Inclusive Nutrition, with Catherine Brown

After becoming a Registered Dietitian Nutritionist, Katie Brown worked in both hospital and nursing home settings providing medical nutrition therapy for several years, where she gained experience working with patients with mental illness and prior psychiatric hospitalizations. Throughout her career and personal experience, Katie has found that healthcare can be very uncomfortable and alienating for people, especially those who are mentally and/or physically disabled. Katie works to mitigate the discomfort felt by those seeking healthcare in her inclusive nutrition practice.

Learn more about Katie's practice here.

Credits:
Host/Writer: Nicole Klem, MS, RD
Guest: Catherine Brown, MS, RDN, CDN
Production Assistant: Sarah Robinson
Video/Audio Editor: Omar Brown
Theme Music: Sungmin Shin, DMA
Faculty Consultant: Nicole Klem, MS, RD

Nicole Klem 0:04
Hi everyone and welcome to another episode of the Buffalo HealthCast, the University at Buffalo's premier health podcast. I'm your host today, Nicole Klem, a Registered Dietitian and Director of the Clinical Nutrition Graduate Program in the school. And with us today is Catherine Brown, a Registered Dietitian and owner of Inclusive Nutrition Counseling, a nutrition counseling practice. Her model focuses on individuals with mental health issues and disabilities. She's working on weight bias in health care, and is focused on a Health at Every Size approach to help clients make and achieve small goals toward overall health success. Thank you so much for taking the time to speak with us today. So I'll begin by asking you to tell me about yourself. And tell me about your practice model and how it's unique.

Katie Brown 0:46
Thank you for having me. Like you said, my practice is focused a lot on mental health, and on treating people with disabilities. My goal is to create somewhere where people could feel safe, who typically don't feel safe in normal healthcare settings, they feel like doctors don't listen to them or just blame either their mental health or their weight for whatever medical issue they're having. And, you know, don't really have the patience to help them work through changes that they need to make to improve their health and quality of life. I like to focus a lot on obviously, small changes, like you said, but also really focusing on the patient and how their life is and how we can find changes that will work for them. Because you know, overhauling their whole diet or making a bunch of changes isn't always very realistic for someone that's already struggling with a lot of things. But that also doesn't mean that there's nothing we can't do to make their situation better and make them healthier.

Nicole Klem 1:40
And what drew you to this type of practice?

Katie Brown 1:42
So I am a patient myself. And I've spent a really long amount of time at doctor's offices, meeting with doctors. And one of my doctors, this was probably five or six years ago, I came in with a variety of complaints. And she told me that it was psychosomatic and that there was nothing wrong with me. And I would never get better. And it was really difficult for me. And I actually avoided doctors for two years after that. And then I finally got diagnosed with lupus. So it was not psychosomatic. And I definitely know a lot of other people out there experienced similar things and really want somewhere where they feel safe, and they feel heard and they can get the help that they need. And so that's kind of where I wanted to create something because I wanted to be a space where people weren't afraid to come see the doctor or the dietician, and they felt like they could be open about their challenges and not be judged. And I think that's really the start to really changing overall. Because you know, if they're not going to be open with their provider, because they're too afraid of being judged, then you can't really help them.

Nicole Klem 2:44
Yeah, all right, interesting. Definitely a little area of dietetics that is important in different populations. How does your practice work to minimize weight stigma, specifically, in nutrition counseling?

Katie Brown 2:56
Obviously, I'm just gonna go over what weight stigma is, but it's basically this bias towards the fact that weight is, you know, the root cause of a lot of issues. And that is what needs to be addressed. And a lot of doctors when you come in for like knee pain, back pain, even depression, they'll be like, Well, have you tried losing weight. And for a lot of patients, one thing is weight loss is not really achievable. And, you know, we want it to be we want it to be like calories in calories out, oh, you're just gonna reduce what you eat, and you're gonna lose weight. But for a lot of people, it's really, really difficult. And the second thing is that some people have lost weight, you know, like, maybe they were 300 pounds. Now they're 200 pounds, and the doctor is like, well, you just need to lose weight. It's like, I lost 100 pounds, which was really difficult, expecting them to lose more is not really realistic. And the truth is that there's no condition that only obese people get. Every condition that obese people get, skinny people get to. And so we have to realize that like, while it might be a contributing factor, usually there's still other stuff going on. And there's usually other treatments. And that's one thing for me is, you know, I was really pushed to lose weight to get better. But as I met more people, there's a lot of people with autoimmune diseases who are very thin, and they still have joint pain, and they still have all of the symptoms I have. And so realizing that maybe it's not weight, and then being able to make changes and feeling better, even without weight loss. So sometimes, you know, we think, well, if you're eating healthier, you must be losing weight. But that's not necessarily the case. You can eat healthier and be maintaining weight and feeling better, and having better cholesterol and better blood pressure and all those things.

Nicole Klem 4:30
In the counseling settings, what tools are you using to, you know, make the patient either feel more comfortable with their experiences of the past in healthcare or combat some of the stigma they might be coming to you with?

Katie Brown 4:45
So I would say my patients actually talk the majority of the sessions, especially for the initial one, and we really go through a lot of different things like what diets have they had done before? You know, how do they feel about certain things? How do they feel about their weight? What has their doctor told them? What are their goals because some people are still kind of interested in losing weight. And, you know, they're like, hey, if I lose a little bit of weight, great, but I don't want to, you know, lose a ton of weight, I don't think that's realistic, which is awesome. There are other people that are like, I don't want to lose weight, I don't think it's realistic. And I have a history of eating disorders. So it could be dangerous. For me, I think actually, the first thing that's helpful is that I am also overweight, there's a lot of people in the weight-inclusive space who are very thin, it's actually a trope of really thin dieticians, who are like, weight-inclusivity, it's great. And it's awesome to have lots of different people have championing it, but they don't really understand what it's like. So I think that's really helpful. And then just really listening to them, listening to their history, what their concerns are, we actually talk a lot about educating. So you know, they'll think, well, I have to lose weight in order to improve my cholesterol. That's what my doctor said. And we actually talk about what is the science behind that? What do you actually need to do to be healthy, and it kind of makes them feel better, that they don't necessarily have to lose weight to improve their health.

Nicole Klem 6:06
And so if folks maybe haven't always felt heard, and part of your goal really is just to listen to some of their story.

Katie Brown 6:14
Yeah, and validate their feelings, because a lot of them feel like, this is really hard, why can't I be successful. And then, as I talk with them, you know, explaining, you're not the only one that's not successful. 99% of diets fail, most people regain the weight. And so it's not unusual that you have those struggles. But also, that doesn't mean you should give up, and that there's nothing you can do.

Nicole Klem 6:38
Sure, I'd be curious to learn a little bit more about the accessibility of nutrition counseling in general, you know, so again, people might be uncomfortable in the healthcare system, but still know that they're, you know, seeking some nutrition changes. Is it something that is affordable that all groups have access to? Or are we seeing some gaps in who can receive nutrition counseling, and who has, you know, access to it or, you know, understand how to seek out someone like you. So here you are providing an excellent service for people who may have been, you know, feel like they've been harmed by the healthcare system, or the stigma or bias out there, but how do they get to you, or gaps that are in sort of access to nutrition counseling?

Katie Brown 7:23
There's a lot. This could be a long discussion. I would say one thing is that doctors and patients don't always know we exist and what we can do. And so people don't realize we can help with mental health, and we can help with a variety of different conditions. And they kind of think, Oh, you just do diabetes and heart disease, and I don't have those, so I don't need to see you. So I'd say the first thing is having people realize that nutrition can affect a lot of conditions, actually, the majority of them. The second part to that is there's a lot of issues with insurance coverage. So some insurances are great. They cover so much nutrition counseling, and actually most commercial insurances cover a huge amount of nutrition counseling, it has no copay, because it's under preventative, usually there's no cap to the number of times they can see you. So if they need to see you every week, they can see you every week. The issue is Medicare only covers diabetes and kidney disease. And they will cap you at two to three hours per year. So basically, you know, if you have any other issues, and you're on Medicare, we can't help you. And this is really hard, because there's people who when they go on disability, they end up on Medicare, Medicaid, if they're permanently disabled. And Medicaid does not cover any nutrition counseling. And Medicare obviously only covers those two. So if people are, let's say they're underweight, they're actually malnourished. You know, I've had patients where they can't absorb nutrients properly. She was becoming severely malnourished because she couldn't absorb nutrients properly. She's like, I'm worried that I'm going to die if I don't fix this, but she's on Medicaid, and it's not covered. And so then you get stuck with like, do you take these patients pro bono because they don't have money to pay you? Or do you, you know, send them away. And this definitely becomes really challenging and very hard because you want to be able to help everyone but also you can't have an all pro bono company. So I know a lot of dieticians, who will have several pro bono spots in their schedule. So like, they'll say, like, Okay, I'm currently going to work with 2 pro bono patients. And then when those ones leave, they then will see another one. But obviously, it's not a large majority of your practice. There's currently a bill to expand Medicare coverage for M&T. And then in Medicaid for New York State, they've expanded it to pregnant women and infants, I believe. So we are getting there and it's likely that the Medicare bill will pass and hopefully it does because then it will expand to so many more areas. It probably will still have the two hour limit, which I think is not enough for a lot of conditions and a lot of people but at least they will be able to get something because right now they can't get anything

Nicole Klem 10:00
And how about the delivery of services? Do you do a lot of telehealth? Are you more virtual? Do you see people more in person? You know, one of the barriers, I think is time and transportation and, you know, scheduling an appointment that might be in a different location than they're used to going.

Katie Brown 10:18
What's really interesting is that for some people, in-person is more accessible. They feel like they struggle with technology, especially older people, or you know, they have hearing problems, they can't hear as well, all of those things. So they like in-person. And then other people prefer telehealth because it's much easier for them based on their needs. I have a patient with six spinal fusions, and she has to spend a lot of time laying down. And so I'm able to see her, she uses her phone, and I actually see her from her bed, and we're able to, you know, talk and provide the care that she needs. I also see patients in other states. So I'm very niche in what I do, and I will have patients who, maybe they have diabetes, but they also have a history of eating disorders, and they need to treat their diabetes in a way that isn't going to trigger their eating disorder or their mental health. And so then they'll come see me, and I actually love it. I have a lot of patients in Washington and California, and it's awesome to be able to have really good provider/client fits because of that.

Nicole Klem 11:17
I think of folks in rural areas that might not have a private practice dietitian, you know, within 15-20 minutes the way we might have in Western New York, you know. I'm sure Washington and Oregon, you know, could be fairly rural areas, and how do we provide services to those folks as well. And so you had mentioned your patient with some of the spinal fusions? Do folks with disabilities experience more food insecurity? And are they maybe more underserved by the healthcare system or by dieticians?

Katie Brown 11:48
A couple of things. So actually going back to that patient for a second, she is on Medicare, which isn't covered as we talked about. And so luckily, she actually lives with her parents at home because of her disability. And her parents were able to pay for her to get nutrition counseling, but if it wasn't for that, she wouldn't be able to access it. And because of the support system, she is able to, you know, get food, her parents help her make food, all of those things. But there are other patients who are actually pro bono who are on Medicaid, where they just get food stamps. And in addition to food stamps, I think they get $1,000 a month. And you know, they live in a really expensive area, they live in the Portland area. And so most of their money goes to rent, they don't have extra money to go towards food. So they have to live on food stamps, and the amount food stamps give you is very low. And what's actually interesting is there was just this kind of like viral thing going on about the Thrifty Food Plan. Have you heard of it? Yeah, so the USDA has this plan. And they're like, this is what cost conscious people should eat that is affordable. And so food stamps are based on this. So basically, they take food stamps, and they're like, Oh, well, you know, you can buy these foods, you're fine, you have enough money, but it is totally unrealistic. It's like, you can't have tea, you can't have coffee, the majority of your food is fruit intake. Like you have to consume a lot of fruits, it's nothing premade, you're allowed to have like one premade frozen meal per month. And the thing is people who are disabled, it's not easy to get on disability. So you are really disabled, like they are not able to cook, you know, and everything is kind of raw form unprocessed, you need to put it together, you need to make it and that's just not feasible for people. And so they usually end up running out of food stamps. And I've had patients where they've literally had to go days without eating because they were out of food stamps. So it's definitely really difficult. And yes, there are community resources, but there's just not enough to cover the amount of people that need more food.

Nicole Klem 13:48
Wow. And so food security really, though is beyond the individual. This is a systemic issue that we see nationwide, and it impacts more people than I think the average person realizes. So I think, you know, nutrition education can play a role in this systemic food system/food security issue. How do you think we can make nutrition education more accessible to people who are challenged by food security issues like the one you described?

Katie Brown 14:20
So there are some grants that will pay for like clinics for dietitians to work in, and then they'll see patients who maybe don't have insurance or their insurance doesn't cover it. And that's something that definitely we're trying to open more of them trying to get more of that access out to people. Definitely just more government coverage would be great, more coverage, you know, through Medicare, Medicaid, but even all the people that are uninsured, how do they get nutrition coverage, and they do have some free community programs that people can go to? There's some online stuff like the the USDA, but it's not really personalized and individualized, and I found that individualized care is really what makes big changes But that takes a lot of time and resources. So I'm not really sure how we can fix it without just, you know, giving everyone universal health care, which would be great for a lot of people, but it is something we definitely need to work on. And at least you know, even if someone's low income, they may with a dietitian, like we can help them with affordable ways to get food or meal prep or different things, you know, for, like, if they do struggle with being able to purchase food and make food, we can help them with those things, and guide them. So you know, even if we can't fix their underlying condition, or help their underlying condition, we can still help them in other ways.

Nicole Klem 15:34
And I feel like some of those canned plans from the internet or from video may not be as culturally inclusive, as we hope. And I think what we're seeing in populations who are challenged by chronic conditions like heart disease and diabetes, the resources are out there, not necessarily the foods that they eat, or the way that they cook or familiar recipes and flavors and textures. So is there, you know, I think it's important that we as dietitians are trained to understand a wide variety of cultural eating and eating preferences and foods. So we can use the tools out there to customize that to an individual. Is there anything that the Academy of Nutrition and Dietetics, or the profession of dietetics is doing to fill some of these gaps or meet some of these needs?

Katie Brown 16:25
So a lot of people that are part of the Academy of Nutrition, and Dietetics, which is basically the professional organization for dietitians, they actually end up being the majority of the board that makes up the Dietary Guidelines for Americans. So this is where they decide MyPlate, Food Pyramid, all of those things. And because we are mostly white women, the board ends up being mostly white women, and it kind of misses those other cultures. So definitely a big issue is education. And, you know, it's really interesting, because I just watched this webinar, and it was about how when dietetics first became a profession, black people were not allowed to go to college, and you're required to have a college degree. So there were all these people that automatically could not be dieticians. And a lot of those issues have continued. I mean, there's two historically black colleges, they don't have dietetics programs anymore. So really trying to figure out how we can get more diverse people into the field. And yet, like, you know, college tuition is rising, and cost of living is rising. So it's really hard for people to go to college. I think, you know, the newer education models are really helping, which I know you have the future education model. But actually, this is the most diverse year of students we've ever had. And if they all graduate and become dieticians, we will have the most diverse dietitians ever. So I think we're on the right path.

Nicole Klem 17:45
Yeah. So you mentioned a little bit before we talked about weight bias and how society really views body size. So even in the the medical community, they pathologize weight. Can you talk a little bit more about what weight bias is and how it manifests in our culture,

Katie Brown 18:01
I would say the biggest thing is that we see overweight people as being lazy or having low willpower. So doctors are actually less - they kind of assume that, oh, they wouldn't take their medication consistently or they won't be as compliant. And that's a really big issue. Because if going into an appointment, the doctor is already like, Well, hey, this thing could help this patient, but it's too difficult, they would never do it anyway, so I'm not going to recommend it, then they don't get the care they need. Other things are that doing certain tests on people who are obese or fat actually needs different tools. So like blood pressure, if you are taking it incorrectly on someone who is obese, it will come out incorrectly. And one of the things they actually think that drives increased mortality in obese people is actually medical errors, because doctors are not properly trained to treat people who are obese, because they are different. And so until we have a system where we can kind of properly care for those patients, we're always going to have these issues. You know, they also - if a doctor has two patients, one's thin, one's obese, they're more likely to spend more time with the thin one because they think, you know, they care more about their health, they're gonna put more effort in, and that's not always the case. So it really leads to systemic problems. The other big thing is a lot of mental health issues because even outside of medical practice, the stigma in general, the way society treats people who are obese, which at this point, I think a third of adults are obese and like 70% are overweight. So I feel like it's actually the norm. And yet people who are overweight feel like they're the outsiders when really they're the majority and so they have really poor self esteem and mental health issues and all those things. So then they're less likely to possibly get help or even just having you know, depression or feeling bad about yourself impacts your health. So it just all snowballs into additional issues.

Nicole Klem 19:50
So there's an approach out there called Health at Every Size. It's been around for a while now but it has seen a lot of popular resurgence now in eating disorder community, nutrition community, registered dietitian community. So how would you describe principles of Health at Every Size for someone who wants to better understand it, who maybe hasn't heard of this or only heard a little bit about it.

Katie Brown 20:15
So Health at Every Size is focusing on basically achieving your best health without focusing on weight loss. So there are so many different things we can do to help improve health without having weight loss. And more and more research is showing that a lot of times when people have improved health with weight loss, it's because they had improved healthy behaviors. So someone started exercising more, they lost weight, and their blood pressure improved. So they're like, oh, it's because you lost weight, when actually, it's because you exercised more. And so really kind of trying to focus on things you can do to be healthier without focusing on weight at all, like taking weight out of the equation. I do have to say that, you know, this movement has really - we have people that are very passionate about how we should never talk about weight, and we should never discuss weight. And I think that there's kind of a happy medium, like, we still want to be patient-centered. And if the patient really wants to lose weight, you know, even if it is for visual reasons, or they'll feel better about themselves. Yes, you know, we talk about the risks, the benefits, how difficult it is, stuff like that, but not really saying no, I absolutely won't help you lose weight. It's like, okay, yes, you know, we can work on your health conditions, and possibly help you lose weight at the same time. But definitely not overselling the likelihood of it. But overall, it's a really cool movement, because it kind of takes that part away where a lot of conditions, people are just like, well just lose weight. And if you take that away, you're like, Okay, what else can we do for them? And I think it provides better care.

Nicole Klem 21:49
Are there challenges to using a Health and Every Size approach?

Katie Brown 21:51
Definitely. I mean, there's some people who think that it's not evidenc-based, it's not ethical because obesity is this huge issue on how could you not treat obesity, but and you know, sometimes with patients that are very resistant, I definitely get patients who are just like, I absolutely want to lose a bunch of weight, and I want to lose it really fast. And I'll tell them, I'm not the right person for you. Because that's not what I focus on, or what I feel good about, a lot of people who lose weight regain it, and regaining the weight is more dangerous than just maintaining. So if someone's 200 pounds, and they maintain 200 pounds, if we can get them to like exercise or eat healthier, even if they maintain 200 pounds, their health will improve. If they lose, let's say 20 pounds, and then regain 20 pounds, their health is going to be worse. And in the long run, they didn't learn any healthy behaviors or they didn't incorporate any long lasting healthy behaviors. So I really think it's not good for the long term health of people to focus specifically on weight loss. I mean, I do think if you do it, right, it can have a place.

Nicole Klem 22:56
Is it challenging when you have patients that might have built environment issues to exercise or nutrition knowledge and skill to prepare healthy meals or to access some of these Health at Every Size tools that aren't just focused on calorie reduction, you know, knowing that situationally, there might be other issues going on with that patient?

Katie Brown 23:21
I would say one of the most interesting things is that exercise is not covered by health insurance, which kind of fascinates me that we're now covering nutrition, and we care about nutrition, but why can't you see a personal trainer as like a thing that's covered by insurance. So I definitely get patients who - there are a few managed Medicare plans that will still cover nutrition so I can see them, but they don't have the money to join a gym or have a trainer or anything like that. And they would really benefit from exercise. And especially, you know, if they are complex, like if they have, you know, spinal fusions, they need someone who really knows what is safe for them to do. So I'd say that is difficult. Obviously, if they have trouble driving, they don't have a car, getting to the gym is hard. And you know, where they live might not be good. Or let's say, you say everyone can walk, well, what if they have knee problems and they can't walk, or foot problems? Or a newer one I've learned about is POTS, which is Postural Orthostatic Tachycardia Syndrome, I think, is what it stands for. But basically, it's that you get really low blood pressure when you stand up and some people get it and you know, they stand up, it kind of equalizes, they're good. There's some people they cannot stand up ever, because they will pass out for long periods of time. So the idea of going on a walk is absolutely out of the question. Like they have to do something that's sitting and what is available to them, you know, like if they had a stationary bike, they could do that, but they can't afford one or, you know, how would they even get it into their house? Different things like that. So I would say there's definitely a lot of barriers and then you know, obviously mental barriers. So people who have autism, ADHD tend to have a lot of food texture problems. And so they'll have different issues with certain foods. So it's really hard to find foods that work for them. And then especially if they're low income, it's like, okay, well, you know, they struggle with fruits and vegetables. And you know, most of the ways that fruits and vegetables are the most palatable to people with these conditions is more expensive, you know, like having smoothies, but then you need to have a blender, and you have to buy this stuff for smoothies. So it's definitely challenging.

Nicole Klem 25:35
Yeah, it sounds like you do some troubleshooting with your patients. Looking at their full picture, particularly as you're using some of those Health at Every Size tools. Another tool in your toolbox is something called intuitive eating. And I'm curious to hear your explanation of what it is, but also what it isn't, because I think there's a lot of confusion about what intuitive eating and the role it plays in, you know, someone's approach to improving their health.

Katie Brown 26:05
So the way I like to start with intuitive eating is that they've done studies on three year olds, and they'll give them a juice box or whatever. And then they'll map - watch what they eat throughout the day. And they will inherently just eat that many less calories. So you can like sneak calories into a three hour diet, and they will just intuitively, like eat less at dinner. And so we're all built with the ability to do that. And even you know, you look at our grandparents, they didn't have nutrition facts labels. The Nutrition Facts Label actually didn't exist till the 90s. And people were healthier before it, which I feel like is an interesting thing to think about. But really focusing on how you feel and how foods make you feel and how they impact you. So you know, in a perfect world, you eat something with sugar, you eat something fried, you like it, it tastes good, but you don't feel so good. So you decide that maybe you're going to not eat as much of that next time. And that's how we're supposed to be psychologically. But then we've created this society that messes with our psychology so much. And now also parents and advertising and everything, that we no longer can connect to that properly and realize that, hey, eating this really sugary food makes me feel bad. So I'm going to eat less of it. And then you get into binge eating cycles, and all those other things. And so really kind of trying to go back to your roots of like, how does this food make you feel? And that's something I really do, is not even changing our diet. But be like, when you eat foods, think about how you feel afterwards. And it's really good for people with chronic diseases to - let's say they have depression, did your depression get worse? Did your joint pain get worse? Did you feel more agitated? Did you feel tired? I mean, most people still get some amount of agitated, tired, nervous, you know, they drink a ton of coffee. And so starting to pair that, because then if you naturally pair with every time I eat this food, my joints hurt more, it's not so much that you're forcing yourself not to eat it, you will naturally start eating it less because you realize it makes you not feel as good. So then you're making changes without it being forceful. And kind of, oh, you need to be disciplined. And instead it's natural, and the way we're biologically meant to be. Does that make sense?

Nicole Klem 28:24
It does. What are some things that you think people think that intuitive eating is, but it actually isn't?

Katie Brown 28:32
I think people think it will help them lose weight. And I think people think it mostly is about fullness, and satiety, like, Oh, this is how much food I should eat, or oh, I'm eating too much fruit. And that's true. And that has like its place in a lot of things. It has not been shown to lead to weight loss, though, you know, without doing other changes as well. But I still think it's really, really good. And it actually ends up kind of ballooning to other parts of your life. So if you ever do mindfulness, mindfulness and intuitive eating are basically really similar. You're just being mindful about your eating and your food. And so it can really help with other aspects of life, like hey, maybe this exercise isn't working for me or this job or, you know, different things going on.

Nicole Klem 29:15
Yeah, I love that I'm starting to see some mindfulness training in elementary and middle school. And there is a little bit of, you know, there's mindfulness curriculum, and then there's some intuitive eating when they get to food and nutrition. And so, you know, thinking about kids controlling thoughts and emotions around food may impact some of their practices or perceptions of food nutrition later in life. And that, you're right, mindfulness is really something that can infuse into the stress of any other life activity beyond even just eating.

Katie Brown 29:52
Can I add something to that?

Nicole Klem 29:53
Sure.

Katie Brown 29:54
So I feel like sometimes actually, things like nutrition labels, calorie counting - it ends up undermining mindfulness because we spend so much time focusing on calories and protein and all these other things that we forget to just check in with ourselves and how we feel, like, do you like this diet? Is it working with your body? And so that's kind of what I was saying about the nutrition facts label is did that have something to do with it? Like, did it just make us so disconnected from how we feel? Because now we see numbers, and we're like, oh, we think we know better than our bodies, but we don't. And we really just need to listen to our bodies again.

Nicole Klem 30:29
I remember, early on in practice while I was in school, you know, what's the best diet like, just tell me what to do? Right, you know, 10 years ago, and I was like, Well, the best diet's the diet you don't think about, right? It's just the approach to thinking more about your health and your hunger and your body and what you're craving and what your family enjoys, and what's in season far more than a very prescriptive, you know, I'm thinking this is like the time South Beach Diet was getting really popular and, Atkins diet was still on everyone's agenda. And they just wanted this prescriptive diet, when it's like, that will cause you more anxiety and stress and worry, and probably ultimately cost you more money, and feel less accessible than some of these Intuitive Eating principles and tools. And it's tough, sometimes I think as dietitians we shouldn't have the jobs we do, because it is ultimately telling people to look at what you eat, think about how you're feeling, practice the foods that you enjoy, and see sort of how, ultimately, that results in your goals. So at times, I feel like it's silly that we tell people how to eat but we're doing a lot more walking alongside people when it comes to using these tools. Health at Every Size and intuitive eating and meeting so many more people, different populations, different conditions where they're at. So one of my last questions is, how really do these types of interventions and tools shift away from traditional approaches that have been used in nutrition counseling, and where have we come from? And maybe, where is nutrition counseling and education going?

Katie Brown 32:09
So I think it's really, really patient centered, which people talk about patient centered care. And I think sometimes we don't really embrace it to its deepest level, because then it's easy to be like, Hey, do you want this medication? Yes, or no. And then it's like, oh, they didn't want it. So we're going to try something else. And yes, on some level, that's patient centered, but you really have to know the patient, you have to know what they struggle with. And then also what they want to change. So sometimes a patient - you'll think, as an expert, that you need to change a specific thing, or they really need to stop drinking soda. But maybe to them, that's not what they want to work on. They want to work on, adding more movement or having healthier snacks. And so then you need to kind of be able to focus on what they want to focus on and look at what they're excited about. So yeah, I really think that is a big thing moving forward. I think a big thing is just really being very integrative. Because it is mental, it's emotional, you need to know the science. And then you need to be able to be practical about things. Because you can know the science and be like, this is the best diet ever. But are patients gonna want to do that? Does that work for that patient? So it's a lot of finesse, and really allowing everyone to be their own person, but helping them achieve their own goals.

Nicole Klem 33:26
Excellent, I think, more optimistic about the direction nutrition counseling is going than ever before. Catherine, is there anything else you'd like to share about your practice, about food access, health equity, some of these topics that we've touched on?

Katie Brown 33:40
Yes, so I was thinking. So all of this kind of ties together in some ways. So there's interesting stuff about how weight bias actually messes with intuitive eating. Because we're so worried about losing weight, we stopped focusing on how we feel when we eat certain foods. So that adds to it. And what's interesting is the cultures that are the healthiest don't really like they don't have a prescriptive diet. You know, they eat their cultural diet, kind of like what you're saying, but they don't think about it. Like they don't stress about their food. They're not like, oh, is this birthday party too many calories, they literally just go to their birthday party, they play with their friends, they do their normal lives, and they're healthy, and they're a good weight. And you know, they're really able to maintain that health. And one of the things some people speculate is that part of the reasons we have so much obesity is because we focus so much on being thin, that it creates disordered eating, which then creates obesity. So if we can move away from that and just be more accepting and caring towards everyone, then we can all be healthier, and we could possibly fix the obesity problem without even talking about weight loss.

Nicole Klem 34:44
About weight loss. This also sounds like it goes beyond the profession of dietetics.

Katie Brown 34:48
It does. I mean it's very, very interdisciplinary.

Nicole Klem 34:51
Yeah. So all of our health care team, you know, should be learning a little bit more about the ways that we can approach food and nutrition and lifestyle. Do you have a lot of interprofessional work experience. Do you do some team care for any of your patients? Or, you know, is there changes in our healthcare system around the conversations of improving patient outcomes through nutrition?

Katie Brown 35:14
Yeah, so team care is much harder in the outpatient setting than I feel like it should be. When I worked in a nursing home, it was very integrative. And I loved it, we actually had integrative meetings about a patient with all the different medical staff. And you know, we would talk about how this patient was doing. All of my patients, almost all my patients have therapists, that's something that, you know, it's kind of required, if they are struggling with emotional things, or body image things, they really need to have a therapist, so we definitely have that, and I would say, we don't really, let's say communicate very much, but we definitely work off of each other and talking with the patient, and you know, sometimes certain things, it's like, okay, you know, you should discuss this with your therapist, different things like that. So I would definitely say that you definitely need doctors involved for like labs, medications, other stuff, I definitely think it could be more interdisciplinary. And I think when you work at a clinic, like an outpatient clinic, where everyone else is outpatient, works really well. I kind of like the idea of having more holistic, instead of it being a doctor's office, where it's like, we're gastroenterology, I want, just, we're an office, and we have like a therapist and a doctor and a dietitian and a physical therapist. And everyone just communicates and cares for patients, because that's really what you need to have good patient outcomes.

Nicole Klem 36:32
That's a great vision for health care model of the future. And I love what we do at UB and at least preparing our dietician students to understand the role that each of those other health professions play. And then to those health professions, the role of the dietitian hoping that eventually they'll, you know, hinge off each other for patient care. But having us all under the same roof would be a benefit to the patient for sure. I've heard this term food sovereignty out there, but I don't know much about it. What can you tell us?

Katie Brown 37:01
So it actually loops back into a lot of the food access things. And so food sovereignty is having control over your own food. It's where you acquire food, make food, grow food. So a good example is where I live, I'm not allowed to have chickens. And so that's kind of a barrier between me being able to produce my own food. And it used to be that people could produce their own foods wherever they wanted, they could forage, they could hunt. And now we have more and more laws saying, well, you can only hunt these times of year, you can't forage in this area, different stuff like that. And so if we allow people to have more control over how they acquire food, they then can have less food insecurity. And there's really interesting stuff happening with that, like in Maine, they made a law that you cannot have any zoning limitations. So if you want to plant your vegetable garden in your front yard in Maine, you can do that. Now, if you want to have goats for goat milk, you can do that. There's none of these barriers. A really common one too, is even with food processing, and sanitation, which is important. But at the same time, they'll create such high costs to properly process the foods that then small farmers or individuals aren't able to do the things that they need to do to make their own food. So the idea is just having food access being more diverse, so you're not just going to grocery store, but what are other ways we can get food, and nourish ourselves and have control of our food environment.

Nicole Klem 38:27
I know there's some environmental challenges, but I see folks who are from, you know, refugees from other countries fishing in the Niagara River all the time. And I'm thinking, you know, they're used to their waterways being a food access point, you know, we have different challenges here environmentally, with using that as food access. And so we've had to put these limitations on fishing in our waterways, essentially, because we know there might be some health concerns from the fish coming out of there, but that these folks are so used to using that as a food source. And we have to tell them on you know, no, we don't recommend it, you can't do it, you know, there's laws against it or recommending against it. So it's interesting that food sovereignty also might play into the environmental conditions in our neighborhoods, and then our built environment here.

Katie Brown 39:20
So I have an interesting story. I went to the Cayman Islands, have you ever been there? So they have just fruit trees growing everywhere, like you just buy a house and it comes with a mango tree or like a coconut tree because it's tropical. And then they had a hurricane like 15 years ago, and all the chicken coops broke. And so now they're just wild chickens on the island. So if you put a roosting box, they'll just lay eggs in your backyard, and then you just have free eggs. So everyone on the island is just like, Yeah, I just got free eggs from my backyard. So it's just a really cool, different way to think about food and how to acquire food.

Nicole Klem 39:53
Yeah, I feel like there'd be another conversation about the role of hunting and even our deer population and the ethics around food procurement of hunting, and how mixed people feel about that sometimes. Yeah, for another day. All right, this has been another episode of Buffalo HealthCast. Thank you to our guest, Catherine Brown, for taking time to speak with us today. Nicole Klem is our faculty consultant, Sarah Robinson is our production assistant, Omar Brown is our sound editor, and our theme music was written and recorded by Sungmin Shin of the UB Music Department. My name is Nicole, your host and writer for this week's episode. Thank you for listening and tune in next time to learn more about health equity in Buffalo, in the US, and around the globe. Thank you.

Buffalo HealthCast

Inclusive Nutrition, with Catherine Brown

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