To the root of the problem

Why is nutrition so hard? Why do 10 people hear a nutrition message, 1 can "easily" make the changes, 7-8 struggle, and 1-2 develop an eating disorder?  Because what we eat is not a cognitive decision.  It has much more to do with our psycho/social circumstance and where we are rooted as people.  

Dietitians (like others in the healthcare field) are trained to teach. We are adept at spouting nutrition recommendations - grams, ounces, calories, portions etc. We are taught that to help people change, we must teach them to read labels, what foods to buy, how to cook, and strategies to navigate the grocery store. And when patients "fail" to follow through, we teach it to them again...and again...and again. Because science is the goal we must all achieve. So we try a new spin or gimmick, but always the same bottom line education. Because their "failure" to follow through must be due to lack of knowledge...right? 

The problem is knowledge does little to inform behavior. I challenge you to find one person over the age of 10 who doesn't know that fruits and vegetables are "good for you." Yet, only 1 in 10 Americans gets the recommended amount each day. Is knowledge really the issue? And if it's not, why we do continue to insist the path is change is to "teach" people what to do? 

How to make sense of it all

Marci Evans is a dietitian and food and body image healer who shares her model of how she explores the connection between our knowledge / action in relationship to our thoughts and beliefs and our deeper sense of self (if you do any nutrition counseling and haven't taken one of her trainings, do it now - your practice will thank you). She uses the visual of a tree to help clients and providers understand why food choices can be so complex. 

Like a tree, the most obvious parts we all see and admire are the leaves and branches. In this analogy the "obvious" nutrition aspects are our food choices and behaviors. It's our outward nutrition expression.

​The trunk represents the thoughts and beliefs. Or how we think about the choices we make. 

The lower level stuff is not as obvious, but is arguably the most influential part of the tree. This is where our deeper relationship to self and others reside. 

These different parts of the tree are connected and influence one another. What happens at the roots, plays into the trunk, and in turn the leaves and branches.

​People have a strong desire to focus on the leaves. It's easier, cleaner, and appealing to analyze and preach knowledge and action. But changing the upper level things like meal timing is connected to thoughts and beliefs as well as personal well being. Disrupting those patterns changes quite a bit.  It's not "just" food choices, it's the mental and emotional baggage tied up in it.

A deeper dive into the tree 

Humans are diverse creatures and the systems in which they grow are complex. Like a tree, humans are impacted by the soil we are planted in, the pests around us, and the nourishment and care we receive. We develop complex root systems that ebb and flow based on what we're exposed to and who we are. 

And like trees, we all have different potential and value - maples, evergreens, birch, willy, palm, coconut etc. All beautiful and valuable but require specific conditions to grow optimally. We flourish and wither in different environments. We can absolutely be transplanted and grow in unique circumstances. But we all share the common denominator of need - water, air, nutrients, and a safe place to root.

What does this have to do with nutrition? 

Many people are "stuck" in perpetual cycles of on-again, off-again health behaviors - increasingly frustrated and demoralized with each attempt at changing their food, usually with the hope of weight management. Often labeling themselves "lazy" or "unmotivated." They focus on the leaves - creating strict rules and expectations without considering what's driving those behaviors. So often, their roots are malnourished leaving the leaves withering and dry. They find themselves trying to put the leaves back on the tree over and over again expecting to "fix" the issue - "If I eat this way, I will be worthy."

But the leaves don't stick...and they won't stick until they start to understand the root. If they do the dirty work to understand what's under the surface, the tree begins to heal itself - eventually developing new, deeper, stronger roots that are resilient to those social / environmental "pests." They flourish without so much effort.  

Dietitians are not trained to work in the roots. That's where mental health professionals work. But in order to be effective, it's important to understand the tree (and the person) at that level in order to best help the individual. 

To note - Providers come to the clinic space with our own ecosystem. We have to be mindful that the support we provide and knowledge we retain is often informed not only by science, but also our own thoughts and beliefs, as well as deeper relationships. To best serve those we work with, we have to be mindful to let our patients grow at their own rate. 

An example - 1 "guideline" and 3 responses

Nutrition recommendations are everywhere - rules about what, where, when, and how much to eat. Many wonder "where's the harm" in doling out nutrition advice. What could it hurt?

Let's consider the general recommendation to "follow the plate method." While it may not seem like a "diet" on the surface, it is based on restricting what you eat to defined rules - 1/2 plate of produce, 1/4 plate of grains, 1/4 plate of protein and typically done with the goal of weight management. 

Based on research, we know that approximately....

• 5% of people who decide to try a diet, will stick with it no problem (Stunkard & McLaren-Huma, 1959) 
• 30% of people who diet, develop an eating disorder (shisslak & crago, 1995; patton et al, 1999) 
• that leaves 65% floundering on and off with the approach....for however long they're willing to try

​
So playing with that data, if 10 people try the plate method, 1 person will succeed in their effort,  1-2 will develop an eating disorder, and the remaining 7-8 will be on the struggle bus, trying to "make it work."  But why? 

Let's look at 3 examples of how the guideline to "follow the plate method" might be internalized by people. 

• For a small percentage of people, they will be told to follow the plate method, and they'll do it no problem. It will cause no anxiety or suffering. They'll follow it when they can and then be flexible about the times they cannot. Their ability to follow the guideline results in little emotional conflict - they won't blame or shame themselves when they're not perfect. And this is largely because they are strongly rooted in their sense of purpose and self that goes beyond their body. They recognize their worth is more than physical and as a result, they have more compassion for their circumstance and outcomes.  
• Most people will struggle with the guideline. They will follow the rules as long as they can but when they don't, they'll experience intense shame and blame for their "inability" to do so. But they don't often go on to recognize and/or have compassion for themselves when the external guideline doesn't align with their personal circumstance whether that's due to limited emotional support, limited personal circumstance / resources such as time / skill, and/or competing demands like cultural norms.  They are left in a place of suffering because what they feel they need to do is not in alignment with who they are. So they try...and try...and try but often spend more time recovering from their efforts than time actually maintaining the behavior. 
• An overwhelming third of people will go on to develop an obsessive relationship with the idea of following the plate method. This can happen for many reasons. But commonly I see it develop out of fear it might harm their physical body (eg, health, weight) and/or impact their sense of self worth / value to the world. They are left in a rigid world guided by food rules - about what they can and cannot engage in leaving them with intense personal suffering. They often begin to believe that more rigidity will lead to greater outcomes and may restrict more...and more...and more. This may lead to a restrict-binge cycle where they obsessively restrict and then become so deprived they feel out of control around food. Still others will feel so limited by the rule itself, they'll eat out of rebellion and/or out of avoidance of the pain the rule causes. Their focus (and life) is fixated on following the rule and not always what the rule (and its promise) really represents in their life - love, connection, belonging, safety. 

The trouble is, some who fall in the 30% struggling with disorder on the surface appear similar to the 5% who easily shift their diet. You can't always "see" the disorder or anxiety from the outside or the thoughts behind the behavior.  And often those with the obsessive relationship are praised for being so "good" and "healthy" and "strong" and mis-construed as having a healthy relationship with self. For those in the 30%, it's easy to begin to think it's normal and "healthy" to obsess about your food.  Let's be clear - it's not. 

Additionally, it's crucial to recognize that the surface behaviors around food and movement are not disorders in and of themselves. Running a marathon, trying keto, manipulating weight, or trying intermittent fasting does not make you disordered. What matters most is what's UNDER the behavior - the thoughts, emotions, and downstream impacts that disrupt and destroy lives. Those behaviors can be symptoms / expressions of disordered behaviors, but they, in and of themselves are not disordered. 

Important note :  There are many reasons these relationships may occur for any one individual. This article is not meant to pathologize eating behaviors but rather provide an examples from clinical practice of how people internalize and response to external nutrition guidance. 

Background about eating disorders

Many think of eating disorders the way it's traditionally portrayed in the media - gaunt, white, young females. But eating disorders do not have a "look" and the perpetuation that you can identify an eating disorder by looking at someone creates a barrier to identification and treatment for many.

What are eating disorders? 

What are eating disorders?

Eating disorders are a range of psychological disturbances characterized by abnormal, or disturbed eating patterns. Examples include anorexia, bulimia, binge eating disorder, and others. They can affect people of any race, gender, ethnicity, and socioeconomic class and they are on the rise. Recent research has shown that eating disorders have more than doubled from 2000 to 2018. They often occur with other mental health conditions and have the highest mortality of any mental health condition, particularly from suicide.

Eating disorders are complicated (to say the least) and it's difficult to predict who and why someone develops them, and in turn how to treat them. Jessica Setnick has developed a model exploring the origins of dysfunctional eating exploring the role of biology, trauma, learned experience, and addiction. The point is an eating disorder is not someone's "fault" (parent or otherwise) and it's not rooted in vanity. On the surface they may appear about weight or nutrition, but on a deeper level they are often a tool people turn to for safety and inclusion.

IT's a spectrum of behaviors

It's a spectrum of behaviors

What's more important to understand is that the rate of disordered or unhealthy eating behaviors is much higher than those that fit into a diagnostic category. Not everyone "checks the boxes" of an eating disorder, but that doesn't mean their body image and food selections aren't causing turmoil in their lives. 

All too often people hide their behaviors behind the mask of health. In our weight focused world, we are taught to revere "good food" and "exercise" and that "no amount is too much" so long as it leads "to the right body / health." But there's a fine line between passion and obsession and it's important to know that you do not need to eat perfectly or exercise obsessively to be healthy. And you do not need a "certain body" to valued and loved. In short, your weight is not your worth.

Summary....

Nutrition guidelines are not "harmless." We have to take care to understand "who" we are talking to and where they are rooted.

Keep in mind roots can grow, change, and shift based on the care they receive.

Working in the roots is hard, dirty work that takes incredible time to unpack. But the changes you see go on to support the "whole" you - not just your food. 

Stay nourished friends!