What Makes A Diet "Medically Necessary?"
The scientific limitations and underlying fatphobia of doctor-prescribed food restrictions.
Disclaimer: You’re reading this column because you value my input as a journalist who reports on these issues and therefore has a lot of informed opinions. I’m not a healthcare provider and these responses are not meant to substitute for medical or therapeutic advice.
Q: How do you avoid diet culture nonsense when on a medically-necessary diet?
Background: I’m 41, and just had my first colonoscopy during which some polyps “of concern” were found and removed. Family history of colon cancer, of course. My gastro commanded a high-fiber diet and said I’ll also want to avoid red meat, cured meats, and alcohol.
Looking for resources on what to eat and how to prepare it has led to a lot of chia-pudding-industrial-complex nonsense in front of my eyeballs. Or gross/restrictive/bullshit, however you want to frame that.
I’m a small fat who is into weightlifting, and generally feel like I look like a sexy tank. I’m at a stage where I understand that weight loss qua weight loss isn’t actually going to help this particular condition, and I know that my weight loss attempts in the past probably led to some of the GI issues I’m facing now.
I presume this is something to take to a dietitian, but I’m not super comfortable with that, due to what I assume will be the obligatory weight loss discussions. Is there weight-neutral food and health advice out there that I’m missing?
I promise, we are going to talk specifically about the health risks of red meat. But I picked this question because I get asked some version of “what if I have to stop eating X for Y health reasons?” often, and so what I really want to do today is offer a framework to help all of us think about whether any particular medical dietary change is necessary and whether that change will be health and wellness-promoting for you.
Sometimes this question is clear cut: When I was 11, I ate a bunch of (delicious) shrimp. I immediately broke out in hives all over my face and inside my mouth, so I took a bunch of Benadryl and have spent the subsequent 30 years never eating shrimp again. My reaction was mild, but allergic reactions can go deadly fast and nobody needs shrimp cocktail in their life that badly. Also: While it’s sometimes a minor inconvenience to skip shrimp, I don’t feel restricted or stressed out by that decision, in part because I can still happily eat every other kind of seafood.
Sometimes food restrictions are necessary even when they cause significant stress. When my older daughter was recovering from life-threatening complications after open heart surgery, we had to put her on a virtually fat free diet for several months and it was an utterly miserable thing to do to a toddler. But we couldn’t have gotten her out of the pediatric ICU without it. Living with Celiac Disease or a peanut allergy likely falls into this category. It utterly sucks and requires a ton of support to navigate, but you can’t live a safe or functional life without this restriction.
More often, though, doctors and other healthcare providers tell us to cut out certain food groups as a preventative or experimental strategy. The reasons for making this change aren’t cut and dried. The strength of their evidence varies wildly. And these prescriptions are very often steeped in diet culture. This means nobody is spending much time helping you consider the toll that this kind of eating pattern may take on your mental health or larger physical well-being. They aren’t watching to see if it triggers a restrictive mindset or adds to your daily stress in other harmful ways. And: Nobody is articulating the underlying anti-fat bias that informs many of these medical recommendations. I’ve asked Marci Evans, MS, CEDRD-S, LDN, an anti-diet dietitian who specializes in the intersection of gut health and eating disorders, in Cambridge, MA to help us think through this much murkier category of Medical Diet Advice. Which, by the way, should always be framed as “advice” and not a requirement. “I strongly believe that decisions around food elimination are for my client to make, not for me,” says Marci. “Body autonomy is incredibly important. And I rarely advocate for removing entire food groups because it’s rarely necessary.”
So on that note, let’s talk beef.