Reflections on Eating as a Health Professional: Lessons Learned from My Care in an Eating Disorder Clinic

I’ve always been overweight or obese by the body mass index measure. So much in my life tells me that I should focus on losing weight. Working in the health field, I feel so much shame in being overweight. And it’s because we shame and blame people for their weight. Throughout my life, I’ve faced ridicule and judgement — from various people in my life including mentors, classmates, and health care providers, who feel it’s their duty to inform me of my “unhealthy” status.

Many health care providers use body mass index (BMI) as an indicator of an individual patient’s health. Likewise, providers are expected to document their patients’ BMI and when it is “outside of normal parameters,” they are expected to document a follow up plan, such as a referral to nutritional counseling. I sometimes wonder if my providers have documented conversations I have experienced as judgmental and humiliating and counted those as “follow-up” for their BMI performance measure.

We treat obesity as a behavior, and we blame individuals for this “bad” behavior (often regardless of their actual behaviors). However, there are a number of factors outside of an individual’s control, or at least make their weight more complicated. Current fad diets focus on eating “clean,” organic, unprocessed food. Eating this way is expensive and only accessible for people who can afford and otherwise have access. People who can’t afford these “healthier” food options are often shamed for their “unhealthy” food “choices.” Some patients need medications for other health conditions that contribute to weight gain. For others, traumatic life experiences are a key driver for their weight. The link between trauma, especially early in life, and obesity/weight gain is well-documented. Anyone who has read Roxane Gay’s book Hunger: A Memoir of (My) Body has glimpsed into how childhood trauma can manifest as weight gain. For many, the relationship and practices around food are a way of coping that cannot suddenly be stopped.

About two years ago, I decided to seek treatment for my own disordered eating. The first health care provider I talked with shared her honest assessment of the insurance and referral system: that it’s incredibly difficult to navigate, get in, and get your care for this paid for. I didn’t take any further steps at that point.

Some time later, I got a new insurance and a new primary care provider. Toward the end of my initial visit, I thanked her for not bringing up my weight and confided in her about my desire to get care for what I thought might be an eating disorder. Six months later, after jumping through many hoops, I was able to start care with an eating disorder clinic, seeing both a psychologist and a dietician individually, as well as participate in group visits with others struggling with compulsive/binge eating. The main goal was to start healing my relationship with food, and for this to happen, I could not focus on any weight loss-related goals.

Below are some lessons I have learned in the course of my treatment:

My behavior and attitude toward my body is more important than my weight.

Diets (i.e., restricting food quantity or type) don’t work to maintain weight loss over long periods of time. Rather than losing weight, my goal is to heal my relationship with food and my body.

Physiologically, my body needs fat, carbohydrates, and protein at least every three to four hours to function well.

Prior to my treatment, it was not uncommon for me to wake up around 8 a.m. on a Sunday and not eat anything until 11:30 a.m., at which point I would eat a large brunch. During the week — if I remembered to take a break for lunch between meetings — I might have lunch around 12:30 p.m. and not eat again until 6:30 p.m. I learned that to keep my body fueled, I needed to eat within an hour of waking up and not go more than three hours without eating. I still do Sunday brunches sometimes, but I try to snack on something small but hearty soon after I wake up. And I might have a snack — maybe even two — between lunch and dinner.

I should move my body and exercise in ways that make me feel good and bring me joy.

I no longer waste my time or set goals around exercise that I don’t enjoy. I’m more likely to continue moving my body and exercising over time if I enjoy it. For me, this has meant going to dance classes that I love, as well as walking and biking outdoors.

Eating mindfully and having an awareness of my level of hunger and fullness is more important than counting nutrients or even portion size.

I grew up as part of the “clean your plate” club: if it was on my plate, I would eat it. This kept me from learning my own body’s signals of when I was hungry or full — and to what degree. Part of my process has been learning to feel the different levels of hunger and fullness that I’m feeling at any given time.

Check on physical vs. emotional hunger.

If I feel compelled to eat, but I’m not hungry, I try to pause and reflect on what I am really hungry for. Am I actually lonely, bored, self-conscious, or experiencing some other feeling? Is there another way to satiate that “hunger” or address that feeling other than eating? Maybe I can reach out to someone whose presence I enjoy, do an activity I like, or maybe take a break or leave an uncomfortable situation.

Let go of guilt around eating.

I have tried to move away from binary thinking about food (good vs. bad, healthy vs. unhealthy) and move toward eating foods that I enjoy. Allowing myself to eat food that I enjoy in quantities that feel good in my body keeps me from bingeing on them. Many of us in my group shared the experience of feeling proud of ourselves when we managed to skip a meal (“fewer calories, yay, good job!”). We often felt we needed to stop eating certain types of “bad” food because they were slippery slopes and once we had a taste, we wouldn’t be able to control ourselves. In fact, these behaviors were setting ourselves up to binge eat, especially at night. Eating foods I want to eat, when I want to eat them, with an awareness of how they taste, how they make me feel, and my level of hunger and fullness has allowed me to actually enjoy my food more and curbed binging.

My body is not “doomed.”

Just because my body is the size it is right now, doesn’t mean it will always be this way. There might be things happening in my life right now that is affecting my weight, and those things may change over time. How can I find appreciation and care for my body as it is now?

Above all, be kind to my body — feed it when it’s hungry and treat it and talk to it with respect.

I try not to talk about my body in a way I wouldn’t want my child or someone I love to talk about their body. I’ve started buying clothes that are comfortable and fit my body as it is now, even if the size on the tag is not I want it to be.

This is all very much a process and a work in progress. In fact, writing this has allowed me to summarize, synthesize, and further process this journey and important healing work to date. Letting go of the goal of losing weight has by far been the most challenging, since this has been hammered into me my whole life.

My ask of health care providers is to consider how you may be reinforcing harmful attitudes patients have about their bodies, promoting unhealthy behaviors and unhealthy relationships with food (perhaps unintentionally), and using ineffective measures of health. What guidance are we giving our patients on weight and eating? How can we better take into consideration their economic situations, their cultural norms, their experiences of trauma, and other physical and mental health conditions they are dealing with at the moment? Their weight may not even be close to the most important thing for their health at this moment.

Based on my own experience, here are some tips for talking with patients about weight:

• Shame and humiliation are not only ineffective in motivating behavior change, they are also unethical and bad care.
• Don’t make assumptions about behavior based on BMI.
• Seek a better understanding of why a person might be overweight, like this nurse did.
• Not all problems patients with high BMI face are related to their weight. When one is, provide additional options beyond recommending weight loss that will help them.
• Don’t give advice without being asked or at least establishing a trusted rapport. When doing so, convey empathy.
• Let go of the prevailing Eurocentric lens and expand ideas of what healthy eating looks like across cultures.

A note of gratitude: I am grateful to my primary care doctor who, at my first visit, helped me navigate getting care for my disordered eating. I am incredibly thankful to my providers at the clinic were I have been seen for the last nine months. Thank you to my fellow patients in my group visits, who showed me that compulsive and binge eating shows up for a lot of different people in different ways, but that we can empathize and show support for each other.