Keeping It Simple

On the first day of my rotation this week, I introduced myself to the dietitians I would be working with. One was significantly older and the other had recently had her second child. They were talking about the challenges of being working parents and when I said I was the new intern, a recent graduate, they recommended I "keep it simple a little while longer." The question of living simply and what that means has stayed with me throughout the week.

This first rotation, which continues for another week, is very hands-on and I am exposed to patients at all stages of the process of bariatric surgery. I observe the consult group where the surgeon explains the different types of procedures, the nutrition classes for patients about the undergo surgery, post-op visits to hospital rooms 24 hours after surgery, phone calls one week later, and follow up appointments with patients six months, one year and two years out. Eligibility criteria for bariatric surgery includes a BMI of >40 or BMI >35 with co-morbidities, such as diabetes, and nearly all the patients I observe have multiple complications and medications. And many of them are young. Younger than me. Their lives are far from simple.

Simple living has become a new aspiration in the green era. I recently watched No Impact Man, the documentary that follows one NYC dwelling man and his family as they try to live "simply," ie. in a manner that generates as little waste and environmental impact as possible. In our modern world, one could argue that living "simply" is a fallacy - in fact, living without many of the conveniences that carbon-emitting technology affords makes life much more complicated. The film reinforces this and after watching No Impact Man, I have a newfound appreciation for my refrigerator. At the same time, the family spends more time together, watches less television, and is far more conscious of the food they eat, traits we associate with simplicity.  

Somehow I felt a strong connection between this film and my work this week. I had mixed feelings about doing a rotation in a bariatric center. Like many people I wonder whether surgery is really the only option for people struggling with their weight. In the consult group I was happy to hear the doctor state that surgery is the last option when all others have been exhausted. When he insisted that the long-term success of the procedure would depend on how well patients had addressed the underlying emotional issues that had led them to this place, I was further encouraged that it was not being marketed as a quick fix surgery. And after watching a laparoscopic gastric bypass, the cynical voice in me that suggested that patients might simply opt for surgery because it was covered by their insurance, that it was easier than actually losing weight, was quieted. The surgery is invasive and the recovery takes time. Even post-op, losing all the excess weight is not guaranteed, as I witnessed in patients who had the surgery years ago and displayed varied levels of success. Whether or not I would recommend it, bariatric surgery provides a second chance for patients to simplify, to start over, create a new relationship with food and new behaviors. I found this reinforced in speaking with patients after their surgery and wished them to best of luck in cultivating new healthy habits.  Today my supervisor told me that last week a patient cried tears of joy when she learned that she could finally transition from the all liquid diet to eating pureed foods. Learning to eat all over again brings such bliss - a good reminder to enjoy life's simple pleasures.

Orientation

A lot has happened in the past month since school ended. I left Seattle, got engaged, drove to Ann Arbor and started a dietetic internship program at the University of Michigan's School of Public Health.  Back in April when I "matched" at UM, I rationalized all of the reasons it would be the best program for me. I remember thinking how being far away from my friends and community would allow me to focus my energy on the internship, and perhaps work on some side projects that never receive any time or attention.  Now I wonder how I will have time to focus on my internship at all, when my thoughts are occupied with Skype dates, travel arrangements and potential wedding plans. So in attempt to devote some reflection time to my various rotations, I hope to use my blog to capture my experience as both an intern and a Michigander over the next six months.

My personalized lab coat.

My internship started last week with orientation. I am one of 13 dietetic interns, but one of only two who did not attend UM for my master's degree. And I am also the only one who has never lived in Ann Arbor (AA) before. I guess that makes me the outsider, though by the end of the first week I certainly didn't feel that way. We spent the first week at school filling out paperwork, touring some of the rotation sites, and attending lectures and presentations on a variety of topics that are either important enough to warrant review (eg. a full-day crash course in food service management!) or were likely not covered in our degree programs (eg. palliative care, hospice). My house turns out to be only a 20 minute walk from school, so I enjoyed a week without use of my car and I'm sure the Echo appreciated a break after the 2,500 mile drive out here. And it only took me about a week to re-adjust to the constant state of sweat that comes with summer's 90 degree temps.

On Friday we went on a field trip to the Henry Ford Hospital in West Bloomfield, MI. I was surprised at how much it reminded me of a mainstream hospital equivalent of the Bastyr Center for Natural Health in its integrative approach to patient health and wellness. Unlike other hospitals, the entrance seems more like a shopping mall or resort, complete with concierge and valet services, a spa and shop selling local products. Just past the shop is the Demonstration Kitchen where classes are taught for the general public by a chef and a registered dietitian.  We peeked in on summer camp program for kids, and noted the space, which could easily serve as the set of a cooking show on the Food Network. 

We toured of the facilities, led by the Culinary Wellness Director (!), a trained chef who explains to us that food used to be used as medicine and it's important that we remind people of that. He showed us the cafeteria, Henry's, where instead of hiring food service workers, the hospital employs cooks who prepare the food on the spot using fresh ingredients. Other interesting tidbits about the place: they host a weekly farmer's market, there are in-house pet "therapists" or trained dogs who visit patient rooms, the salon stylists are trained to recognize melanomas, and every single room has a view of nature.  The attention to detail is so completely impressive - from the room service menu model to the private rooms to the massage therapists that make room calls - I really walked away with the impression that patient satisfaction is paramount.  We were told that the hospital was designed to reduce stress and alleviate fears  and it certainly achieves that effect. In fact, we noticed several groups of women from the community utilizing space in the atrium to play bridge and mah jong. 

Henry, one of the hospital's pet "therapists" takes a rest.

I couldn't help but wonder, who pays for these services and who does this hospital serve? (The question was later answered by my roommates who explained that West Bloomfield is the wealthiest township in the state.) Part of me wondered about the increasing income gap, and as I continue to hear how economically devastated Michigan is as a whole and Detroit in particular, I hope to gain a better understanding of the socio-economic landscape around me. Still, I walked away from the Henry Ford feeling like maybe in this Midwestern pocket I'm not as far away from Seattle as I feel, maybe the Bastyr bubble is larger than I imagined and maybe there are some ways in which our country is moving in the right direction. 

Commencement

This week I celebrated graduation and the completion of my master's degree in nutrition surrounded by my classmates, family and friends. In the mad rush this last month I sacrificed the time it takes to put my ideas together in a cohesive manner and so you'll notice the absence of blog posts. Instead, I focused on compiling a speech to deliver at graduation, after being voted graduate student speaker by my peers. It was an honor to represent the class at the university-wide commencement exercises yesterday. Here's what I had to say:

"'Why should I care about this?'

Her question caught me off guard. It was back in the fall when I volunteered with an organization that offered weekly cooking and nutrition classes to homeless youth. It was not an easy group - the participants faced many challenges living on the streets, and sometimes those issues surfaced during class. Most nights the group was eager to cook together, to discuss nutrition and ways they could apply these lessons to their lives, but on this occasion one girl sat there most of the night with an angry look on her face and finally she said “I’m 18, pregnant and live on the streets. Why should I care about this?”

I had been prepared to answer questions about good protein sources or meal planning on a budget, but her question ran far deeper. And while I could have suggested all of the reasons I believed that health and nutrition should be important to her or the way it would impact her baby, what she really seemed to be saying was, I have bigger issues than this, and the way I eat is not going to solve my problems.

I was humbled and could not offer her a good answer, so I did what I’d learned from so many of my teachers. I threw the question back at the class, why should she care? Adding, why do you care? It allowed the group to explore, develop and refine their perceptions and beliefs about themselves, their circumstances and their ability to enact change.

As we peel away these questions we find others that probe the impact or futility of our actions. Why should I care? Can I really make a difference? My fellow graduates, your decision to study at Bastyr reflects that you believe in making a difference. Many of us entered Bastyr after a period we sometimes refer to as “our first life” and in breaking from that first life we made a conscious decision to invest our time and energy into a new field of study, a new career, at a university that supports our values - values like mindfulness, respect for the natural world and the integration of mind, body and spirit that extend to our actions, to the way we choose to eat, live, teach and practice natural health. And it will likely be challenging to translate those values into other settings.

In the coming days and weeks many of us will be moving to parts of the country where the name Bastyr may not bear the meaning that it does around here. Where the term "natural medicine" will draw quizzical looks and recommending a whole-foods based diet may be construed as suggesting someone shop at a specific grocery store. Many of these places will not offer such a multitude of options for sorting trash into recycling, compost, light bulbs, packing materials, batteries and cell phone bins. They may not provide the salad bars with seemingly endless supplies of beets and kale. And yet these are the places where we are most needed, where we have the most work to do and the most to contribute.

There are times when we may feel disheartened, and wonder why should we continue to care? Why should we bother? A few years ago Michael Pollan addressed this in a piece entitled, "Why Bother?" He poses this as a question faced by anyone who feels discouraged by the mounds of evidence suggesting that individual behavior cannot affect climate change. To which he offers that living and acting on principle can set an example for others, can trigger a chain reaction and possibly even a change in consciousness. Finally, he proposes that people must find one thing that lends them meaning.  Pollan recommends planting a garden and discusses how it can nourish and empower us, how the act of planting a seed demonstrates faith in our potential to make a difference.

Lately I've been wondering why commencement is held here, in Benaroya Hall, in the center of bustling downtown Seattle, rather than on the beautiful grounds of our picturesque campus up in St. Edwards State Park. And I think the message is this: It is time to leave the walls of Bastyr, where we can easily live in line with our values, surrounded by like-minded peers. While we have chosen to focus our careers on health and wellness, we must remember that we are in the service of others who often have competing priorities and concerns , and we will likely face hard questions like, "why should I care?" Stepping outside our comfort zone we may feel discouraged, turn inward and ask ourselves, "why bother?" but it is precisely then that we identify and empathize with the challenge many of our patients face. Because beneath both of these inquiries lies the same philosophical question of human agency: Does my life matter? Do my choices have an impact? How can I make a difference? When we can elicit these questions and help people find meaningful ways to answer them, we find meaning ourselves. We plant seeds. We exercise our faith in change."

Congratulations to the Bastyr University Master's of Nutrition Class of 2011!

Can Spinach Save America?

Last weekend I saw “Forks Over Knives: How A Plant” the documentary arguing that the key to health and longevity is a plant-based diet. Joining the emerging genre of food-centric documentaries over the past few years the film focuses on the work of Dr. T. Colin Campbell, author of The China Study, and Dr. Caldwell D. Esselstyn, Jr. a physician at the Cleveland Clinic. Based on the epidemiologic findings of the China study, and Dr. Esselstyn’s clinical findings, the movie argues that a change in diet is all that’s necessary to combat the current “diabesity epidemic.” It examines the research, the (already well-mined) history of agricultural policy in the United States, the problematic position of the USDA in serving to protect farmers but also determine dietary guidelines andthe role of the media in disseminating dietary recommendations to the public. The film also follows several individuals as they transform their diets from animal-based and processed foods to a whole foods based, primarily (although not exclusively) vegan diet. The result is an imperfect but impassioned polemic against the Standard American Diet that raises many interesting points (I never considered erectile dysfunction as an early sign of heart disease!) and undoubtedly many eyebrows.

Certainly there are those who argue that the film’s claims rely too heavily upon epidemiological research that cannot necessarily be applied clinically. Personally I don’t see this as a problem when the proposed intervention involves no prescription medication, nosurgery, no calorie restriction – it simply recommends that people eat less meat and dairy and more fruits and vegetables, less processed foods and more whole foods. As the movie states, “it’s so simple, it’s criminal.” So what are the problems then? One might argue that the cost of such a diet would be significantly more, but with proper education and smart shopping, that need not be the case. And if it is the case, that’s certainly incentive to get cracking on the Farm Bill coming up next year. Another argument voiced in the film is that people cannot get the amount of protein they need from a plant-based diet. Sadly this position is stated by Connie Diekman, former president of the American Dietetic Association, and advisor to the National Dairy Council (and also a professor of nutrition). The ADA calls itself “the food and nutrition experts” and is the accrediting body of nutrition programs nationwide. In July I will begin a dietetic internship, not because I want to incur more student debt and work full-time with no pay, but because the ADA requires that dietetic students do so in order to sit for the exam to become a registered dietitian. As a student member of the ADA I am professionally insulted that this woman with a clear conflict of interest was highlighted to convey the views of dietitians nationwide. In fact, in its position paper on vegetarian and vegan diets, the ADA states:

It is the position of the American Dietetic Association that appropriately planned vegetarian diets, including total vegetarian or vegan diets, are healthful, nutritionally adequate, and may provide health benefits in the prevention and treatment of certain diseases. Well-planned vegetarian diets are appropriate for individuals during all stages of the lifecycle, including pregnancy, lactation, infancy, childhood, and adolescence, and for athletes.

Furthermore, as someone who limits consumption of animal-based foods and focuses on whole grains, legumes, fruits and vegetables, I am personally offended by this misinformation. But the segment was just the latest attack on the ADA, which is increasingly under fire for its dubious support of and from the food industry. And I find myself increasingly frustrated with the leading organization in my profession…but that’s a topic for another day.

“Forks Over Knives” is not nearly as sleek and professional as Food, Inc. but unlike that more politically charged documentary, it asks its audience to seriously consider shifting toward more unrefined, whole foods plant-based diet and for that I greatly applaud its effort. The film indicts the meat (protein!) and dairy (calcium!) industries for driving the increased consumption of these foods over the past few decades to which they link increased chronic disease. The filmmaker also mentions oils as harmful, he then glosses over it without addressing it any further– a somewhat problematic oversight since not all oils are created equal and certain oils can be extremely beneficial and necessary for the body.

And while the doc’s vignettes of people altering their diets provided a softer human element, these portions of the film had the weakest production values and might have been better compiled and more tightly edited. Still, they were important points in demonstrating that it is possible to eat and live the way Dr. Campbell and D. Esselstyn suggest and dramatically alter your health for the better in a surprisingly short period of time. The film was weakest when showing graphic images of coronary bypass surgery, reminding me of the anti-smoking videos I watched in high school. It was also very defensive about the “manliness” of eating a vegan diet. More compelling were the graphs showing correlations between meat consumption and chronic disease over time in various parts of the world.

For many people diet and lifestyle are the “on/off” switch in our genes. We may be genetically predisposed to weight gain, diabetes, cancer and heart disease but a plant-based diet may prevent the expression of these conditions. It may not be enough, but it is the part that we have within our power to control. There has been tremendous backlash against the film, with many calling it vegan propaganda. And it's true that ardent vegans and animal rights activists hail its message as supporting their own. I am not vegan but thought it made a strong case for reducing animal product intake and I’m comfortable with that idea, from a nutritional, environmental and ethical standpoint. Apparently it’s a touchy subject. Maybe people see what they want to see. The film’s bottom line: choose wisely with your fork and you may spare yourself from going under the knife.

My Big Fat Social Stigma

Obesity is everywhere. Articles, news segments, conversations abound about childhood obesity, fat as an epidemic, a public health problem that weighs on our health care system and national economy. At the same time, the more we talk about it, rant about it, focus our energy on preventing it, curing it, fixing it, the more we reinforce social stigmas surrounding body size. In fact, the stigma is so strong that it's fueled some of the fire against the war on obesity. Oddly, as this country's fat-phobia continues to grow so do the population's waistlines. So while the percentage of overweight or obese children and adults has increased, so has the weight bias against them. Somehow our efforts to encourage healthy weight and behavior have been perverted into shame campaign targeting large sectors of the population. If you're not convinced just watch these anti-childhood obesity PSAs (note: I considered embedding one of the videos, but they're too awful to promote). And, we are seeing further global spread of this stigma, as America has exported its unattainable cultural ideal of thinness and its fear and disdain of fat to countries worldwide.

While cleaning and sorting through my stuff this weekend I was watching Hulu, which was promoting a Lifetime movie called To Be Fat Like Me. And, while I'm slightly embarrassed to admit it, I watched it. With this issue of fat stigma on my brain for the past few weeks, I was secretly hoping that Lifetime had tackled this issue, neatly tied it up in a two hour made-for-television movie that I could point others toward and say, here: this is what I'm talking about.

No such luck. The movie reveals the constant bullying, discrimination and somehow publicly acceptable slurs that people of size endure regularly. At first Aly, the protagonist, a high school jock and popular pretty girl is shocked to learn how she is treated when wearing the fat suit and going undercover as a fat girl. But when she gets upset and feels low, she can still take off her fat suit and live her thin life. The scenes are interrupted for commercial breaks with ads for weight loss cereals and products and at the end of the movie Aly's message undermines everything she has learned about the challenges facing overweight individuals. She still criticizes her diabetic mother for everything she eats, she diets because she is concerned by the weight she gained from a sports injury that has prevented her from training, and in the end goes back to her hot boyfriend who admits to her that he probably wouldn't be attracted to her if she were heavy. In the final scene, Aly talks straight into the camera and morphs from her larger self to her thin one, encouraging people who are overweight (her audience is presumably teenage girls), saying that they are the ones who must sum up the courage to find their inner identity. Armed with a healthy sense of self, she seems to be saying, no one can make you feel small.

To me, the film's mixed message supported the work of Linda Bacon and the Health at Every Size movement, which aims to teach people that a healthy diet and lifestyle may not pave the road to thinness for every single person. But being thin does not equal being healthy or being happy. One of my favorite passages from Geneen Roth's Women Food and God was about just this:

"We don’t want to be thin because thinness is inherently life-affirming or lovable or healthy…We want to be thin because thinness is the purported currency of happiness and peace and contentment in our time. And although that currency is a lie – the tabloids are filled with miserable skinny celebrities – most systems of weight loss fail because they don’t live up to their promise: weight loss does not make people happy. Or peaceful. Or content. Being thin does not address the emptiness that has no shape or weight or name. Even a wildly successful diet is a colossal failure because inside the new body is the same sinking heart. Spiritual hunger can never be solved on the physical level."

Roth's approach deviates from Bacon's in that she sees weight issues stemming from underlying emotional and spiritual issues, and for many that may be the case. Her argument loses strength when she claims that once you address the root of eating that pounds come off and disappear, because that is not always true. People are also programmed differently, have different metabolic needs and ideal body weight can be very difficult to assess. Right now our society does not leave much room for individual difference and as we export our thin ideals around the world we reduce cultural difference as well. At a time when we're so concerned the recent release of radiation into our oceans and environment, we fail to think about the toxic ideas, values and stigmas we constantly spread by word, by page and by action. Why aren't we more concerned about preventing, reducing, reversing the spread of toxins that are in our control?

Women, Food and Good Company

The past few weeks have not been lacking for inspiration but I have resisted the urge to blog for fear that the real overwhelming issue on my mind would seep in and take over any attempt for a cohesive discussion of anything else. The looming question: (where) will I get a dietetic internship?

The dietetic internship is not something I fully understood when I entered the field of nutrition. It is a requirement of the American Dietetic Association that after completing the bachelors or masters level coursework in dietetics, students spend 1200 hours in supervised practice before they can sit for the exam to become a registered dietitian (RD). While it certainly makes sense for students to be exposed to clinical nutrition settings before entering the field, the dwindling number of internship positions and growing number of people entering the field of dietetics has led to the supply and demand imbalance:

More than 50% of applicants will not find placement for an internship, which is conducted via computer matching, and candidates can re-enter the pool for up to five years. This only increases the applicant pool every subsequent year (as evidenced above) and floods the market with nutrition degrees who are prevented from practicing and serving in the field. At a time when public health outcries call for nutrition education and more emphasis on food and diet, the ADA's internship system is a disservice to its cause.

Some universities have coordinated programs in dietetics, which means that admission to their program ensures your placement in their dietetic internship. I now see the repercussion of attending a school that does not have a coordinated program and in retrospect such a decision is difficult to justify. Internships are unpaid, with a handful providing modest stipends. Most, instead, have hefty price tags, with some tuition exceeding the cost of a year's graduate tuition. I was horrified to learn that they offer no financial aid or living expenses money. When I first met with my advisor a year ago she jokingly asked if I had a rich husband. I later learned that she wasn't really joking.

Beyond the financial pressure is the psychological stress. Having spent over six months now agonizing over the internship, the sheer weight of that pressure casting a shadow over my entire year, I can't help but wish I were guaranteed a position next year, in the same city where I studied, where I want to live, where I have a social network and a strong committed relationship. Instead, I wonder if and where I might end up next year. Which coast will I be on, if any? Will I start my internship in June, July or September? If I don't get an internship should I start looking for a job? The uncertainty was reassuring at first. It's out of my hands. I did my part and now I just wait. But the waiting slowly dissolved into the torturous "what-if" downward spiral of thought.

After working hard throughout the winter to perfect personal statements, complete applications, nail interviews while simultaneously satisfying the demands of a rigorous course load, part-time work and volunteer schedule, I was looking forward to spring break. But with no plans to leave the rain-slogged Northwest it was hard to unwind and relax, despite more free time on my hands. In fact, this simply gave me meant more time to wonder what the future holds. I tried yoga. When the rain let up I went for runs. I watched movies and television, read books and magazines. My mind kept coming back to the same thing. Then I left town. Everything changed. Just a few hours south in the crunchy northwestern parts of Oregon I spent time with friends, ate good food and forgot my fears. I rode my bike around Portland and counted the number of birds I saw adorning pretty much everything (okay I didn't count but should have!). I left my laptop at home and rode around in the rain. I spent hours in the car listening to old mix tapes. I sat around with smart, funny women, reading tarot cards, playing games and laughing at the absurdity of the internship process. Discussing fad diets and nutrition issues. Remembering all the reasons I do love this field that I rededicated my life toward three years ago.

Food is about communion and being with people and sharing, nourishing, giving life. A few weeks ago I'd read Geneen Roth's Women, Food and God. I like my friend Ginger's review of it, and like her I found its underlying message was positive. Overall, though, the book was lacking. God was lacking. The author's credentials seemed to be lacking. But mostly the "women" were lacking. Peppered with anecdotes from some of the women Roth has encountered through her retreats and classes, the book doesn't provide the reader with a sense for these women in all their glory. They are abused, looking for love, depressed and masking their emotions with food and detrimental eating patterns. They seemed deflated, one-dimensional case studies, cautionary tales to glean lessons from. Over the last week though I've learned that there is no substitute for spending time with real, strong women, honest about their shortcomings, regrets, fears, hopes and dreams. Returning home I am not so much afraid for the internship announcement on Sunday as I am excited. Excited to start planning for life after June, to jump the next hurdle, to be one step closer toward practicing my profession, to put this application experience behind me and embrace the next.

Conspicuous Consumption

A few months ago I mentioned how some people are utilizing Facebook and Twitter to track their diets and lose weight. On the flip side, more recently I've encountered the phenomenon of in-your-face eating, a public gorging of sorts, and I'm wondering what the motivation is for such behavior.

My interest was piqued after reading an article in the New York Times about actresses' "documented instances of public eating." It is more common than not, that high profile interviews with female celebrities are conducted in restaurants where the waif thin starlette will indulge in an unnecessarily decadent meal, documented in print as she discusses her latest film, television show or theater project if to say that she is a "normal" person too. Public displays of eating, particularly of comfort food and fast food, has become a type of countercultural way for people to prove that they aren't obsessing about their weight like everyone else is. And in some circles it's become downright obnoxious, with Facebook photos of gluttonous meals that instill envy (intentionally or not) in friends who watch what they eat or struggle with their weight. Last week a friend of mine was particularly peeved at the implication of a friend's gratuitous photo of a meal that could only be called pornographic (see CSPI's food porn column for more on this). She was offended by the Facebook post because to her it screamed,"I'm so lucky the rules don't apply to me."

Thinking back to my sociological theory days, Veblen's term "conspicuous consumption" was meant to point to the ways wealth is often displayed to demonstrate social status. Similarly I think that in a post trans-fat world the conspicuous consumption of excessive saturated fats, refined carbohydrates and sugars can sometimes be used to convey a level of luxury, a transcendence of health concerns, a liberated and carefree approach. Maybe that's what is so infuriating to some. But then I wonder, oh why take everything so seriously? Whatever happened to the phrase "eat, drink and be merry, for tomorrow we die"? What are your thoughts?