May 2014 Issue

Dietitians and Their Weight Struggles
By Juliann Schaeffer
Today’s Dietitian
Vol. 16 No. 5 P. 32

RDs speak out about whether they can be effective nutrition counselors when they’re overweight.

In a culture that places so much emphasis on physical appearance, and weight in particular, it’s no surprise that many people have a love-hate relationship with the size of their bodies. A client’s weight loss one week can lead to sheer jubilation, followed by extreme guilt and shame after he or she “falls off the diet wagon” soon after.

Many RDs can relate to their clients’ weight struggles through their own past experiences. But what happens when a dietitian’s weight issues aren’t a thing of the past? Can dietitians who have been trained in diet and nutrition be effective nutrition counselors if they still battle with weight themselves? And how much (or how little) weight denotes such a struggle anyway?

It’s a hot-button issue, one about which many RDs are passionate. But this dietitian weight debate has many sides—and, for some, the issue really isn’t about weight at all.

Weight Matters (or Does It?)
When it comes to the size of a dietitian’s body, does weight matter? According to Susan Linke, MBA, MS, RD, LD, CLT, a Texas-based dietitian who works primarily with patients who have food sensitivities, this answer depends on the type of advice an RD is giving clients.

For dietitians offering total parenteral nutrition guidance or designing menus in a hospital office, Linke says people are looking for specialized expertise in these cases, and weight may not matter. But when clients are seeking advice on healthful eating or weight management, then they’re looking for role models, she says, and weight absolutely is an issue—and an RD’s image is important.

“People do judge by appearance, and we are walking billboards,” Linke says. “If someone has a weight issue, then in my opinion, they should choose a specialty that does not conflict with being overweight.”

With the level of competition in the marketplace, Linke believes it’s even more important for RDs to compete using appearance as well as knowledge. “If you can’t make it work for you, how can you make the case for someone else?” she says. “I’ve seen others counter this by saying that people need to learn to look beyond the physical, but the reality is that health care is a business, and people do judge you by appearance. Is it right or wrong? That doesn’t make a difference. It’s a business, and it is what it is whether we like it or not.”

But a patient’s judgment, often based on unrealistic cultural expectations, doesn’t take away from a dietitian’s knowledge base, says Jessica Wilson, MS, RD, owner of My Kitchen Dietitian and PR/social media chair for the Association for Size Diversity and Health, an international organization that promotes Health at Every Size principles. According to the organization’s website, its mission is to “promote education, research, and the provision of services which enhance health and well-being, and which are free from weight-based assumptions and weight discrimination. Health is measured by many factors, including the right to be peaceful in one’s body.”

“It may matter to the patient because of this country’s preoccupation with getting rid of fat people and negative media images of people in fatter bodies,” Wilson says. “But I do not believe that the RD’s weight impacts their ability or knowledge. I don’t see how the presentation of someone’s body would detract from their knowledge. Do shorter RDs know more than taller ones? Does skin tone play a role in knowledge?”

RDs as Role Models
Yet whether it’s a dietitian or a cardiologist, Linke says appearance matters because clients are using that information in part to choose the health care professional they believe is most likely to help them—and she’d do the same. “I wouldn’t think much of advice from a cardiologist if I knew he had had a heart attack,” she says. “Yes, genetics might play a role, but I’d rather listen to one that’s fit and has good cardiovascular health.

“People have choices,” Linke adds. “If given the choice between someone that practices what they preach and someone that seemingly doesn’t, the public will usually choose to get advice from someone that’s practicing what they preach. If it doesn’t work for the practitioner, how will it work for the patient?”

Lisa Ellis, MS, RD, CDN, a New York-based dietitian, agrees that as role models, how RDs present themselves is important. “Advice on regulating eating disorders coming from someone who even appears to be at the mercy of his or her own eating disorder may lack credibility, even if that advice was sound,” she says. “On the other hand, an RD need not have a perfect physique, just one that appears healthy.

“Weight standards should be irrelevant so long as the RD is healthy, both physically and attitudinally,” Ellis continues. “RDs, like many professionals, stake the vitality of their businesses on their client pools. An RD who appears to be unhealthy may seem to be a less-than-credible health care professional to clients and may not keep those clients very long. This is likely a case of the market determining its own standards.”

But what does it truly mean to practice what you preach, and what does healthy even look like? According to Sharon Salomon, MS, RD, a dietitian who previously wrote the article “Confessions of a Fat Dietitian” for Today’s Dietitian, this phrase brings up more questions than answers, and she notes that anyone (RD or client) would be hard-pressed to determine the healthfulness of her daily habits simply by looking at her.

“Practice what they preach?” she says. “You mean eat healthy foods? Does eating broccoli mean that you’re going to be thin? And are all thin people healthy? What is a healthy weight? Is it weight, BMI, or waist circumference? Is it having good cholesterol levels, low triglycerides, a strong heart, regardless of weight? And how do you know that I do or do not practice what I preach? You cannot tell by looking at me.”

“We cannot make assumptions about people’s lifestyles and behaviors based on what they look like,” Wilson says, noting that this stereotyping behavior can lead to discrimination.

Wilson cautions RDs against holding up healthy-looking physiques as an example because just as an overweight build could lead to wrong assumptions about poor eating habits, so could a thinner body type lead to mistaken beliefs that it was the result of healthful behaviors.

“I believe there are plenty of ‘normal BMI’ dietitians who may be smaller but who are not practicing what they preach,” Wilson says, adding that disordered eating behaviors, such as binging and purging, or lackluster exercise regimens are just two examples of behaviors that may hide behind a thin body type. “And I don’t believe that these RDs should be treated with greater esteem just because of their size. I think that a profession that’s only open and welcoming to people with a BMI of 18.5 to 24.9 is discriminatory, shortsighted, and a disgrace.”

First impressions based on appearance alone also won’t tell you whether a person recently gave birth to twins, is on an antidepressant or other medication, or experienced any other life event that may have caused a recent weight gain or loss, says Theresa Moutafis, MA, RD, LDN, CLC, a community nutritionist in the greater Boston area. Rather than weight itself, she says how an RD handles his or her life experiences is the example to demonstrate to patients.

Health vs. Weight
Maye Musk, MS, RDN, a dietitian in private practice in Los Angeles, struggled with her weight throughout her life but says that with continual diligence, she now maintains her size 6 at the age of 65. Despite her firsthand experiences, she believes an RD’s weight is important because experts giving health counseling should look healthful, too. Musk believes RDs should aim to keep themselves within the recommended BMI of 20 to 25, noting that “we need to be a healthy weight. I find people and other RDNs laugh at overweight dietitians, realizing it used to be me.”

But Juliet Zuercher, RD, a faculty member at the Timberline Knolls Clinical Development Institute, rejects the notion that only those who fit within a normal BMI range are healthy. “The problem is the culture has this dead wrong,” she says. “The idea that a healthy body weight can be reduced to a BMI chart or mathematical equation is absurd.”

An effective nutrition therapist is authentic as a role model, Zuercher says. But does that mean he or she fits into the narrow cultural definition of a particular body weight? “Definitely not,” she says. “It’s impossible to determine health simply by looking at weight.”

In fact, Zuercher says, in most cases, the issue of healthy weight really is code for attractive weight, “which is an entirely different conversation,” she says. “What we find attractive is not necessarily the same as healthy. The culture gets this confused all the time. Health comes in all shapes and sizes.”

Whereas she agrees that RDs should practice the same lifestyle habits and patterns they recommend to clients, she says weight is determined by a multitude of factors, including genetics, and “if [a client] is following healthful patterns, her weight will be what her body wants it to be and health is the end result, regardless of whether this meets cultural norms.”

Salomon gives a firsthand account, illustrating how her weight may not fall in the range of today’s cultural ideal, but her lifestyle habits and abilities spell “elite” much more than “overweight.”

“I’m an almost–70-year-old competitive power lifter,” she says. “My BMI is very high, but I’ve lost no bone since my 20s, when I maximized my bone density by drinking lots of milk and eating lots of ice cream. My muscle mass is that of an elite athlete in her 20s, according to a test done a few years ago. Yes, I’m also fat. My abilities and my lifestyle are what influence people to want to be like me, not my weight.”

Salomon doesn’t believe a dietitian’s weight should ever be an issue, but she encourages RDs to live the lifestyle lessons they teach, focusing on overall health, not weight-based goals.

“We’re here to improve health,” says Kasia Tupta, MHSc, RD, a Toronto-based dietitian. “We’re here to assist our patients/clients in finding their optimal weight—not according to BMI cutoffs. BMI was never meant to be used in individuals. It isn’t a good proxy measure for health. It is possible to lose weight without improving health or with negative consequences to health.”

Tupta believes dietitians would do well to remove weight loss from the picture and advocate instead, as a profession, for size equality and adequate care in health care settings, regardless of weight or size.

“As dietitians, we’re also in a great position to spread the message of Health at Every Size and make other health care professionals aware of how damaging to health the message of weight loss can be,” she adds. “We see this in practice several times a day: restrictive eating, skipped meals, disordered eating, binging as a natural response to starvation common in restricting calories, cutting out entire food groups, usually grains—all measures to lose weight. This is not healthful eating, and this needs to stop.”

“‘Healthy weight’ as a term is entirely problematic from the get-go,” Wilson adds. “Healthy weight for whom? For a native Samoan person or a native Chinese person or someone from a diverse cultural background? Since healthy weight is often a function of BMI, and BMI isn’t a proven indicator of health, I believe that people of any weight can counsel people about nutrition.”

“We need to get over this idea that we can diagnose health by looking at someone’s outward appearance,” says Glenys Oyston, RD, a Los Angeles-based clinical dietitian. “We need to start looking harder at the science of weight loss and admit our limitations. And then we need to get on with the business of helping people build healthful habits and good relationships with food.”

Symptom of a Bigger Problem
According to Oyston, weight can be a symptom of a bigger health problem, be it an eating disorder or otherwise, but it also can be a symptom of nothing at all. “Weight can definitely be seen as a symptom of something going wrong or it might not be a symptom of anything; that person just happens to be a larger or smaller person,” she says. “I like to look at trends. Has the person’s weight been steady or have there been large swings over time? Those big fluctuations tell me something is off-balance with that person; either they’ve been sick or they have been chronic dieters.”

But even if an RD may have a greater weight issue, Oyston still doesn’t think anyone should be deciding who gets to practice nutrition counseling based on weight alone. “That is just blatant discrimination,” she says.

The only time Zuercher believes nutrition therapists’ body weight may be an issue is if they’re practicing disordered eating behaviors, at which point she says it’s certainly an issue. “Dramatic shifts in body weight can sometimes indicate the presence of food and body struggles,” she says. “That said, weight is only an issue if it’s symptomatic of underlying pathology.

“Some of the very best nutrition therapists in the current field have overcome past struggles with an eating disorder or disordered eating,” Zuercher adds, noting it’s important that the issue is in the past.

“The key is that the professional has crossed over to a place of freedom instead of plagued by fear around food choices,” she says. “This is the precise crossover we ask of clients. Therefore, I believe the best we can offer is to be authentic as role models. A major red flag for a newcomer to the field is to attempt to work out personal issues by working in the field. This isn’t only unethical; it hinders the individual’s recovery as well as the client’s.”

Especially in eating disorder counseling, where the clients already have a strong bias toward a particular body size by the nature of their illness, Zuercher says using the RD’s body size as a teaching tool can be a valuable lesson for the client, hence the importance of RDs practicing healthful behaviors.

“Sometimes we counsel best when we have experience to draw from,” Linke says. “However, most people are wanting to know how we overcame those obstacles and became successful at achieving our health goals. So a past history with a health issue shouldn’t be a problem, or even a current struggle, as long as we’re on the winning end of the struggle. If our advice works, then it should work for us, too.”

Takeaway on Weight
Regarding the takeaway message of how RDs should deal with weight issues among their peers, Wilson encourages dietitians to stop the snap judgments and start embracing size diversity within their ranks. “In health care, to me this is a black-and-white issue,” she says. “I do not believe we have the right to go about policing the bodies of dietitians any more than we have the right to go about smacking ‘unhealthful’ food out of the mouths of our patients and passersby. We’re not the food police, nor are we the fat police.”

Rather than impede RDs’ abilities to stand as nutrition experts, Wilson says size diversity, and diversity overall in the profession, will enhance dietitians’ capacities to serve a range of patients. “Fatphobia is rampant among individuals in the profession, as it is in our society,” she says. “I think that this directly impacts our ability to effectively work with fat clients and contributes to this nonsense of fatter RDs putting the image at risk and is clear stereotyping and discrimination of dietitians in larger bodies. I think that it would be wonderful to have people of all sizes talking with clients about having a healthful lifestyle and modeling such behaviors for people of all sizes to align with.”

“If our profession’s perception or image is at risk having fat dietitians, it is worth the risk,” says Julie Duffy Dillon, MS, RD, NCC, LDN, CEDRD, a North Carolina-based dietitian. “Believing a fat dietitian is not acceptable, not successful, and not with a respectable body are beliefs that express the dire state of this civil rights issue. Fat people, including fat dietitians, are discriminated against because of these stereotypes. And stereotypes produce stigma.”

And rejecting larger colleagues says more about a person’s own body image conflict, Dillon says, and she questions the message RDs are sending with weight judgments. “We as dietitians say we’re against diets yet reject those who can’t be ‘successful’ with them,” she says. “We also tell clients to not let the scale define you—except if you are in this work and outside the ideal. It’s time for us to stop talking out of both sides of our mouth. I firmly believe we need to take better care of each other and ourselves. We do this by accepting each other as we are. Fat, skinny, tall, short, gay, straight, black, white—all of us. Our profession is stronger with this diversity.”

Of all professions, Rosanne Rust, MS, RDN, LDN, a nutrition communications consultant, says the nutrition community should be leading the charge with showing compassion about weight management and weight prejudice, not turning on its own. “We need to be the ones who help other professions become more compassionate,” she says. “We can benefit by showing that not only is there more than one way to eat a healthful diet but that health can come in different shapes, sizes, and colors. And we should support each other on that.

“It’d be more productive to stress being professional,” she adds, including honing good communication skills, dressing professionally, and keeping up with continuing education, “rather than perpetuating our society’s shallow views on first impressions.”

— Juliann Schaeffer is a freelance writer and editor based in Alburtis, Pennsylvania, and a frequent contributor to Today’s Dietitian.

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