getting right in a well world

In a photo accompanying a recent NY Times trend piece, a smiling, healthy-looking woman stands next to her soup rations for the day. The woman is souping, a new type of cleanse/detox just like juicing, but without all the sugar and calories that come with it. The article is interesting not because souping is interesting (it’s not), but by virtue of what the author, Rachel Felder, has decided to leave unasked. Lacking are questions addressing the purpose or efficacy of cleanses, or the veracity of claims made by their proponents. Without these paths of inquiry Felder unmasks the true purpose of cleanses and detoxes: as signs in the new semiotics of weight loss. They function to allow one to wish for, and work toward losing weight in situations where it would be considered culturally or medically taboo to do so. They allow for those on the leftward side of the body mass index J-curve to push lefter still, to negate a possible increase in the risk of all-cause mortality with benefits, such as clarity, glow and a reduction in toxins, that are much more difficult to measure. This is all presented as perfectly reasonable. Even the dietitian interviewed presents a 1200 calorie soup cleanse as only 200 calories less than the diet she often recommends to her patients. (She works with diabetic patients, many of which undoubtedly have type 2 diabetes, are overweight/obese and who would medically benefit from weight loss.) Meanwhile, discussions of diets and weight loss are reserved for overweight/obese people. Consider the experience of Sarai Walker while on a book tour to promote her new novel. She wrote, also in the NY Times,

During the audience question-and-answer period, people stood up, one after another, and made negative comments about weight. I felt like a witch surrounded by torch-wielding villagers. It was clear that even for many urban sophisticates paying to attend a festival about difficult ideas, thinking about fat as anything but bad was borderline impossible. 

Given her weight status, Walker's search for wellness was incomprehensible. A detox or cleanse would not be adequate for her because at her weight only dieting and weight loss are considered appropriate. She cannot be cleansed until she rids herself of that pesky toxin called fat. But the demand that overweight/obese people hate their bodies does not stop those of a normal weight from doing the same, they just need to discuss the treatment differently. So cleanse yourself of inadequately defined abs and thighs that touch, and get right with the well world.

dietitians should not try and make snap work

The twitter account for the professional arm of the Academy of Nutrition and Dietetics (AND), @eatrightPRO, recently retweeted the following,

How do we eat better with less $$? #SNAPedWorks #rdchat @eatrightPRO
RDN's can help people shop, choose, cook, eat better

— Karen Ehrens (@KareneRD) January 27, 2016

Obviously, Ms. Ehrens heart is in the right place, but there are two problems with her tweet.

First, it promotes the idea that with the right combination of knowledge and skills that it is possible to eat healthy with the allowance afforded by SNAP. This notion is problematic because it concedes that SNAP is sufficient as it is currently structured and therefore could be used to argue against continuing SNAP benefits, or against a future expansion of benefits. Someone who is against the expansion of SNAP could construct an argument along the lines of: (a) Dietitians say that at current benefit levels all it takes is a little knowhow and ingenuity to eat healthy on SNAP, (b) Dietitians are nutrition experts and should therefore be trusted, (c) Thus, SNAP benefits are adequate for ensuring a healthy diet.

Dietitians should want no part of that. AND should want no part of that because as an organization that prides itself on being evidence-based the evidence on poverty is pretty clear: it’s bad.

The second problem with Ms. Ehrens’ tweet is that in reality dietitians possess no special knowledge that for most people dependent on SNAP simply having more money would not fix. For instance, just recently Rogers et al (2015) published work that found pediatric obesity and poverty are highly associated in Massachusetts. Less poor means less overweight/obese. Their findings speak to the fact that dietitians should be arguing for poverty reduction strategies such as a more robust welfare state, or simply making payments to poor patients for attending counseling sessions, rather than repping their own ability to make healthy food choices on the meager budget afforded by SNAP. Obviously, expanding welfare is the preferable option, but paying patients to attend counseling is interesting and could result in a not insignificant cash exchange. Using pediatric obesity as an example, current best practices (see: Barlow, 2007; Lenders, 2016 (in press); Whitlock, 2010) are recommending upwards of 25 contact hours with patients and their family, and may serve to essentially put people deeper into poverty. Wright et al (2014) found that the mean parent-incurred cost per child was $30 for an intervention consisting of approximately 2.2 contact hours (4 25-minute in-person visits, and 2 15-minute telephone calls). For a patient and their family to achieve the 10-25 contact hours that seems to be necessary to make a meaningful change in weight status, the parent-incurred cost would be between $136 and $341 – 1-2 times an average monthly SNAP benefit. And programs that can effectively increase contact hours are in demand. For instance, the CDC is currently funding research to find low-cost interventions that include 25 contact hours and can quickly scale. As similar interventions are established families will be encouraged (or even pressured) to attend an increasing number of visits, but their attendance is costly. And sure, a disease like obesity is associated with significant healthcare costs, but these costs, especially for poor patients, will be borne by the state not the patient. If patients were paid $15 per contact hour we could negate the patient-incurred cost of attendance. If patients were paid even more, say $30 per contact hour that would provide them an additional 10-20% of the average SNAP benefit over a period of six months to a year (the timeframe in which the 10-25 contact hours is recommended). And payments could simply be added to an EBT card, or a new one could be issued. Paying patients will not lift them from poverty (again, expanding welfare is a better option), but it could provide underserved populations some additional income that would allow them to implement changes recommended during visits.

At the risk of rendering a large number of dietitians useless, dietitians should be advocating for an expanded welfare state because poverty is largely the problem, not a lack of nutrition knowledge or food-related skills.

motivational interviewing

[An obese pediatric patient around eight years old and his mother are at a pediatric weight management clinic. They enter the office of the clinic’s registered dietitian.]

RD: Nice to meet you both, please have a seat. Thank you for coming in today. In this part of the visit we will discuss food and nutrition, but before we begin I want to have a better idea of why you think you’re here. So, in your own words, what brings you to the clinic today?

Patient [with some hesitation]: Because I’m bigger than the other kids.

RD: Actually, you’re here because the sovereign, or in our case the government, has replaced punishment with discipline, primarily through its use of biopower. What this means is that the government is going to do everything in its power to maximize your utility – your ability to make money essentially – by expanding the number of years you are healthy, which really means useful. So, what grade are you in?

Patient: Uh, 4th grade. 

[End.]

on rectal feeding

From Dudrick and Palesty (2011, my emphasis),

 In 1910, Max Einhorn used his “duodenal pump,” a tube with a metal capsule on the end (which was usually used for sampling duodenal content) to introduce milk, eggs, sugar, and water directly into the duodenum in patients who could not be fed by mouth or stomach. He also vigorously condemned rectal feeding because of the high incidence of rectal irritation and the poor absorption of the nutrients.

 The efficacy of rectal feeding was debated in the nineteenth century (Harkness 2002).

Einhorn's "duodenal pump" minimized feeding intolerance and rectal feeding fell out of favor, although administration of water, saline, and glucose rectally continued until 1940. Gresci and Mellinger (2006) describe numerous bedside placement methods dating back to the sixteenth century,

In the 1790s, Hunter described the use of a hollow tube introduced into the stomach for feeding. He successfully treated a patient with paralysis of the muscles of deglutition by using a tube made of a whalebone probe covered with an eel skin and attached to a bladder. The eel skin–covered probe was placed orogastrically, and the suggested feedings were jellies, whipped eggs, sugar, milk, or wine.

Which is to say, the rectum should not be considered a serious route of administration for enteral feeds. And yet,

CIA used "rectal feeding" on some prisoners, which led to gross medical complications: #TortureReport pic.twitter.com/4EkTcSuKDY
— Alejandro Alvarez (@aletweetsnews) December 9, 2014

Einhorn would not be surprised.