A BLOG ABOUT WEIGHT LOSS (EEK!)

What is an eating disorder dietitian doing writing a blog about weight loss!? In truth, I work with many clients who wish to lose weight. It is, after all, once of the defining characteristics of multiple eating disorders. And it would be ignoring reality to deny that the desire to lose weight is often on the minds of many, eating disorder clients or not, thanks to the social and psychological constructs of diet culture, patriarchal culture, racial injustice, trauma history, underlying illness, developmental interruption, unconscious defenses, and a host of other factors that drive thin ideals.

One of the reasons I do not use “HAES” or “Health at Every Size” language in my work is that to me, this is a value inherent in every human, akin to saying “respect at any size” or “humanity at any size”. The fact that there has been entire movement devoted to reminding people that everyone matters speaks to layers of complex oppression and narcissistic devaluing of the “other” that cannot easily be untangled. My clients are, first and foremost, human. And it is my job to know them, and if they want to discuss their weight loss wishes and goals and fantasies, is not my job to stop or deter them, but rather to understand them and approach their wishes with curiosity and inquiry.

I can’t make bodies lose weight. In fact, I can’t make bodies do anything! It reminds me of when I work with parents of younger children who come to me and say, “I can’t get my child to eat (vegetables/anything beyond pasta/fill in the blank) and often my first thought is, “of course you can’t!”. The only way we can “get” people to do something is usually through some kind of manipulation or cult-like adherence, neither of which are ethical or part of my value-system as a clinician and as a human.

What I can and do provide assistance with is developing and recommending emotional and behavioral interventions that provide sufficient energy and nutrients, alongside complex illness treatment recommendations, environmental stability and relational strength, so that the body can settle to a weight range where it is naturally (i.e. genetically, environmentally, psychologically) inclined. Whether or not clients accept and apply these recommendations is a complex journey, rarely linear, that may involve repeated return to restrictive food behaviors and more active weight loss pursuits. By helping clients to work through resistances to treatment and real health, I can in turn help clients know themselves and understand what drives potentially destructive behaviors and what motivates the pursuit of more meaningful, growth-oriented ones.

In discussing weight loss, it bears discussing what is meant by “health”, as many clients and clinicians alike often tout weight loss in the name of health. In my work, it is important to understand each individual’s definition of the word, and not simply apply my own understanding. For example, I am consistently reminded that the same clinicians who recommended 1200-calorie diets to their patients to lose weight in the name of “health” then deem the same clients "lazy" because they have (obviously) been unable to maintain such unsustainable intakes, don't have the literal energy to exercise, have poorer psychological functioning, and ultimately gain more weight than where they began. This constant "yo-yo" dieting has left many patients in larger bodies than when they began their journey, and no amount of dieting and exercise is going to correct years of poor guidance by clinicians and laypersons alike, from a weight perspective.

What could help is focusing on factors besides weight like sufficient nutrient, fiber, and energy intake, cardiovascular stamina, weight-bearing exercise, and treatment and management of underlying illness that will vastly improve an individual's metabolic health markers, but not automatically move the needle on the actual scale in a meaningful way, at least by societal standards. Avoiding absolutisms about weight loss AND easing the myopic scrutinizing of numbers on the scale may very well be the most healthful approach - both are disrespectful to our clients at best and downright condescending at worst.

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.