eating in a restrictive, restrained manner that is the current popular conception of “healthy eating.” Instead, it focuses on understanding internal signals of hunger and fullness, truly getting enough to eat, improving one’s attitudes toward food so that you are not feeling guilty or anxious, and getting balance, variety, and pleasure in the diet.

What I am saying:Weight is not a behaviour. Weight is a multifactorial trait that is highly heritable. It is not completely within anyone’s control, and no one can simply choose how much to weigh.”
What I’m not saying: “Weight is never, ever influenced by behaviour [see the first point, above.]”

In arguments about fat and health, people often enjoy claiming that fatness (a phenotypic trait) is opposite but equivalent to anorexia nervosa, an eating disorder with a specific set of behavioural and clinical diagnostic criteria. I think they do this because it gives their arguments (often very abusive, stigmatizing arguments) a veneer of respectable concern and clinical authority, but it’s a false equivalence. Fatness is actually the opposite of thinness, which is also a trait. Traits can be associated with diseases, they can even be implicated in diseases, or symptomatic of diseases, but they are not, in and of themselves, diseases. If you believe fatness is an eating disorder, then in order to be logically consistent, you would have to believe that thinness is also an eating disorder. It’s not. Binge eating disorder is a disorder, and it can cause people to gain weight. However, most fat people do not have binge eating disorder. Moreover, the treatment for binge eating disorder is not dieting and weight loss, it’s learning to eat normally and intuitively, without shame.

What I am saying: “Giving fat people the autonomy to make their own choices around food and exercise and weight, instead of abusing, threatening, and coercing them, is not only more ethical, but also more likely to result in people prioritizing their health in a way that makes sense for them.”
What I’m not saying: “Encouragement to eat well, exercise, or value one’s health is inherently oppressive to fat people.”

Health at Every Size actively encourages people to eat well and find activities that suit them, while not hating themselves. Random strangers on the street shouting abuse at fat people “for their own good”? No. Not acceptable. Doctors withholding effective treatment for certain health issues on the condition that fat people engage in a risky, non-evidence-based treatment (dieting)? No. Not acceptable, and not health-promoting. Well-meaning but ignorant, or even frankly abusive, family members or friends tossing off health advice to adults who have not solicited it? No. Not acceptable.

Black-and-white thinking is the order of the day when it comes to discussions about weight and health. It’s tempting, but don’t get sucked in. A fun trick I like to use, when I encounter two statements that seem to be totally at odds, is to ask myself, “Is there any way both of these things can be true at the same time?” (e.g. Is it possible to believe both that fat people may have a higher risk of disease, and that they can take steps to gain health without losing weight? I think so!) Reality is usually complex enough to sustain seeming paradoxes. Sniff them out. They are good medicine for dichotomous thinking.

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Refreshing nuance in comments.

Posted in Fatness | 33 Responses

Why I’m doing a dietetic internship.

For the last four months, I’ve been working on something pretty exciting.

When I graduated from my nutrition program, I wrote, very emotionally and fairly defensively, about not being a Registered Dietitian. I wrote about how, even though my original intention in starting school was to become a dietitian, I had discovered that in order to do the type of work I wanted to do (teach people eating competence) I did not actually need to be one. And that some of the things I’d encountered along the way — including the research my peers have done on the experiences of dietetic internship applicants — made me question whether I wanted to be one.

However, at the end of November 2013, I attended a lecture at my alma mater given by a nutrition professor who’d greatly encouraged and inspired me when I was a student. It was my first time back on the university campus since graduation, and I wasn’t sure how I would feel. It was a wonderful evening. The lecture was great, of course, but I was surprised how affected I was by seeing former classmates who had since moved on to being dietitians, catching up with former professors, and meeting new RDs and dietetic interns who were promoting Health at Every Size in their work.

That evening, after reconnecting somewhat with the world I’d left behind, I started to seriously consider applying for a dietetic internship.

First, I love clinical nutrition. I did not know when I began studying nutrition whether I would enjoy clinical subjects at all. As a student, I looked forward to them as a sort of litmus test of whether this field was really for me. It turns out that I did well in those clinical courses. No one was more shocked than me, I assure you. I enjoyed calculating TPN requirements and enteral feeds, even. My experience in the working world bore that out: I really do love clinical nutrition, even though it is not entirely what I came into this field to do.

Second, becoming an RD would solve the difficulty of trying to explain to people and the media exactly who I am and what I do. My position right now, as someone with an accredited degree, specific training, and years of experience — but without that overarching credential — makes this surprisingly confusing. I want it to be clear.

Third, one major reason I did not apply for internship immediately after graduating was because it is beyond me financially. I’m simply not in a position to not work for nine months without any financial aid. This prevented me from applying for a very long time. Ultimately, I decided it was worth it to see if I even had a chance, and then find a way to raise funds.

Fourth, I want to learn more. Nutrition is an ever-changing, complex field. I want to understand it better, have more intensive training, and have the resources to remain current with the research. As a dietitian, I will be able to do this by being a member of my dietetic association and by completing the continuing education requirements that all RDs must fulfill.

The fifth, and most important reason: I originally entered nutrition as a way of doing something positive for fat people. After teaching eating competence for four years, I feel I can serve people in a broader way if I am a Registered Dietitian. I can continue to teach eating competence, but I can also address clinical nutrition concerns when they arise. I am especially interested in finding out how eating competence might be combined with certain therapeutic strategies, as for diabetes.

So, I applied. I went through the fairly harrowing process of gathering references (four wonderful dietitians and one doctor were very helpful with this, you know who you are!), researching internship programs, writing letters, and restructuring my resume. I applied for several programs, I was called for interviews and, two weeks ago, I was successfully matched to an internship.

It was a bittersweet moment, because, on the morning I received the offer, I knew that many qualified and deserving nutrition students were staring at a rejection letter and experiencing the despair, the intense emotional pain, and the personal sense of having done something wrong that comes with it. To those students: you did nothing wrong. This is not your fault. There should be an internship spot for every student who meets the requirements, and I believe there should be financial aid to allow students of various income levels to train as dietitians.

Sadly, I am not in a position to change those things, but while I go forward with joy and excitement to attempt this thing that seemed so impossible to me, I will not forget the very deserving students who have to make other plans.

For now, I must turn my attention to fundraising so that I have the best possible chance to make good this opportunity I’ve been given. The last four months have been a wild ride, and things are only going to get more intense. I hope you’ll wish me luck.

Posted in Critical Dietetics, Dietetic Internship | 81 Responses

Cooking for yourself: You are worth the effort.

I think this is a lesson that all of us could stand a refresher in, myself included, as we continue down the path toward feeding ourselves like competent adults.

Caveat: Feeling that it’s not worth the effort to prepare food for yourself is very different from literally not having the energy or resources to prepare food for yourself. The latter happens sometimes to all of us – either we are just bone-tired and pressed for time and eating is just not going to happen (or can only happen in rudimentary form), or we honestly don’t have the money to buy the food we want or need, or we haven’t yet learned to cook in the way we want or need. I have personally been in every single one of these situations at some point, and none of them are easy. But they are not what I am talking about in this article, just to be clear.

What I am talking about is that feeling, when you genuinely do have time and energy and food and skill on hand, but you manage to talk yourself out of making food that would truly nourish you because somehow cooking “just for yourself” doesn’t feel worthwhile.

Story time: the last time I was in this situation was when my husband starting working really late hours, not getting home until like 8pm. Previously, we were eating dinner together around 6:30, and then I would have evening clients afterward. This change in his schedule meant we were each on our own for dinner, and I wouldn’t even see him until 9pm.

For the first couple of weeks, I was THE SADDEST, gazing out the window like fat Cyndi Lauper. I completely abandoned the wifely habit of having dinner ready promptly at 6:30pm (smoke detector blazing) and would just sort of listlessly snack on whatever random food came to hand. Toast, cereal, Cheetos, peanut butter from the jar, whatever.


Many cat selfies were taken during this dark time.

I was a tragic, grazing Camille, and inside a week, I felt horrible. Even more horrible than lonely. I soon connected the horribleness to the lack of eating an actual dinner. (Thank you, nutrition degree! $20,000 well spent.) So I resolved that I would Cook An Actual Dinner, no matter what time my husband came home, and I would even dish up a plate for him like the saddest make-believe tea party of all time.

It took some activation energy, no doubt. I had to convince myself to stop dragging my feet, and remind myself that not feeling like crap truly was worth the effort, that my own well-being (and by extension, I) was truly worth the effort. Through the bad-and-wrong feelings and the internal toddler whining, “I don’t waaaaant to,” I did it once. And it was tasty and made me feel better. So I did it again. And again.

I plated my husband’s part, wrapped it in foil, and put it in the oven to warm, just like I imagine many pre-microwave era housewives had done. He was appreciative, and most importantly, both of us were well-fed instead of coasting on fumes.

So, anecdote concluded. Not feeling like death: it’s worth it!

Let’s talk strategies. For those of you with roommates or significant others who share food, the cooking-and-keeping-warm strategy I did above can work if you’re already in the routine of cooking most nights. You could also keep it cold instead by putting leftovers in the fridge. Either way, you’re staying out of the temperature DANGER ZONE. (As well as the Kenny Loggins DANGER ZONE.) And for some reason, just feeling like you are cooking for more than one person, even if that person isn’t physically there, can get you over the hump.

For those of you who live or eat alone, things are a little trickier because you don’t have another person depending on you (and therefore motivating you) to cook something every night. When I was single, I solved this problem by cooking once or twice on the weekend and freezing it in portions. I tell you this as someone who is not a fancy cook: it’s not as hard or as fussy as it sounds. I believe in cooking things in a single pot, if at all possible – especially since at the time, I lived in an apartment whose kitchen was a stove, a fridge, a sink, one rickety square foot of counter, and a cart I bought from Canadian Tire.

More importantly, it is worth it if you are sick of eating out or scrounging. I have five or so basic recipes that I learned can be frozen in portions and reheated rather well: Hoppin’ John with rice, Beans Bretonne with arborio rice, beef stew, creamed chicken and mushrooms with mashed potatoes, and chili con carne. These all have the advantage of being one-pot meals (oh, except the mashed potatoes), and several of them make good vegetarian recipes with small adjustments. I make them all in a Dutch oven.

The trick is to remind yourself that having a stash of frozen meals does not mean you are obligated to eat those meals every single day. If you pressure yourself with this, there will be resentment and tears, trust me. These meals are your safety net for when better plans (going out with a friend, getting a roasted chicken from the store, ordering a pizza) don’t materialize. You will never be in a situation where you regret having a few frozen meals stashed away. Eventually, you may even come to prefer your own cooking to ordering pizza. But only if you don’t force it. Intersperse eating them with your scrounging method of choice.

I still cook and freeze something every other week, so I can have a hot, homemade lunch during the weekdays, and for emergency dinners. In fact, I just finished a nice cup of chili, an apple and some rye bread for lunch. It was delicious. Furthermore, I made it spicy enough that my husband won’t go near it. TIGER BLOOD.

(I know Charlie Sheen jokes are very 2011, but I’m old and time moves more rapidly for me.)

Alright, so here’s where I ask for your input, like a good little blogger: I am a pretty uninspired, workmanlike cook, so I’m sure the rest of you have even more brilliant ideas for 1) convincing yourself you are worth the effort, and 2) using amazing Crock-Pot technologies to sink further into lazy debauchery. Go for it in comments.

Posted in eating, Food and Recipes | 106 Responses

Health at Every Size is not fat politics.

Despite all the words I have spent on this topic over the past decade or so, there are still a lot of misunderstandings about what Health at Every Size is and what it isn’t.

People often conflate the Health at Every Size philosophy with the fat political movement, assuming they are one and the same thing, while simultaneously framing Health at Every Size as completely opposed to current weight and health science.

In truth, Health at Every Size does intersect with both fat politics and weight science, and yet it is neither of these things. It incorporates parts of both to form a bridge between them.

Health at Every Size developed as something of a response, or corollary, to fat politics. The principles of HAES arise from a foundation of (personal, and maybe political) fat acceptance, while not actually being the fat acceptance movement. It is a different, but attached, thing.

Health at Every Size is also not in complete disagreement with current weight science — or at least, not any more than weight science is in disagreement with itself much of the time. Health at Every Size acknowledges the data of weight science, but interprets its methods and context critically — sometimes agreeing, and sometimes disagreeing with its conclusions. It is a different, but compatible, thing.

I’d like to offer a more in-depth definition of these terms, and describe how they relate to Health at Every Size, starting today with the fat political movement.

1. Fat Politics

Fat politics is sometimes termed “the fat acceptance movement” or “fat liberation,” but it goes by other names as well. The goal of this movement is political and social: to address societal power imbalances affecting fat people, and, hopefully, to restore balance through political actions like agitating for legal protections from size discrimination, and advocating for change in how fat people are treated in settings ranging from the sidewalk to the workplace to local businesses to the doctor’s office.

People who benefit from thin privilege may feel excluded from fat politics and from the social milieu that has developed around the fat acceptance movement. That is because fat politics is primarily a movement for fat people — even though fat stigma affects people of all shapes and sizes, even though a reduction in fat discrimination and inequality is likely to benefit everyone as a side effect, and even though, fundamentally, the problem of fat oppression is not located in the fat body itself, but rather in a hierarchical social order that is pathologically devoted to defining certain people as worthy, and others as garbage to be thrown away.

Because it is intended expressly to help fat people, the fat acceptance movement is one of the few areas of our thin-centric culture that does not prioritize the needs, viewpoints, and feelings of thin or average-sized people. This can make it an uncomfortable place for thin or average-sized people to be, especially if they are not well-versed in these concepts.

That’s okay; as a thin or average-sized person, you can still educate yourself and be supportive of people of all shapes and sizes without needing to access fat politics or fat social spaces for your own personal use. I know it hurts to feel excluded on the basis of your body size, trust me. You will survive.

Within fat politics, sometimes people talk about the science of health and weight, but that science is presented to make a political and moral argument: that fat people are worthy of rights and equal respect, and that negative stereotypes about fat people (most of which centre around health because, in our culture, health is used as a proxy for moral goodness and deservingness of basic human rights) are both inaccurate and morally wrong.

I actually wish that the conversation about health within fat politics would shift more to a social model of disability perspective — which means affirming that people naturally come in a diverse array of different bodies, and rather than labeling some bodies “right” and other bodies “wrong,” and setting up societies to only accommodate “right” bodies, and then seeking to address the resulting inequities by forcing the “wrong” ones to more closely resemble the “right,” it is actually the responsibility of society at large to ensure that all bodies are accommodated, valued, and given equitable access to the human world.

I also wish the conversation would focus more on social determinants of health and less on individual health habits, and also less on stereotype-busting to prove that fat people can be “healthy” by what I think is an exclusionary, unrealistic, and ultimately oppressive definition of “health” — but you can’t always get what you want.

When people discuss health and science within fat politics, you must take those points in context, for what they are: they are tools to serve an ultimately moral, not scientific, argument — that fat people are human beings who belong in the world, and who deserve basic rights, compassion, and dignity. They are not intended, in the context of a political discussion, to be engaged in a search for the ultimate medical and scientific truth about body weight (interesting as that subject is to me), nor are they being used with clinical detachment. This doesn’t make the scientific arguments inherently untrue, but it does mean they are secondary to the moral agenda.

There is always some bias in using scientific evidence to service what is fundamentally a moral argument (as opposed to a political argument that arises from scientific findings.) The truth is, regardless of what the science says about weight and health, the moral argument will always stand: fat people exist, they are in the world, and if human history is any example, they will continue to exist — and therefore, they must be afforded the same rights, access, and dignity that other human beings enjoy. Regardless of their health.

Within fat acceptance, some people do a better job at scientific accuracy than others, and many fat political arguments using weight science have been published in peer-reviewed journals. But when you enter the world of fat social gatherings, Facebook status updates, message board grudge matches, Twitter and personal blogs, you are going to witness wide variation in the accuracy and subjectivity with which science is presented to service the moral argument. Some arguments will be painstakingly accurate. Others will highlight one truth while displacing another to make a larger point. And some will be hopelessly garbled, or oversimplified to the point of uselessness.

There is also going to be heat and defensiveness and loss of temper — because people are not really fighting about whether science shows that fat people can be healthy, they are fighting to be treated as human beings.

That is true for any political movement. Politics are emotional. Politics are important. But they are not science, and they are not exactly Health at Every Size.

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This should always be assumed, but I want to make it clear that I am not the official ambassador for Health at Every Size or the fat acceptance movement, and the above is just my viewpoint. I’m sure people involved in either movement might disagree, and that is fine.

Posted in Fatness | 34 Responses

On wheat and death.

Several months ago, I happened upon this little review about the connection between wheat (and other grains) on inflammation, which was pretty interesting.

It reports that there are plausible physiological mechanisms linking wheat to inflammation, that there is some animal and some human evidence available to back them up, but also that population-based studies and human trials have either not shown a significant effect, or haven’t been controlled in such a way to properly isolate the question of whether wheat and its inflammatory effects have measurable, significant health outcomes on people.

The evidence is suggestive in some respects, but not conclusive by any stretch – meaning that the basic dietary advice given to the general population stands: eat a variety of foods, including whole grains, provided you can tolerate them. If you can’t, you probably already know that by now. If you aren’t sure, go see a doctor (preferably an allergist and/or gastroenterologist) to get assessed, and see a dietitian for appropriate nutrition advice. (And beware of geeks bearing IgG tests.)

What follows is a selection of quotes from the review about the limitations of the research in humans:

  • “It should be noted that whole grains contain phytochemicals, like polyphenols, that can exert anti-inflammatory effects which could possibly offset any potentially pro-inflammatory effects of gluten and lectins [73].”
  • “Most of the intervention studies mentioned above attempted to increase whole grain intake and were using refined grain diets as controls, thereby making it very difficult to draw any conclusions on the independent role of cereal grains in disease and inflammation.”
  • “There are few studies that investigate the influence of a paleolithic type diet comprising lean meat, fruits, vegetables and nuts, and excluding food types, such as dairy, legumes and cereal grains, on health.”
  • “Because these [paleolithic diet] studies are confounded by the presence or absence of other dietary substances and by differences in energy and macronutrient intake, factors that could all affect markers of inflammation, it is difficult to make a concise statement on the impact of cereal grains on these health outcomes.”

The authors call, as most reviews of this nature do, for more research, preferably of the randomized controlled trial variety, or population studies that do a better job of controlling for confounders.

In other words: don’t panic. There’s a whole lot we still don’t know, and no one is taking anyone’s wheat away.

One thing that is missing in this discussion, so far, however, is acknowledgement of the cultural and practical importance of wheat and other grains in our diets. It always concerns me when this is left out, because whether we want to believe it or not, tradition, cultural foodways, and plain old accessibility probably inform the average person’s eating habits to a much greater extent than biochemical considerations of the inflammatory response provoked by selected components of a given staple.

Even though we might not want this to be true, it is true – and even though we might not want this to be important, it is important. We are humans. We are omnivores. We eat lots of different things, and not all of them for reasons of pure biochemistry.

It is difficult to overstate wheat’s importance in feeding the people of the world, both in a biological sense and in a cultural sense. Wheat forms the basis for cultural food staples spanning from bread to noodles to couscous to pastry to beer to gravy to breakfast cereals.

Wheat, a grass that today feeds 35 percent of the earth’s population, appeared as a crop among the world’s first farmers 10,000 years ago. It increased in importance from its initial role as a major food for Mediterranean peoples in the Old World to become the world’s largest cereal crop, feeding more than a billion people in the late twentieth century (Feldman 1976: 121).

-Cambridge World History of Food, Volume 1

Which means you are going to need seriously strong evidence to impugn a food source that supports a huge proportion of our world’s nearly seven billion people. If there really were something nutritionally catastrophic about wheat, it would be a major concern – but, again, extraordinary claims require extraordinary proof. And this paper is not it.

Aside from its pure biological importance, the cultivation of wheat also marks a technological milestone in human evolution –

…with the domestication of wheat, humankind began the shift from hunting and gathering food to producing it. This change in lifestyle set humans on a new evolutionary course, and their society and environment were never the same after farming was established.

-Ibid.

– making it not only an extraordinarily important food source, but an extraordinarily symbolic food. Wheat is one of the pivotal crops of modernity. Though its first cultivation well predates the modern era, it set us on the path that led to the industrialized food production systems many of us rely on today, for better or worse.

Wheat and similar grains also require more intensive processing to be edible, compared to many fruits and vegetables that can be eaten whole and raw, compared to dairy, which is often processed for either safety (pasteurization) or preservation (cheese), but which is still consumable in raw form, and even meat and fish which, at its simplest, requires killing, butchering, and cooking (and sometimes not even cooking.)

From an early time, wheat was harvested, milled into flour, stripped of various parts of its grain, and further combined with other ingredients, then boiled or baked to produce edible products. Or the grain was fermented and/or distilled for alcoholic beverages. In modern industrialized food systems, wheat and other grains provide the basis for many highly-processed, and profitable, food products that are shelf-stable, very palatable, and very cheap.

I don’t think this fact of processing is lost on people, even people who don’t routinely think much about where their food comes from. Humans are masters of symbolic thinking, and I believe there is some level of awareness that wheat and other grains are subject to high levels of processing and refining which, depending on how you view those activities on a social and moral level, imbues the food product itself with either a sense of purity and goodness, or contamination and risk.

I regularly speak with people who are concerned about “nutrients being stripped from, and then sprayed back on” wheat products like enriched flour. There is a sense that all the good things have been taken away through refining, and suspect, man-made substitutes sneaked back in to fool everyone into thinking the food is nutritious. And yet, it is this same enriched flour that has significantly reduced the incidence of vitamin deficiencies and neural tube defects in the decades since its implementation in Canada and the U.S.

Humans are naturally both curious and suspicious of their food, in a sort of Hegelian dialectic referred to by food scholars (namely, Claude Fischler and Paul Rozin) as “the omnivore’s paradox.” We express anxiety about this paradox in a variety of different ways, including, in my opinion, through popular food fads – both positive fads, where some food is (usually temporarily, and often misleadingly) awarded the health halo and exalted to superfood status, and negative fads, where a former superfood or a perfectly neutral-seeming dietary staple is blamed for all human misery and misfortune.

I believe this is happening currently with several foods, the most notable, to me, being wheat. I believe this is due to several factors: our natural suspicion about food and its potential contamination or toxicity, combined with an increasing cultural discomfort with the products of modernity which has focused largely on industrialized food production and its discontents, as well as a growing awareness of Celiac disease, food allergy and intolerance, and non-Celiac gluten sensitivity.

Add to this our frustration with the fact that, despite all our technological advances, there still exist medical conditions that defy treatment or explanation, our ever-present fear of death, our idealization-bordering-on-worship of perfect biomedical health, our vulnerability to placebo and nocebo effects, and a soupçon of trendiness derived from evolutionary nutrition theories, and you get a heady cocktail intoxicating enough to produce a damn-near religious conversion.

If wheat doesn’t work for you, for whatever reason, you don’t have to eat it. You can find ways to live well without it, though it will take some effort and some money.

But if you’re looking for something to believe in, something to resolve existential angst, the discomfort of ambiguity and not-knowing, and the fear of your own mortality, avoidance of wheat is probably not going to do you much good.

Posted in Research | 138 Responses
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