Healthy Eating, Nutrition and Body Image: Katie Loth, PhD’s Research
Katie Loth, PhD, MPH, RD, is an associate professor and vice chair for faculty affairs in the Department of Family Medicine and Community Health. Dr. Loth is both a researcher and a practicing clinical dietitian. Her research explores social and environmental influences on child and adolescent dietary intake, eating behaviors, weight status and disordered eating behaviors.
Dr. Loth provides nutrition counseling and medical nutrition therapy to patients of all ages at M Physicians Broadway Family Medicine Clinic. She is also on the faculty for the North Memorial Family Medicine Residency Program, where she helps to train residents on topics related to medical nutrition therapy.
Watch: Dr. Loth talks about her research in disordered eating
What drew you to pursue research in eating disorders? What are the most important questions that you're trying to answer?
My interest in disordered eating began pretty early in life. From middle school all the way through college I was a competitive swimmer. Because of this I was always interested in health, wellness and nutrition. I was constantly surrounded by incredible athletes with bodies that were able to do amazing things. Yet my teammates often talked so negatively about their bodies and were always trying to pursue looking different or weighing different amounts.
Their pursuit of weight loss often made it harder for them to achieve what they could have in the pool. I was struck by how these people are at the peak of physical performance and how they could be still so caught up in a body image ideal in a way that felt surprising, and honestly heartbreaking to me.
In college I was studying dietetics with the goal of becoming a registered dietitian. That's a field that's fraught with a lot of assumptions and stigma around how you should look and what you should or shouldn't eat. And listen, I know nutrition matters. And I know that what we eat matters for our short and long term health. But what I became ultimately interested in is how we help promote health without such a focus on weight and numbers that people become overly consumed with how much they weigh and what they're eating.
It is answering this question that has always driven me. Once I became a dietitian my path was somewhat meandering. I pursued a master’s degree in public health nutrition. I worked for several years at an eating disorder treatment facility as a dietitian and then eventually came back to school to pursue my PhD in epidemiology.
How do physical health and mental health intersect when it comes to healthy eating and body image?
I’ve always been interested in public health. For me, that really comes down to understanding how much what we eat impacts our overall health. At the same time, I think it’s just as important to consider mental health. It’s about finding a balance—being mindful of how we eat to support our physical health, without letting it come at the expense of our mental well-being.
What I'm especially interested in now is shifting my focus to research with younger children. How do we first begin to form a relationship with food and first begin to form the relationship with our bodies? What are the things and people in our environment, like parents, coaches, teachers and doctors, who influence that narrative that we begin to form inside our own heads like “Am I a good eater? Am I a bad eater? Do I have a good body? Do I have a bad body?” And how do we help to promote the positive without inadvertently promoting the negative?
You were recently named a fellow in the Academy for Eating Disorders (AED). What does that recognition mean to you? And what does your involvement with AED look like?
I have been a member of the Academy for Eating Disorders since I was a doctoral student. I've been involved in the organization as a student, a postdoc, and then an early-career investigator, and have taken on various leadership roles during my time. It means a lot to me because it feels like this is my academic home, and I'm receiving the highest honor there. The Academy for Eating Disorders is an international organization and so this means I'm being recognized by colleagues both in the U.S. and around the world for my commitment to research and clinical practice in the area of eating disorders.
A lot of my leadership in AED has centered on bridging the gap between research and clinical practice. It's an organization that has a lot of clinicians and a lot of researchers, but there's not as many people who are doing both. So I've tried to bring that lens of how we come up with questions in a clinical space and then research answers. And how we use the research that we do to inform the clinical practice that we engage in, making sure that those things are moving back and forth and are not siloed.
The other lens I bring that's unique is the public health and primary care lens. A lot of folks who are in AED are in eating disorder-specific clinical settings or eating disorder-specific research groups where their work can be really in the weeds around specific disordered eating behaviors or clinical treatments. Whereas I think about this from a public health lens: Of the things that we're doing to promote health and well-being for people, how can we transform those to be done in a way that's protective against the development of eating disorders?
Looking forward, I hope that I continue to lead in both those areas, bridging that gap and then bringing that public health or prevention-based lens to the work of the academy.
Eating disorders can be more often misunderstood compared to other mental health conditions. What still needs to change in terms of research awareness or clinical care?
One of the biggest things that need to change, especially in the primary care world, is the assumption that eating disorders are rare. In medical school, people learn the real small prevalence of anorexia or bulimia nervosa, and that can lead them to conclude that eating disorders are not something that they are going to see as a family medicine doctor.
While clinically diagnosed eating disorders may be less common, what we see in research—particularly from studies like Project EAT—is that engagement in disordered eating behaviors is actually very common across the population.
I use the term “disordered eating behaviors”—which encompasses all of the behaviors that are disordered but may not meet that threshold for true clinical diagnosis. Or it may mean someone who's engaging in all of these behaviors and at a very problematic frequency, but they never receive that clinical diagnosis.
We know that the prevalence of these behaviors is really high. So when you're in primary care, when you're a dietitian, when you're in behavioral health, and when you're a family medicine doctor, you are seeing patients who are engaged in disordered eating behaviors. And these behaviors impact people of all races, all gender identities, all ages, all socioeconomic statuses.
More recently we've begun to learn a lot about the impact of food insecurity on the development of disordered eating, dispelling the myth that these are rare or that they only impact a certain type of person. That is one of the biggest changes that we need to see.
Once we begin to recognize that folks with eating disorders are showing up in your office, then it becomes easy to see why it is critical to start asking more questions. The questions become: What can I do to prevent it? How can I screen? And when do I need to refer out? Those are the things we need to be asking in primary care to make sure that we're doing right by our patients.
We're living in a time when weight loss drugs are reshaping how society thinks about body size and food. From your research perspective, what concerns do you have about how these drugs intersect with eating disorder risk, especially for people who may already be vulnerable?
The most popular question I'm receiving these days is how I feel about these weight-loss medications. One of the first things to know is that these medications are so new, which means there's so much we don't know. This is always true of science: an answer that you give today may not be the answer that you give tomorrow or the next day, because hopefully we're continually researching, continually learning, and continuing to allow what we learn to shape our clinical care. That’s how we grow as scientists and as clinicians.
But at this point, one of the things that is important when you're meeting with a patient who might be considering a GLP-1 is that you're thinking about truly informing them of what the medication does. A lot of the ways that the medication works in our bodies have an impact on hunger and fullness cues; they impact how often you're driven to eat. And so changing some of these things about the way that our bodies react to and have a drive for food can trigger an eating disorder or can exacerbate underlying disordered eating.
For every patient who comes in your door, having an understanding of past history and current use of disordered eating behaviors is key before you give any type of diet advice. That's even more true with GLP-1. So knowing whether your patient is at high risk and having that conversation with them is critical.
This is what I call true informed consent. It's not simply asking a patient whether they want to take the medication or not. It's important to discuss what the medication does, how it works, and what the risks and benefits are.
I also talk about expectation management—what a person can expect from being on a certain medication and how that fits with what they’re looking for. They need to know what a particular medication will and won't change about their body and their life.
So much about disordered eating is a desire to change one's body because you feel like this or that will happen when you experience those body changes. It’s important to dive into some of those expectations with your patients to make sure that the things they're thinking are going to happen are realistic for them. They should know what is likely to happen if they begin the medication and understand the risks that come with it.
Careful monitoring and following up to be sure that somebody is tolerating it well is critical as well. These medications are potentially helpful for some, yet are certainly not appropriate for all—and we need to be prescribing them with a lot of caution and support.
We've seen public concern around extreme thinness in celebrities, for example, yet there's also a stigma around being too large, especially for women. What do you want people to understand about healthy eating and healthy weight?
One of the biggest things that I spend a lot of time talking to people about, both in the clinic and when I do resident education, is pulling apart the idea of health and weight. People can exist at a variety of weights and be healthy, and people can exist at a wide variety of weights and be unhealthy. So we shouldn’t look at somebody and see their weight, their shape, their size or look at a growth curve, for example, and use that to make assumptions or conclusions about their health.
Instead, what we really need to understand are the behaviors people are engaging in. In my clinical practice, I use a weight-inclusive approach and spend a lot of time teaching it. That means I’m not focused on changing someone’s weight when they come into my office.
I'm not centering weight in the conversation when they're in my office at all. Instead my focus is on the behaviors that we know lead to healthy outcomes for people. Behaviors like dietary intake, physical activity, stress management, sleep and relationships. So if somebody has all of those things in good working order, they will see positive health outcomes come from that. If somebody has an imbalance in one of those areas, then my job is to work with them to address that behavior.
We may ask questions like, “How can we help improve your nutrition?” and “How can we help get you more active in a way that feels good to you?” Because any changes that you can make to improve those behaviors are going to lead to a positive health outcome, regardless of whether you change their weight.
So it's not about doing those things to make the weight go up or down. It's not about looking at someone and saying, “Hey, your weight's fine. Who cares what you're eating?” It's thinking about how we check in with our patients about each of these behaviors and then work with them to maximize those things.
What should people know when it comes to talking about weight?
It is so important to examine how we are having conversations about weight—about celebrities being too big or too small, about family members being too big or too small, about going home for the holidays and having people comment on weight loss or weight gain. One of the most harmful things that we can do for ourselves and for our children, for the people who are in our presence, is make those weight-based conversations a part of every day. And, unfortunately, they are a part of everyday culture in the United States.
We should instead be thinking about how we can begin to not have those conversations ourselves and then think about shutting them down when they do pop up in our presence. In particular, I do a lot of work with children, in particular young kids, and making sure that we're just focused on behaviors, not bodies.
Eating disorders can feel like something that primary care providers don’t do. But, in fact, talking with patients about how to have a healthy relationship with food is what so many of us do. And it's not black or white. Nutrition is not just good or bad. When we begin to focus on the good or the bad or having that high preoccupation with weight, shape or size, then that's when these things can become harmful.
So if there’s one takeaway, it’s that health is much more complex than appearance. The more we shift our focus toward supportive behaviors and away from body size, the better we can support both individual and public health.
Additional resources:
- WithAll is a nonprofit organization that empowers adults with the tools they need to help children and young people foster a positive body image and relationship with food. View their free educational toolkit.
