MEASURING WELLNESS: A MOVING TARGET

In our modern healthcare framework, measurable biomarkers of health are standards of care uniformly applied to patients, based on scientific precedent, and generally embraced by clinicians for clarity of diagnosis and direction of treatment. Relying on standards of treatment to match measurable tests - whether weight/BMI, blood tests, ultrasounds, or bone density scans - are widely considered a foundation of effective, efficient healthcare in America.

But what happens when this foundation reveals tiny fissures that lend uncertainly to the stability of the well-hewn structure? For example, when blood test results don’t show anything outside of normal range, despite patients reporting real and sometimes debilitating symptoms; or when a BMI chart places a patient in the “overweight” category, despite recovery from an eating disorder and other positive clinical markers of health. Who are we to rely on for clarity of direction then? The piece of paper showing a concrete data point or the individual sitting in front of us expressing their pain, or their satisfaction? And how can a clinician take both seemingly incongruous pieces of information into account, in an effort to help the patient improve their wellbeing and ultimately, ‘to do no harm’?

These intersections often appear in my work with chronic illness and eating disorders, especially with “invisible” conditions where an individual may appear conventionally healthy with no visible or laboratory signs of ill-health, but still express ongoing physical and mental anguish that prevents them from living a full, meaningful life. I am reminded of Leslie Jameson’s essay, “The Devil’s Bait” on the ambiguous Morgellons disease, and what it was like for her to attend a conference on the condition, not as an investigator for its scientific validation, but as an examiner of patients’ real-life experiences with the condition.

And perhaps that is the key to reconciling these two distinct paradigms: Seeking to understand patients’ experiences as paramount always to the facts on a page. In the end, it is individuals’ unique inner experiences that drive their behaviors, their fears, and their decision-making processes for treatment.

In recent months, the BMI chart has been in the news for its unreliable nature as a predictor of disease states, for all it doesn’t take into account: An individual’s muscular composition, genetic frame, fat distribution, race/ethnicity, history of disordered eating, childhood growth curve, and myriad other factors. In fact, the BMI chart with its arbitrary categories for overweight and obesity was originally developed in Europe in the 1800s by a male for males, for the purpose of establishing characteristics of “the normal man”. Over time, the chart was adopted into Western medicine to use as a “convenient” marker of disease risk, mistaking the quantifiable categories as telling the whole story about a person without any actual information about patients’ lives to support the conclusions.

And it’s not only clinicians who are susceptible to over-adhering to numbers on a scale or lab values within normal limits as solace that all is well. Patients too are often liable to feel physically and mentally sound, with well-established feeding and eating competency tools under their belt until they see a number on a scale that feels dissonant to their lived experience. Or they may be clear on their concerning symptomatology until labs show all-normal results and then begin to wonder if their condition is all in their heads. Numbers and data points often seem to wield disproportionate power to an individual’s authentic experience; it requires far less effort to trust an “authority” than to believe in what are bodies are uniquely telling us and move through a decision-making process accordingly.

This is not to say that scientific test results and measurements should be ignored; far from it. Sometimes it’s more a matter of finding the right tests, especially by asking the right questions, and listening closely to the patient, that leads to more ease and progress in the clinical encounter, and to a much more meaningful therapeutic relationship, one of the primary predictors of the successful treatment.

WHAT WE TALK ABOUT WHEN WE TALK ABOUT FOOD

Sometimes I imagine that people see the word “Dietitian” and instantly conjure images of a woman in a white lab coat, making notes on a clipboard, while doling out rigid advice about what not to eat to improve health outcomes. But I can’t think of a role farther from what I hope to achieve as a Registered Dietitian Nutritionist practicing through a psychodynamic ( or “relational”) lens. Some people might be surprised to learn that sessions about food often turn into conversations around a wide variety of unexpected topics that, while seemingly unrelated, almost always tie-in to food and body image.

And perhaps that is the keyword: Conversation. I invite my clients to come with their own agendas, asking them “Where should we begin today? What should we be discussing?” and letting the dialogue flow from there. I pay close attention to what the client is saying and describing, and equal attention to what I am feeling - what is being “stirred up” in the session. If someone says they don’t have much to talk about, but they happen to mention a recent meal with a parent or sibling, and I feel tension in the room, I might inquire how that meal went. What was it like to eat with that person? What was the conversation like? How did they feel afterwards? How did it impact their appetite and how much food they were actually able to take in? It usually leads to a larger conversation about the context of the meal and how it might be informing their reticence in our session that day, far beyond the nutritional content of the meal itself.

Other times, a conversation about anxiety over weight loss or weight gain might prompt me to ask what the client’s anxiety level is like when we talk in session. This allows them to put words to what is happening in the moment and understand how weight fears can be tied to relational fears. In short, it’s using the clinical relationship as a “proxy” for what is happening with the client’s relationship with food and body. In another example, a client might come to session feeling desperate to lose weight, trying many different diets and extreme measures, in an attempt to reduce the desperation. I might ask about what it’s like to not receive a diet plan or diet advice from me, and allow them to put words to their desperation, wanting something so badly and arriving at disappointment and helplessness that I cannot give them what they request. But perhaps I can offer them something else, and sit with them in their despair so they can tolerate it in relationship.

I think it bears considering that most, if not all, of people’s relationships with food and body are born in relationship to other people, usually the parents or caregivers, so it stands to reason that relationships with food and body will also be healed in relationship, with clinicians and sometimes with other clients in group settings. And while I am a Dietitian who can and does provide concrete recommendations around meal and snack ideas, nutrient and energy needs, and strategies for grocery shopping and feeding oneself, I find it far more effective to simultaneously refer back to the clinical relationship in order for any real, meaningful change to occur. Otherwise I could simply give clients worksheets and books and other learning materials and send them on their way - God knows there are enough materials out there! But it is the unique bond, the “therapeutic third” in the room that allows for something more, something intangible that invites the client to cultivate deeper meaning beyond behavioral change alone. This blog on grief by Jasmine Cobb, LCSW gives a beautiful example of the therapeutic third in grief work, which often comprises a signifiant portion of eating disorder work.

So if talking about food is really talking about desperation, hopelessness, fear, disappointment, grief, and so much more, it would only make sense that I invite these feelings into the room too, naming what is happening between myself and the client, and allowing equal space to digest food and feelings.

"PHANTOM LIMB" FEEDING

In June’s blog post, “When Food Hurts,” I wrote about how we might consider feeding ourselves when food causes digestive distress - because of an untreated chronic gastrointestinal condition, for instance. But I thought it would be interesting to explore the flip side of that: What happens when the digestive condition is effectively treated or managed and food that was once “off limits” can now be eaten freely? Is it the relief we might expect? Or are there other feelings that might surface in response to such “food freedom”? 

When I work with clients who have been suffering for an extended period of time with undiagnosed, untreated digestive distress, the focus is so often on what cannot be eaten - what must be avoided to prevent exacerbating the symptoms and how the client can structure their life around these limitations. But when foods that historically caused pain no longer have the same effect, I have seen a sort of “phantom limb” effect: There is an expectation of distress and pain, but none exists. And as relieving as this may be on the one hand, it can feel disorienting and frankly, a little disturbing, to live in the absence of the expected reactions. It’s like a familiar structure is no longer present; something that governed nearly every aspect of meals is no longer there to provide a sense of stability and direction when it comes to feeding.

So now there is the opportunity for clients to create a new frame and set of guidelines around how they choose food, but it can feel overwhelming at first and stimulate new, unfamiliar feelings of being nourished, of feeling a different kind of fullness and satisfaction, and of being deserving of this kind of food. And these feelings, while perhaps “good” may also feel overwhelming, scary, and unwelcome. There might be complicated feelings about a food that once felt so bad suddenly feeling and tasting really good. And perhaps even fear about new potential repercussions, like weight gain.

And while it might make practical sense to start incorporating all the once-unsafe foods back into the diet once it is physically possible, it may not be emotionally possible or tolerable right away. The same can be said for “fear foods” with clients have who have suffered from eating disorders. Just because they come to nutrition therapy for help with the eating disorder doesn’t not necessarily mean they are emotionally prepared to introduce these fear foods; they may introduce them more slowly, on their own terms, even when they are physically capable of handling more. And this process might take longer than a regularly scheduled introduction of fear foods, but in my experience, it is also a more effective, long-lasting result.

The same can be true for re-introducing foods that once caused physical pain. This is not to say that we don’t also find ways to make sure the client is properly nourished with energy and nutrients in the interim; it might just be with a more limited spectrum of foods right off the bat. It might also take many introductions of the same food before there is trust that this food is safe. Just like a young child learning to eat solid foods: There are multiple studies suggesting that it can take up to 20 times of introducing a food before a child accepts it as part of their regular food repertoire. Some of the clients with whom I’ve worked have carried digestive distress with them since early childhood, so in some ways, eating without pain and introducing foods really might feel like the first time. And so we proceed accordingly.

A final note about foods that have caused pain in the past: Let’s take something like ice cream. There may be a lingering sense of waiting for the other shoe to drop. So ice cream hasn’t caused pain for the first 10 introductions, but what about the 11th? And the 12th? There can be a sense of foreboding around a food that one has had to avoid for so long. And keep in mind, there is no requirement that any particular food be re-introduced, despite its safety, as long as energy and nutrient needs are being met with other comparable foods. Yes, it can be something to work through and explore, but I have found that making any food a requirement tends to have the opposite effect and lacks true, meaningful integration.