Healthy At Every Size?

Read first, then decide.

Today I saw a 12 yr old girl, I’ll call Gabrielle, whose weight was off the charts. She was referred by her doctor, supported by her concerned parents. And here's what I told her, because I believe it to be true.

Her place on the weight chart is likely the right place—for her. Since the age of 2 yrs she has paralleled this curve at just above the 95^th percentile, (in spite of being only 5 ft tall, much shorter than average), resulting in a very high BMI. She is an active, healthy girl—more active than most thin girls and boys I see, with no apparent suggestion of health issues. She eats well—appropriate portions, as I'd expect for her need, a healthy balance of foods, including those I'd call "junk" food, and she eats the same when she is alone and when with others. In other words, she’s got a healthy relationship with food. Most importantly, she feels good about herself, and the last thing I wanted to do was add mental health issues to any perceived, but non-existent risk of physical health issues.

Gabrielle is one of several patients I’ve seen recently, fitting this description. Some individuals are larger than average size, some smaller, kids and adults, males and females. And we should not assume that’s a problem, as several bloggers are sharp to point out. Health At Every Size, The Fat Nutritionist and others enlighten those who don’t know better, who don’t ever question their assumptions, that large people can be healthy, fit, and in fact happy.

End of story? 

Not quite. The key word is can be. While we cannot and should not assume that an individual’s weight is causing them medical or emotional problems, there are overweight individuals who are not healthy or comfortable at their size, for whom weight loss may help. I question the belief that striving to lose weight, in all cases, is bad. And I am not talking fad diets, mind you.

I am not simply projecting here. I speak on behalf of the patients I have seen over my 25 years of practice. Just as we cannot assume that they’re distressed at their current weight, we cannot assume they are very comfortable or healthy at their state of health and size either.

There are kids, and adults, like Gabrielle described above—always large, but healthy and fit. Many are self-accepting, many self-loathing, perhaps due to society’s discrimination and learned messages they need to unlearn. And I do my best in my sessions to convey this very message, that they are just fine as they are—their eating, their activity and their weight. I am not addressing these “Gabrielles” in the remainder of this post.

Rather, I am speaking about those for whom obesity, or the degree of obesity they are living with, is not their norm, the men and women who have gained weight outside of their comfortable and usual weight range. This includes individuals struggling with compulsive overeating, as well as those without any emotional baggage. It applies to those who no longer take time to meet their needs for exercise, or who might have suffered an injury, which forced a decrease in activity, without adjusting their food intake. I’m describing those who don’t know how to prepare a healthy meal as well as those who eat many meals out, juggling the modern life of working and parenting, soccer practices and carpooling. And those who minimally eat throughout the day, only to eat excessively at the end of the day.

I am not judging them, merely conveying what I hear from them day in and day out. They put off travel because airplane seats feel too tight, and European cars fail to accommodate their size. They want to be off the medications they now take daily, for hypertension, high cholesterol and joint pain. They want to be free of their sleep apnea and their heartburn. 

Sure, there are plenty of normal weight people, thin even, who also develop such conditions (count me in—thin with high blood pressure). But as a population, increased weight increases the odds of developing such conditions. The damage to their knees may be already done, but it is easier to move a body with a lower mass versus carrying surplus weight, particularly when you’ve got pain.

I’m not picking on the obese. If you read any of my posts you’d clearly see my philosophy. Similarly, I do not believe there can be health at every size at the low end of the spectrum. While not all slim individuals have eating disorders, (some are naturally thin, always were and always will be) I can tell you that a low body weight that contributes to loss of menstrual periods, low body temperature, a very low pulse, distorted thoughts and preoccupation with food similarly would benefit from a change in weight. 

And if you think these individuals are immune to society’s judgment, think again. There is equally little sensitivity to those struggling with weight issues on this side of the spectrum. Yes, sometimes the very people who preach size acceptance are all too quick to dismiss, insult and disregard the opinions and insights of someone who is thin, simply because they are thin.

A rabbi friend once said jokingly “Anyone who is more religious than me, is a fanatic. Anyone less religious, a heretic.” Sometimes that’s how I think we all behave around the issue of weight. It’s fine if you are my size, but thinner or fatter we accuse of needing to change and have a difficult time accepting.

Ultimately, the primary focus should not be on losing weight. Yes, even for those who truly care to lose weight, for whom a high BMI was not the norm. Rather, they need to address their behaviors and experience tangible benefits—a sense of accomplishment, having set a realistic goal and achieved it; better sleep; better endurance; better concentration; less irritability by honoring their body’s need for fuel; and a better relationship with food. As these changes occur, weight loss also follows.         

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

Where do you fit in all of this?

Does your activity need to be addressed? Are you even at a healthy enough place to be exercising? What modest goal can you set that you’ll be able to achieve?

Do you allow yourself to eat when you need to? Or do you push this to the limits, thinking you are too fat to be eating? Everyone, 

regardless of her size, needs and deserves to eat throughout the day.

Do you give yourself permission to eat foods you enjoy? Do you even remember what those foods are? Or are you so stuck following everyone else’s rules (including your own), absorbed from years of dieting and denying yourself?

Yes, allow yourself to eat whatever you’d like—no single food makes a person fat. And have it when your body needs it—when you are hungry, any time you are hungry. But learn to have just as much as you need (do read through the many older posts that address this topic).

In fairness, the palpable anger I feel from those who blog about fat acceptance is understandable. They have been mistreated by our society, including those that should know better, such as the medical community. They include those, like Gabrielle, for whom weight loss may be inappropriate. They are repeatedly told to change, when change is truly not necessary.

But let’s not over generalize. There are also those overweight individuals who would like nothing more than to be accepted for who they are but have medical conditions that may be assisted with weight loss. And they deserve to be supported on their journey to a healthier place.

Weight Management Gelato Style

The first time I traveled to Italy I was 19. I recall marveling at marble fountains, being seduced by sculpture and impressed by massive stone architectural creations while touring through Rome and Florence. But perhaps as memorable as Michelangelo’s larger than life David (http://bit.ly/nyY9rx), with which I fell in love, was the smooth and creamy gelato. Twice daily I would indulge in such intense flavors as nicciolo (hazlenut) and espresso, midday and late evening. 

In fact, I would purchase a scoop regardless of the hour, whenever I had an excuse to pass through the famous square the gelateria occupied. I had purchased it fearing I’d never, ever, see gelato again. It was now or never, as gelato doesn’t travel well in luggage. This, by the way, was the early 1980’s.

During my recent trip, however, I was older and (somewhat) wiser. I had gelato only twice in 7 days. (Okay, I did share some bites of my husband’s on a third occasion, I admit, but does tasting just a bite on those tiny plastic spoons really count?). It was not because I was watching my weight (I was not), but because I trusted this time; I knew it wasn’t my last chance to get this fabulous Italian ice cream. Boston has great gelato, as does NYC, which I visit not infrequently. In fact, you can even purchase some good stuff from the supermarket these days—at least where I live (check out Whole Foods). Or, as I’ve done, you could make it at home with an ice cream maker.

But back then, I harbored many a diet thought. As a teen, I had dabbled in the Scarsdale Diet, and wasted my time at Weight Watchers (Now you understand my vengeful post! (http://bit.ly/gY2653) 

My thoughts about food and eating and my body have changed enormously over these years. At the age of 19 and by the end of college, my BMI was out of range and it was not okay—I was sedentary and hardly fit—and I was rather disconnected from my body’s signals and needs. And I was not a large-size person from early childhood, genetically predetermined to exceed the BMI charts, justifying this above average size.

I’m older and wiser now at 48. On my return trip to Italy, I savored the rich and flavorful, slow cooked meals of the Piedmont, filled with mushrooms and truffle oil—but I didn’t fear it was my last supper; I lingered over multicourse meals, filled with flavors I adore. And I stopped when I had had enough—even though it was delicious. 

I skipped desserts when they seemed unnecessary, but took advantage of the aforementioned gelato when I needed a snack.  I sampled many a local Pecorino cheese in Tuscany and savored the hearty Tuscan Ribollita soup filled with beans, bread and vegetables. We enjoyed divine meals artfully prepared with local ingredients, served by Italians passionate about their culinary art. 

Among the very best meals was at La Coccinella, located in the small town of Serravalle DiLonga in the Piedmont. Fabulously prepared fish, as you can see from this photo. But like the gelato of old, I will never forget the dessert lovingly prepared with local hazelnuts, a delight of textures and flavors I can never duplicate.

I write this not on behalf of the Italian tourism department—no one is advertising for your clicks here. Nor, to brag about my travels I feel fortunate to have taken, along with my husband who enjoys great tasting food as much as I. Rather, it is my hope that this will inspire you. 

You may never care about great olive or truffle oils, perhaps. And traveling may be the furthest thing from a reality for you right now. But enjoying food can start at home, wherever you live. Sure, it may require some prep time (although good gelato, like fine chocolate, could easily be obtained and consumed). It requires you to start asking yourself “what do I feel like eating?”, when you are hungry, not just “what am I supposed to be eating?”, yearning later for the very items you’ve prohibited yourself from having.  It necessitates giving yourself permission to eat now, and again later—even if what you choose to eat later is ice cream. Because when you know you have permission to eat it again, you can stop when you’ve had enough. You’ll begin to trust this is not your last chance.

And after doing this for some time, and really trusting your body, you’ll note something strange. Sometimes, there may be times when you’ve truly had enough gelato, and there’s nothing more desirable than a fresh, juicy piece of fruit. And that’s ok to eat too.

Making Enemies 101: Tips From the Blogosphere

Anger. All I could feel was their anger. Their perhaps valuable messages got muffled, but I was left with my tail between my legs. That was my experience of reading a couple of blogs I respect and frequent often, one with a focus on eating disorder recovery, one on size acceptance of the obese. No doubt this post of mine may provoke more anger—that is not my intent. And while these two topics may seem vastly different, I hope to show that they have many commonalities.

Laura's Soap Box

I have learned a lot from Laura’s Soap Box: http://www.laurassoapbox.net

It has, more than anything, strengthened my stance that we have no time to waste, when it comes to recovery; that the ever-hopeful practitioners that patiently wait while engaging in therapy often do so for way too long. And especially for the young anorexics and those new to their eating disorder behaviors and thoughts, those with a narrow window of time for weight restoration for growth and development, for preventing hard-wiring of their approach to eating. The parenting style, more loving tiger mom than most of us like to approach, has its merits. Yes, for survival and health, it takes a tough parental stand.

Yet when I read the post http://www.laurassoapbox.net/2011/10/why-words-matter-and-whose-job-it-is-to.html I was struck not by this very appropriate message, but by the anger and frustration at parents and practitioners who haven’t mastered the art of (eek) Maudsley? Family-Based Therapy? Modified? I’ll refer to it as Maudsley-style from this point forward, so as not to incite more anger.

I’m guilty. 

It's a long way to travel to get to where we need to be.

I admit it. In my 25 years practicing as a dietitian, I have never formally been taught this approach. (Nor, for that matter, was I formally trained in an academic setting on eating disorders; they were only minimally covered in my graduate studies). I have learned what I know by educating myself through eating disorder conferences, literature, as well as more recently through blogs like hers. And, through seeing vast numbers of eating disordered individuals over my career. From my understanding, in this approach, nutritionists/RD have no place. But that’s another story. In my version, RDs play a very valuable role.

Anorexia recovery is not one-size-fits all.     


Many families I see are not candidates for this approach. Some are quite dysfunctional, frequently making supervision at mealtimes disastrous; it would take years to educate them about their inappropriate messages, to correct their nutrition misinformation—I could go on. And we just don’t have that kind of time. Caution: I am in no way suggesting that these dysfunctional families caused their child’s eating disorder, merely that they are in no position to take charge of the recovery.


Some families aren’t candidates, as I see it, as they have too many other demands, such as caring for another family member—a parent, a child with special needs, a newborn, working multiple jobs, etc.

Some families certainly could learn to use a Maudsley-style approach—if they were prepared to take the time. Yet I find many parents want their kids fixed—they bring them for care with an unrealistic perspective on what recovery entails, how it is measured and how long it might take. And most importantly, they have no idea how important a role they play as parents, Maudsley-style or non-Maudsley-style.

I say some intentionally. Many parents couldn’t be further from this description. They are present, physically, and emotionally for their kids; they are anxious to know just what they could do to help their child, and how best to do it, and they adjust their schedules to make treatment appointments a priority. They are scared, but they work on accepting that treatment is a process and takes time. 


In such families, some of the kids with anorexia may be supported by their parents, without the parents having the level of supervision and involvement I understand a Maudsley-type approach to have. They set appropriate safety limits, from a health standpoint (ie—they respect and enforce the outpatient team’s recommendation that there is to be no physical activity, for now). But their children are able to make progress, measurable progress with weight restoration and vital sign changes, that enable them to continue in this setting, without their parents taking charge of their food plating or supervising their snacks. And they are able to engage in therapy, both mental health counseling as well as nutritional counseling in the process.

But then there are those for whom the Maudsley-style approach is perfect. A willing family, with the time it takes to be an active player, to be intimately involved in refeeding. Parents willing to shift the relationship to that of supportive team members, fighting the anorexia along side their child, taking charge the way their unhealthy child can’t, at this time. And I have seen recovery with both these approaches.

Treatment for eating disorders needs to be as varied as the individuals with the eating disorders. As health care providers, we too are not a homogeneous group, not by specialty, not by style and approach. We also get frustrated and angry, when we encounter patients and families, as well as other medical providers who fail to support our stand, to set appropriate limits to ensure recovery. We too recognize that it takes a nourished mind to engage in the process of recovery and decision-making, a role many starving anorexics simply cannot do.

I believe we all share the very same goal—to foster recovery and normalize life for the individual as well as the family dealing with anorexia. And we need to stand united in this goal. There is no single best treatment for all individuals. But educating with a consistent message about the seriousness of eating disorders of all types and the need for treatment and support is essential.

We put our heart and soul into doing the work we do.  But few will respond well when faced with angry rants—by me, by parents, or by Maudsely-style bloggers. We, too, are works in progress.  

And yes, I will soon address the other angry blog in an upcoming post.

This Time It’s Simply About The Calories

Piedmont: Great Wine, Great Challenges

I’m a snob. I admit it. When it comes to food, it’s got to taste good. Because I intend to really taste it. To enjoy it. To savor it. Every bite of it.

But Thursday, after many long, hot hours biking the grueling hills of the Piedmont region of Italy, we were hungry. Really hungry. The hills took us much longer than expected; we had no idea what it really means to be in shape for riding hills!  And the snacks we carried? We downed those within the first couple of hours.

So we rolled into a tiny town, known for its hazelnut production. Now give me a dessert with hazelnuts and chocolate and I would’ve been just fine. But that didn’t happen—no bakeries in sight. But it didn’t take us long to identify the only eating establishment around. Think retro, stale, cigarette-smoke-filled air luncheonette before it turned quaint and chic.

In our broken Italian we ordered the only Panini that sounded acceptable. Oh, and a salad.  What comes to your mind when you think salad? Fresh, crisp vegetables? A brilliant assortment of colors, flavors, and shapes? Think again. They offered what is known as Russian salad—a heaping mass of mayonnaise, containing diced potatoes, peas and a speck of carrot.  We had it along with the white bread sandwich packed generously with cheese. And I neglected to mention (how could I forget?)—that there were two rolled up sardines with olives. At least they added some color.

Well, I ate at least 90% of this lovely meal. And I hated every bite. (Although given my sweating from the unseasonable heat, the sodium rich sardines and olives were much appreciated.) This was so far from the fabulous cuisine I had heard so much about and had begun to enjoy my first day in the Piedmont (more posts about those meals to follow). The Piedmont, after all, is know for the Slow Food movement http://www.slowfood.com/international/6/faqs, amazing wines (Barolo, Barbaresco and Barbera) and white truffles (these are intense mushroom like fungus, not chocolates, my friends), with their distinctive flavor which embellishes foods with a mere drop of a truffle infused oil.

At this point, exhausted and overheated, depleted of energy, it was strictly about the calories, the fuel. I wasn’t going anywhere without eating this awful meal. I had no other options. I couldn’t find my voice in this language I barely spoke, and I suspect there were no other options, given the appearance of this place. Yes, mayonnaise-laden salad with a bland cheese sandwich was the only answer. Simply non-negotiable. There was nothing else to do but eat it.

Provence, not Piedmont!

What’s the meaning of this post? It’s not about my disappointment, of things not going as planned—that could be a whole other post. It’s not about adjusting expectations, because who could have expected this? Never mind that the biking was a total drag, nothing like our fantasy rides through Provence with climbs we could manage and stunning varied vistas to distract along the way.

No, the meaning is much more literal. Sometimes it comes down to Nike’s message—Just Do It.

For those of you who undereat—I know there are times when you are not hungry, and eating seems totally unnecessary. And when a fat-containing food may overwhelm. Or you question why you have to eat more than everyone else around you. Or the uncertainty of a meal’s content leads you to want to choose the safest route—food aversion. Or the allure of not eating, or restricting, promises a pleasant disconnect which might be so welcomed at this moment.

As for the overeaters and binge eaters (and anorexics, too)—skipping meals or snacks certainly sounds promising. Why take in those extra calories when a coffee will suffice? Because sometimes, you need to just do it. And when you’re feeling hungry even if no one else is, you need to just eat—because you need to begin to listen, to trust your body and its signals. Because you so deserve to be well nourished. Because your size has nothing to do with your need for nourishment in the moment. Yes, you too, need to trust it’s okay, it’s necessary to eat. And that you deserve to eat, regardless of what others’ glances may suggest, in spite of the messages from family members you hear or replay in your head, regarding your need to lose weight. Be in the moment, and trust that you should eat.

A cool drink after a long day of unmanageable hills and bad food!

I won’t be heading back for another Russian salad-filled lunch in the Piedmont. But I’m pleased I was able to fuel up for the challenging ride back. In the end, we enjoyed a lovely meal at dinner, and a refreshing drink just after unclipping from our pedals.