Recently, I was asked to speak at the San Francisco dance school "ODC" for the "Dancer's Day of Health." This day was all about health information and free screenings for freelance professional dancers. We had medical doctors, mental health professionals, physical therapists, and of course - dietitians, all giving their time to screen and educate the dancers.
The panel I spoke on asked us each to briefly say what our role is on the dance medicine team. Here are my bullet points of what the Registered Dietitian does:
“The #1 goal of nutrition counseling is behavior change” – Herrin & Larkin
We help dancers specifically:
When you work 1-on-one with a RD you are going to get help on eating for your individual lifestyle, medical needs, and your personal preferences. No generic meal plans, and any RD worth their salt will come from a place of “all foods fit” and “health at every size” meaning we can focus on health behaviors and risk factors without weight being the focus or “fix.”
Do you need a RD in your dance life?
Lately I have seen an uptick in clients who “look” fine on the outside need urgent medical care. This got me thinking about the lies that the eating disorder voice (“Ed” for short) tells us.
Ed wants to be in control (which is funny because most people with eating disorders think they are in control. Silly humans.) and will tell you lies to keep up the disease process.
Have you ever hear the voice in your head say:
“You’re not thin enough yet.”
“You are not sick enough/you're not as sick as [other person].”
“Your heart rate is so low because you work out so much”
“You’re doing fine, you can [insert ED behavior] more [often/more strictly]”
“You’re the exception to the complications, it won't happen to you.”
Or something similar?
These are often precursors to the downfall of health.
Recently, I saw someone who had been dealing with bulimia on top of being an athlete have such low iron that she needed an immediate blood transfusion in the emergency room (Thank you to the doctor I work closely with for catching that!). I had another client peeing reddish urine with a “puffy” body that she said was hot to the touch that we believe is doing damage to her kidneys (or maybe experiencing rhabdomyolysis) from restricting (she ended up in higher-level care). Another is having severe gastrointestinal issues that are most likely due to years of laxative abuse and restricting that was misdiagnosed as “gastroparesis” until she finally saw a specialist.
The thing that all of these clients had in common? They said they were “fine” and didn’t need to go to the doctor. They weren’t “that bad” in their ED behaviors.
This is what scares me. How many people are walking around with medical issues that they have become so used-to that it feels normal?
PSA: Tell all of your providers from primary care physician, to specialists to therapists and dietitians about your eating disorder. Yes, even if you haven’t told anyone else. We can’t help you if we don’t know what is going on, and some providers won’t ask.
If you are struggling with disordered eating please take this as your sign to make sure you are getting regular check-ups from medical professionals that understand eating disorders and the hidden dangers. It can save your life.
Don’t wait to seek help. You have to be your own health advocate.
Clifford D, Curtis L. Motivational Interviewing in Nutrition and Fitness, 1st Edition. New York, NY: The Guliford Press, 2016 (1). This review was written for graduate nutrition class "Obesity," 2016.
Elizabeth Parker, MS, RD
About the Authors
Author Dawn Clifford is an Associate Professor and Director of the Chico State University Didactic Program in Dietetics (1). She earned her B.S. in Dietetics from Northern Arizona University, and M.S. and PhD in Nutrition Science from Colorado State University (2). Clifford is a speaker on topics of motivational interviewing (MI) and non-diet health and wellness, as well as a published researcher. She has received the “Outstanding Dietetics Educator,” and is a member of the “Motivational Interviewing Network of Trainers” (1).
Author Laura Curtis is the Director of Nutritional Services at Glenn Medical Center (1), she also teaches Medical Nutrition Therapy at Chico State University where she earned her B.S. and M.S. in Nutrition, and where she followed-up with her dietetic internship (2). She had held several positions as a Registered Dietitian, including nutrition counseling where she pairs her extensive MI skills with non-diet principles and “Health at Every Size” (1).
This book, written for nutrition and fitness professionals, is broken down into five sections, with an introduction and appendix. The introduction covers motivational interviewing basics, starting with an introduction mentioning the latest research in a shift of how health practitioners counsel - from “weight-focused” to “weight neutral”(1). This helps prevent eating disorders, fat-shaming, yo-yo-dieting, and “miserable exercise regimens” (1). The focus has shifted to more realistic lifestyle changes for health and emotions that occur with eating, not weight-focused counseling. The chapters aim to break down parts of Motivational Interviewing (MI) both in descriptions, and examples of dialogues in vignettes.
Section one: Motivational Interviewing Basics
Chapter one briefly discusses why habits form (benefit or reward outweighing the cost), and the “Stages of Change” or “Transtheoretical Model,” that was created by Prochaska and DiClemente (1). Other topics explained are “ambivalence” or uncertainty of wanting to change, neural plasticity, when your client wants a “quick fix,” and the “righting reflex” of the practitioner to correct the client’s wrong beliefs.
Chapter two talks about the “Spirit of MI”: partnership, acceptance, compassion, and evocation. This puts the practitioner and client on the same level, and places the client as the “expert” of their own body, instead of the practitioner telling them “you should [do what I say]...” This chapter is about respect and building a trusting relationship between the client and practitioner.
Section two: The Four Processes of Motivational Interviewing
Chapter three starts with two of the processes: engaging and focusing. This is the start of the MI process, where rapport is built and the focus of the session is determined. This is done through warm interactions and asking questions that invite the client to pick a direction or topic to focus on. Chapter three also points out the similarities of MI and the Nutrition Care Process (NCP) of “Assessment, Diagnoses, Intervention, and Monitoring” (1), as well as the importance of nonverbal communication (body posture, eye contact, etcetera).
As any good practitioner knows, listening is of utmost importance, and this chapter devotes a section to the benefits of really listening. By listening effectively, the practitioner can help the client choose a topic to focus on for change, and can break an overwhelming health concern into smaller, simpler, steps. By working on just one step at a time, the client is set up for success, is more likely to build confidence in tackling future change, and the practitioner has a solid topic to bring focus back to when conversation strays.
Chapter four: Evoking. Listening for certain communication cues, the practitioner can pick up on the client’s ambivalence and/or preparation to make a change. A mnemonic device that the authors like to consider where a client stands, is “D.A.R.N. C.A.T.” (4); this stands for: “Desire to change, Abilities to change, Reasons to change, Needs for change, Commitment to change, Activation, Taking steps.” When these intentions are missing the client is likely using “sustain talk,” or the lack of desire to change.
Chapter four explains how to respond to ambivalence to nudge a client toward “change talk” (1). One way that this can happen is by using “scaling questions” which ask the clients, on a scale of 1-10, where do they stand in terms of confidence to change, importance of changing, or readiness to change (1). Additional sections of chapter four go over what to do if a client is crying in a session, and why to not “jump the gun” when getting to the planning process, at risk of losing motivation for follow-through.
Chapter five offers advice on how to plan for change without giving unsolicited advice. Asking permission is a key concept to MI, in which the practitioner asks the client if they would like to hear the information they have. This can be done in many ways, but overall it follows the format of “elicit-provide-elicit”(1). Elicit-provide-elicit, means finding out what the client already knows and asking them if you can give them information they are missing, providing the information once you have their permission, and following up with a check-in to see how they feel about that information. Chapter five finished up with assessing confidence to change, and potential barriers to making the change.
Section Three: Mastering the Microskills: OARS
Chapter six, the “O” in OARS is for “open-ended questions.” Open-ended questions (versus closed-questions) elicit thoughtful responses that are more likely to promote change talk (1). The chapter gives several examples of good open-ended questions for a variety of ways to direct the conversation, as well as closed-questions to avoid. Scaling questions are once-again used to question readiness to change.
Chapter seven, “Affirmations” is the “A” in OARS, building self-efficacy through how the practitioner acknowledges positive changes. This chapter explains that affirmations are not “cheerleading,” but building self-confidence through empowering the client by acknowledging what they have done and how they have noticed the benefit of the change. Affirmations can also help reduce defensiveness.
Chapter eight, “R” is for “Reflections,” or a statement paraphrasing what the client has said in a way that shows they are heard and understood. Reflections can be used after nearly every client statement, and the book covers several types of reflections for different occasions or goals. These include: how to reflect when the client is expressing change-talk, ambivalence, or sustain talk; using metaphors or reframing negative statements, double-sided reflections (using “and” in place of “but” when listing both sides); and several other types of strategic reflections.
Chapter nine, “Summaries,” rounds out OARS. Similar to reflections, summaries can, and should, be used frequently throughout a counseling session. Summaries work well to show the client you are hearing them, and are a way to assess if you have understood exactly what the client is expressing. Summaries are good for transitioning to another topic, bringing the conversation back on track, and bringing closure to a session.
Section four: Beyond The Basics
Chapter ten covers common pitfalls of trying to direct a client that is not ready for change. Some poor choices include, “the expert trap,” the “question and answer trap,” using “scare tactics,” “information overload,” and others. The chapter goes over how to “read” and work with a client who feels forced to be in the session.
Chapter eleven covers “what to do when there’s little time.” How to use MI with brief interactions, covering all four processes of MI, is coupled with how to keep a client on track. The chapter emphasizes the importance of staying true to the MI structure and focusing on one small change instead of taking on too much and/or driving the client away by providing information without asking permission.
Chapter twelve teaches how to address misinformation that the client has picked up, in an unthreatening way. This involves the practitioner letting go of their own agenda, and focusing on what the client finds important. Diminishing the “righting reflex,” or “temptation to provide unsolicited advice” (1) gives the client autonomy and feel they are in control. Providing information (in easy to understand terms) should only come after asking permission from the client. This chapter also covers how Cognitive Behavioral Therapy (CBT) fits into the MI process.
Section Five: A Closer Look at Motivational Interviewing in Nutrition and Fitness Industries
Chapter thirteen is about how to use MI in nutrition counseling, specifically. This is broken down into subtopics, including: dealing with a new diagnosis, meal planning, grocery shopping, expanding food variety, and more. This chapter does a good job addressing emotional eating, disordered eating, and when it would be helpful to refer to someone when the issue is out of the practitioner’s scope, or needs other professionals on the treatment team.
Chapter fourteen explains how to use MI in fitness counseling. It problem solves how to fit depth of MI into training sessions, when talking becomes more limited. The differences in “autonomous” (internal) and “controlled” (external) motivation are explained, with tips to progress each type through the stages of change. This chapter addresses potential barriers to change with tips to guide a client through each.
Chapter fifteen, “putting motivational interviewing to work to address weight concerns and disordered eating,” focuses on weight-neutral talk, and “health at every size” (HAES) (1). It takes away using weight as a measure of “goals” to meet, and focuses on being healthy and happy at whatever size your body wants to naturally maintain. Although this chapter addresses eating disorders, it does not go into depth on counseling clients with eating disorders. This chapter does promote a smart way to speak to any person to not trigger negative body image feelings.
Appendix 1 covers when and how to make a referral to a therapist or other health professional. It covers “scope of practice,” specifically the scope of a registered dietitian, and when it is smart to add to the treatment team or refer to a specialist. This chapter gives a script of what to say to a client when making a referral, so the client feels supported and is more likely to follow-through.
Appendix 2 is additional resources for counseling techniques. This appendix lists more books on MI, resources for nutrition counseling techniques, resources for fitness counseling techniques, and resources for addressing body image concerns.
Personal commentary and evaluation
The authors are extremely qualified to write this book on MI. Both are registered dietitians with a master’s degree (and Clifford has a PhD in Nutrition), and have had personal experience using MI to counsel and teach the principles of it in their other work. Curtis was a student of Clifford’s, so they should be of the same mindset and training.
The authors have written a strong book for teaching the essential counseling skills, laying them out in a well-organized fashion. Although this book was somewhat “dry” reading, it could not have come to me at a better time, as I was finding my counseling becoming very complacent. Working slowly though this book, I was able to shake-up my counseling practice and have better interactions with clients using the MI skills I had let slide.
The only weaknesses I can think of with this book are not covering every area of
nutrition and fitness that could come up in a session (which would be impossible to do), and that there are already many books on MI available, many of which from the same publisher. This being said, a strength is that they filled a specific need by tailoring the book to the specific issues that credentialed nutrition and fitness professionals face, staying true to science-based information and not teaching fad diet principles. I was very pleased to see the use of weight-neutral talk and how to speak to promote positive body image.
It was too difficult to pick out very specific tidbits of information that were supported by other works of literature, because MI is so prevalent in the counseling world. In light of that, I choose two books that I have used, as support for Motivational Interviewing in Nutrition and Fitness. In their book on treating eating disorders, authors Herrin and Larkin state that the process of nutrition counseling should allow clients to make their own decisions (except in the case of harming self or others), and that advanced training in counseling skills including MI is expected of the nutrition professional (5). A section on MI is included in their book, highlighting the same skills that are laid-out in depth in Motivational Interviewing in Nutrition and Fitness. Likewise, the book Counseling Overweight Adults (6) has a section devoted to MI practice and its importance in the counseling process for nutrition professionals, including using “scaling questions” to determine confidence in making a change.
I would highly, highly, recommend this book to nutrition and fitness professionals (and even other health professionals). This resource breaks down each step of MI into useable tactics, and gives clear examples of when the principles are being used or not used. While the general public might not need this nutrition and fitness-specific book on MI, MI is a skill all professionals should have, regardless of what type of counseling you do, and this book is a wonderful resource to teach it.
1.Clifford D, Curtis L. Motivational Interviewing in Nutrition and Fitness, 1st Edition. New York, NY: The Guliford Press, 2016.
2.Linked-in profile: Dawn Clifford. https://www.linkedin.com/in/dawn-clifford-38210b19. Accessed October 17, 2016.
3.Linked-in profile: Laura Curtis. https://www.linkedin.com/in/lccurtis. Accessed October 17, 2016.
4.Rollnick S, Miller WR, and Butler CC. Motivational Interviewing in Health Care. New York, NY: The Guilford Press, 2008.
5. Herrin M, Larkin M. Nutrition Counseling in the Treatment of Eating Disorders. New York, NY: Brunner-Routledge; 2013.
6. Kushner RF, Kushner N, Blatner DJ. Counseling Overweight Adults: the Lifestyle Patterns Approach and Toolkit. Chicago: American Dietetic Association; 2009.
Eating Disorders, A Guide to Medical Care and Complications, 2nd Edition. By Philip S. Mehler, M.D., and Arnold E. Andersen, M.D. This book was published in 2010 by John Hopkins University Press. The original edition was published in 1999. This review was written for "Nutrition Therapy for Eating Disorders" college paper (2016).
Authors Mehler and Andersen, are both medical doctors, and professors at Universities. Dr. Andersen is a board-certified psychiatrist who, with colleagues, has started programs for inpatient, PHP, outpatient diagnostic and continuing care for eating disorders. He attended medical school at Cornell, and has spent 15 years as faculty at John Hopkins Medical Institution. He has published research focusing on many aspects of eating disorders.
Dr. Mehler is a graduate of University of Colorado Medical School, and is now the Chief Medical Officer of Denver Health Medical Center. He is a Certified Eating Disorder Specialist (CEDS) and a professor at the University of Colorado Medical School. He is widely published, and is especially interested in research of patients with weights 30% or more below ideal body weight, and treatment of anorexia and bulimia nervosa.
The goal of Eating Disorders, A Guide To Medical Care and Complications, is to provide a single-source of most treatment recommendations for the medical treatment of patients presenting with an eating disorder. The authors provide a step-by-step approach: determining a diagnosis of an eating disorder, the purpose of the treatment team, medical evaluation, nutrition recommendations, specific complaints/ signs/ and symptoms patients present, special topics (including athletes and males with eating disorders), ethical conflicts, and information for non-medical educators. The authors use each chapter to give case studies and answer specific frequently-asked questions about the topic of the chapter in hopes to increase best treatment practices.
Eating Disorders, A Guide to Medical Care and Complications is a reference manual for both medical doctors seeing patients with eating disorders, as well as non-medical professionals (psychiatrists, psychologists, dietitians, nurses, sport coaches, and others who interact with individuals at risk of eating disorders). There are 15 chapters, plus an appendix, in this nearly 300 page book. I will go into more depth on the main messages from these chapters in the following paragraphs.
Chapter 1, “The Diagnosis and Treatment of Eating Disorders in Primary Care Medicine.” This chapter (as well as many parts of the book) emphasizes that eating disorders (ED) present in “many disguised forms” (p. 3) to clinicians, and that the diagnosis of an ED is not made by ruling-out every other possible issue. This chapter focuses on risk factors that increase chances of getting an eating disorder, as well as diagnostic factors to be assessing (including cultural value of thinness), and an overview of treatment modalities such as Cognitive Behavioral Therapy (CBT). Tables throughout the book give concise lists of things to look for (in this chapter, list of myths and facts about EDs, for example), questionnaires, and laboratory ranges.
Chapter 2, “Team Treatment, a Multidisciplinary Approach,” explains the other members of the treatment team, why different professionals are necessary (not just one clinician doing everything), and how to effectively communicate with the team. This chapter includes the registered dietitian (RD), but explains that the physician, nurse, or RD can do weight restoration and meal plans (more on my thoughts about this later). Chapter 2 also covers the levels of care, how to decide which level is appropriate, and when to change the level of care; as well as the details of treatment approaches, including “having fun.”
Chapter 3, “Medical Evaluation of Patients with Eating Disorders, an Overview,” discusses the role of the physician in assessing clinical signs and symptoms of patients with EDs. This includes which exams and lab tests are recommended for each specific type of ED, how to read them in the context of an ED, and when labs/exams need to be repeated. Lists of physical signs and complaints from patients are given, and differential diagnoses that an ED might present as. The authors again state, “The guiding principle is that a diagnosis of an eating disorder is not made by a rule-out approach of all possible medical disorders, but by confident determination of the presence of an eating disorder through screening questions and a brief mental status examination” (p. 70).
Chapter 4, “Nutritional Rehabilitation, Practical Guidelines for Refeeding Anorexia Nervosa Patients.” It is worth noting, that this is the only chapter on nutrition in the book, and it only focuses on very underweight anorexia nervosa patients – no other eating disorder diagnoses. The majority of the chapter, although short, focuses on refeeding syndrome and enteral/parenteral feeding modes, with help from the “dietician” (yes dietitian with a “c”). Good discussion of medical complications with refeeding accompanies this chapter.
Chapter 5, “Evaluation and Treatment of Electrolyte Abnormalities,” gives excellent information about lab values associated with EDs and what they mean in regards to malnutrition, and different methods of purging. Notes on treatment of abnormal labs are given.
Chapter 6, “Gastrointestinal Complaints.” This topic is of high interest to RDs that read this book. The etiology of several issues with malnutrition and binging or purging are explained, as to what the patient may complain of, and clinical evaluation is provided. The explanations given are great talking points with patients on how to treat their discomfort. For example, gastroparesis, or delayed emptying from the stomach to small intestine is common in restriction. It explains that patients will often complain of bloating, which is worsened with a high fiber diet. Treatment includes weight restoration, resuming eating, and limiting high fiber foods like legumes and bran.
Chapter 7, “Cardiac Abnormalities and Their Management.” It is well known that malnutrition can have horrific effects on the cardiovascular system including sudden death. This chapter explains vital signs, etiology, and when to order EKGs or other tests.
Chapter 8, “Osteoporosis and Gynecological Endocrinology.” Up until the DSM-V, amenorrhea was a diagnostic factor for anorexia nervosa. With the DSM-V it was removed, but it is still important to the health of the individual to understand the hormonal issues that occur with malnutrition. This chapter goes into great detail on reproductive hormones, bone density (including DEXA readings), % of body fat needed for normal menstruation (10%, for most women), hormonal therapy (contraindicated, for the most part), and nutrition for bone health.
Chapter 9, “General Endocrinology.” Beyond female reproductive hormones, there are many other potential endocrine issues with EDs. This chapter covers these hormones, such as cortisol, growth hormone, insulin-like growth factor, thyroid hormones, blood glucose, and more. Complications of diabetes with EDs is discussed here.
Chapter 10, “Oral and Dental Complications.” Dentists and dental hygienists are often the first to see patients with bulimia nervosa and can be an integral player in identifying these patients, who might not be noticed otherwise. These oral signs and symptoms of bulimia nervosa are listed with descriptions, and some treatment methods are given.
Chapter 11, “Athletes and Eating Disorders.” The book explains that many sports increase the risk of a person having an eating disorder, especially those that have a great desire for a specific body type or “making weight,” such as ballet, wrestling, rowing, running, and others. Female Athlete Triad, over-exercise, perfectionism in athletes, and performance anxiety are discussed, along with anabolic steroid complications. Treatment recommendations, and the “role of coaches in promoting or preventing eating disorders” (p. 191), are excellent sections in this chapter.
Chapter 12,”Males with Eating Disorders,” shows that males are often overlooked, and not treated differently than females with EDs. This chapter gives excellent insight into the differences with males, and “reverse anorexia” or the need for a “big, muscular body.” Insight into what males are most at risk, and why males diet are interesting points in this chapter.
Chapter 13, “Using Medical Information Psychotherapeutically.” The main point of this chapter is when, and how, to discuss medical information with the ED patient, to not cause fear or make it sound trivial.
Chapter 14, “Ethical Conflicts in the Care of Patients with Anorexia Nervosa,” covers modern biomedical ethics parameters, and how they apply specifically to treating patients with anorexia nervosa. This is of particular concern when a patient refuses recommended treatment. The authors re-iterate, “patients with severe anorexia nervosa give the illusion of sanity even when they are driven by deadly irrationality, failing to appreciate that anorexia nervosa has the highest death rate in psychiatry…” (p. 234).
Chapter 15, “Medical Information for Nonmedical Clinicians and Educators.” This chapter is geared toward coaches, teachers, therapists, and others with a non-medical background that work with eating disorder patients (or in trying to prevent them). Out of control dieting and excessive weight loss, healthy nutrition, exercise, and risk factors are discussed. Also discussed are when should one be referred to treatment, how to approach someone you think may have an eating disorder, as well as easy-to-read information for coaches and parents.
“Appendix: Behavioral Guidelines for Staff to Use with Patients Who Have Eating Disorders.” This chapter gives guidelines for treatment center meals and other issues, as taken from the University of Iowa Hospital and Clinics, Behavioral Health Services, Eating Disorder Program.
My Thoughts on the Book:
Overall, I found this book to be a wealth of knowledge. Not much is published on the medical complications and treatment of eating disorders, and this was exactly what I was looking for to use when helping the doctors of my clients give the best care. I appreciated the tables, which neatly laid out information such as lists of symptoms, lab results and what they mean, medications, and in-depth explanations of complications such as gastroparesis and cardiac complications.
It was distracting that the authors did not correctly spell the word “dietitian.” Half of the time they spelled it correctly, and the other half they spelled it with a “c” (dietician) or they wrote “nutritionist.” The authors also misspelled “monounsaturated” as “monosaturated” fats (p. 220). Furthermore, they left the RD out of the list of team members in the section on “communicating with eating disorder specialists” (p. 29), listed the “physician, nurse, or dietitian” as the person in charge of weight restoration and refeeding, did not include the RD in learning how to shop for groceries and prepare food, and the fact they said, “…once-a-week psychotherapy with an experienced advanced registered nurse practitioner” (not a psychotherapist?) (p. 44). The International Association of Eating Disorder Professionals states, “RDs are the experts, in both food science and nutrition science, trained through education and experience to understand the complex relationship of food intake to overall physiological health” (IAEDP, 2015). Furthermore, the chapter on nutrition, was short and not very informative, which confirms my understanding that M.D.’s, though able to write diet orders and give “nutrition counseling” legally, are often not well versed in nutrition, or how to effectively explain it to someone else.
This book will be helpful to nutrition professionals, like myself, in understanding what clinical manifestations eating disorders are causing, as well as how to interact with physicians sharing patients, and how to explain to patients what is going on from etiology to treatment. Despite my issues with the author’s lack of understanding what the RD does, I would recommend this book to others working with eating disorders. There are other books specifically for nutrition treatment best practices. For example, Nutrition Counseling in the Treatment of Eating Disorders, 2nd Ed., by Herrin and Larkin, references this book in their description of refeeding syndrome (p. 193, Herrin & Larkin), gastrointestinal discomfort, and in referencing other topics. While Eating Disorders, A Guide to Medical Care and Complications comes from the perspective of treating the symptoms, the fundamental goal of nutrition counseling is behavioral change (Herrin & Larkin, p. 51).
Herrin, M., and Larkin, M. (2013). Nutrition Counseling in the Treatment of Eating Disorders, 2nd Edition. New York, NY: Routledge.
International Association of Eating Disorder Professionals (2015).The CEDRD in Eating Disorder Care. IAEDP.
Mehler, P.S., and Andersen, A.E. (2010). Eating Disorders, A Guide to Medical Care and Complications, 2nd Edition. Baltimore, MD: John Hopkins University Press.
There is now an updated 3rd edition you can get HERE.
Libby is a non-diet Registered Dietitian focusing on eating disorder treatment and prevention. She approaches health from the inclusive standpoint that any "body" can focus on health regardless of size. She is a ally in diversity.
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