Episode 125: Welcome back to Real Health Radio. This week is a rebroadcast of my guest interview with Emma Louise Pudge.
Emma is an eating disorders researcher and activist and Masters student at University College London (UCL) in Health Humanities. Emma researches eating disorders from a feminist, sociocultural and social-justice oriented perspective, and she is particularly interested in exploring how biological, psychological, environmental and sociocultural factors interact and intersect to uniquely shape people’s experiences of the world, their bodies and their interactions with food. Emma’s interest in eating disorders is at once academic and personal as she was personally affected by anorexia as a teenager, and her experiences of receiving inpatient treatment and navigating recovery have informed and motivated her work in the area. Emma is ambitious about creating change in the field of eating disorders treatment and research and hopes to undertake a PhD and pursue an academic career whilst also engaging in eating disorders advocacy and activism.
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Chris Sandel: Welcome to Episode 125 of Real Health Radio. You can find the links talked about as part of this episode at the show notes, which is www.seven-health.com/125.
Before I jump into this episode, I have an ask for you guys. A couple of times a year I take on clients. Client work is the core of my business, and it’s how I spend the vast majority of my time. After working with clients for the last decade, I feel confident in saying that I’m very good at what I do. Yes, I help clients with various symptoms, but it’s actually much bigger than just removing symptoms.
These are struggles that these individuals are obsessed with and defined by. Their problems have become how they identify and think about themselves. My clients have often worked with multiple practitioners and are on the verge of giving up. It really isn’t uncommon for me to be the fourth or the fifth or the sixth person they’ve come to.
Where I see myself being different to others is by combining science and compassion. I’m evidence based in what I do and have a strong grounding in physiology and why the body is functioning how it is, but at the same time, I’m compassionate. I listen to the mental and emotional side of the client’s experience and know that these aspects are of equal importance to health as the physical side is.
One of the aspects I like most about the work that I do is how positive the process is. People believe that they’re going to have to give up so much, that it will be painful in so many ways, but they’ll convince themselves that it’s better for their long-term health. But what they find is that the changes actually add to the quality of their life. They enjoy the changes in their new life. Their physical, mental, emotional health improves now, not in some far-off distant time in the future.
After working together, my clients are able to regain what they thought was impossible – having their periods again, conceiving, feeling energised, purposeful, alive, walking by a mirror without the dread of seeing their own reflection.
I put out so much free material. The podcast is free, the blog posts are free. While I stand by this free material that I put out, it is much more general. You have to discern what is and isn’t relevant for you. But when we are working together, I’m the one who can sort through this and can show you what is important, what’s the low-hanging fruit, and what are the levers that are going to make the biggest difference.
If you want this kind of precision in helping you recover your health, now is the chance to work with me. If you’re interested in finding out more, you can head over to my site, www.seven-health.com/help. There you can find out about how I work with clients and you can also apply for the free initial chat.
Welcome to Real Health Radio: health advice that’s more than just about how you look. And here’s your host, Chris Sandel.
Hey, everyone. Welcome back to another episode of Real Health Radio. This week, it is another guest interview, and this time I’m speaking to Emma Louise Pudge. Emma is an eating disorder researcher and an activist and a Master’s student at the University College London (UCL) in Health Humanities. Emma researches eating disorders from a feminist, sociocultural and social justice orientated perspective, and she’s particularly interested in exploring how biological, psychological, environmental, and sociocultural factors interact and intersect to uniquely shape people’s experiences of the world, their bodies and their interactions with food.
Emma’s interest in eating disorders is at once academic and personal, as she was personally affected by anorexia as a teenager, and her experiences of receiving inpatient treatment and navigating recovery have informed and motivated her work in the area. Emma is ambitious about creating change in the field of eating disorder treatment and research and hopes to undertake a PhD and pursue an academic career whilst also engaging in eating disorder advocacy and activism.
I first became aware of Emma about six or nine months ago. I’m a member of a Facebook group called the UK Non-Diet Professionals. It’s a group set up by Laura Thomas, who I’ve had on the show before. Emma is fairly active in that group, and I was always impressed with what she had to say and the content that she was sharing there. I started listening to at least one podcast based on her recommendations, and have read through many scientific papers that she’s posted here.
I then became aware that she was writing her own papers and went to her Academia page, where she hosts all of them, and read through them all. I liked what she had to say, so I reached out and asked her to come on the show.
As part of this episode, we principally focus on anorexia, looking at what it is and what causes it. These aren’t questions with straightforward answers. This is really the bulk of what our discussion is about. We use a paper that Emma had written on the topic as a springboard for our discussion, and like I do with all of my guests as part of this show, we talk about Emma’s background and her story and how this has impacted on her life, but also the work that she does.
I really enjoyed this discussion. Emma is only 22, and this is the first podcast that she’s ever done, although you wouldn’t know it. She’s smart, she’s well spoken, and despite her age is very knowledgeable about eating disorders, particularly anorexia.
With that intro out of the way, here is my conversation with Emma Louise Pudge.
Hey, Emma. Thanks for joining me on the show today. I’m excited we’re finally getting a chance to chat.
Emma Louise Pudge: Thank you. It’s really a pleasure to be here.
Chris Sandel: Today we’re going to speak mostly about anorexia. I’m sure that we’re going to stumble onto other topics as well, but anorexia is the main focus. You’ve written a number of papers on the topic, but you’ve written one recently that we’re going to use as the backbone or the launch pad for today’s discussion.
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But I guess a good place to start is with you. Are you able to give listeners a bit of background on yourself, on your training, and how you spend your day to day?
Emma Louise Pudge: Sure. As you said, my name is Emma Louise Pudge. Online, people might know me as @takeonEDs on Twitter or @EmmaHitstheSpot on Instagram. I’m 22 years old. I live in the UK, and I’m currently a Master’s student at University College London (UCL) in the Department of Health Humanities. My research focuses on eating disorders and mostly anorexia, as we’ll cover today.
But I do go back and forth between talking about anorexia and eating disorders more broadly because I’m aware of how anorexia is prioritised within the field of eating disorders research, and I do want to expand the conversation outwards and make it a bit more inclusive.
But in terms of my academic background, I did my undergrad at the University of Exeter in English literature with study in North America. This gave me the opportunity to spend a year out in Canada at the University of Victoria on Vancouver Island. I know it’s kind of a huge cliché to say that you go abroad and you find yourself, but in many ways that year was pretty life-changing, mostly because I had done my first year in English literature and then went away to Canada, where it’s much more of a liberal arts type setup. I began taking courses in gender studies and sociology.
It was there that I really found my feminism, really found myself in a strongly feminist and politically and socially conscious academic community. It was there that I had the opportunity to start writing on eating disorders as something that the department recognised straddled all the aspects of gendered and social life. As I’m sure we’ll go on to touch, it had affected me personally and was something that I was really keen to pursue.
When I came back to the UK for my final year, I’d already established quite a strong trajectory for my work writing on eating disorders during that year abroad. I continued this with my dissertation, which was called ‘Un/re-covering Subjectivity in Anorexia: An Autoethnography of Inpatient Treatment’. What this dissertation offered was an account and re-analysis of my own experiences of having had anorexia as a teenager and going into inpatient treatment.
It was through reclaiming and rereading the extensive medical notes that were taken about me during my treatment and really using this as a launch pad for my research and to think more carefully about what it means to be someone in treatment and how we divide the role between patient and researcher that I began to pull together parts of my personal and academic life and carve myself out a place in this field. Which is what led me to do my Master’s in Health Humanities at UCL.
Right now I’d say my work on eating disorders straddles a number of disciplines which are supported by the Health Humanities Department, including medical sociology, gender studies and food anthropology. Really, it’s a very interdisciplinary perspective that I take on eating disorders, and one that I’ve developed through partaking in all these different academic spaces and personal life experiences relating to eating disorders.
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Chris Sandel: That’s a really good starting place. You’ve given me some ideas of things I want to dig into. You mentioned about having that year away and going to Canada, and I guess I, and maybe others, have a view of Canada as being quite a liberal and progressive place. I think you even mentioned that. Do you think that was a big part of it? Or do you think you would’ve found yourself into this place no matter where you went on that one year gap, just because of the self-development aspect of it?
Emma Louise Pudge: I think there was definitely a huge self-development aspect. I’d always had an innate drive to do something in my life relating to eating disorders, but I was indoctrinated in that very narrow framework of thinking that people who work with eating disorders are medically trained. They’re doctors or psychologists, psychiatrists, etc. That wasn’t my academic background, so I didn’t really see a place for me to engage academically with eating disorders. I didn’t have that science background, and I was working within humanities and social sciences.
But it was through that infusion of social justice and feminist perspectives into the subjects that I took out in Canada, but also just the culture at large, that really allowed me to position eating disorders as something that wasn’t limited to a medical sphere, something that couldn’t be understand in clearly biological terms and that really warranted exploration from these different angles.
I think that was supported quite specifically by this culture that, at least where I was, was very attuned to issues of social justice and gender inequality and food sustainability as well. That’s one of the neat things about being on an island like University of Victoria is; the food system is very much something that they have to consider. I think that allowed me to really begin to think about how these larger structures impact our food environment, how our sociocultural messages impact how we engage with this food environment, and where this fits in relation to our own attitudes, beliefs, and behaviours around food and how that might impact on our physical and mental health.
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Chris Sandel: You’ve alluded to the fact that you’ve had an eating disorder yourself, but what was it like growing up in your household as far as food was concerned?
Emma Louise Pudge: Despite going on to develop anorexia, looking back, I was exceptionally lucky to have grown up in a household with almost entirely positive experiences around food and really vivid memories of food growing up that surround pleasure, travel, exploration.
I think it’s really important that I acknowledge how both thin privilege and socioeconomic privilege shaped these experiences because undoubtedly the fact that all of my family are constitutionally slim, we’ve always had access to opportunities to engage in physical activity and access good health care and had a wide range of food on offer – it was always plentiful, it was never restricted from a financial perspective, etc. – these aspects of my familial environment really should’ve offered me protection against eating disorder risk factors.
I think that will become interesting in light of the conversation we go on to have, because it can seem surprising to some people that despite having this very positive food environment, I nonetheless went on to develop anorexia. Some people will take that as evidence that families and the environment play no role at all in the development of eating disorders, but actually I think it’s a provocation to think more deeply about what we’re really talking about when we say the family or the environment have a role, and to really recognise the interaction between these and a whole host of other factors that include genetic, temperamental, developmental, sociocultural variables or vulnerabilities, so that even in the absence of one risk factor or even in the presence of another, there are things that buffer or protect us against developing eating disorders.
But none of them are determinate, and that’s why people like myself may go on to develop eating disorders and other people exposed to similar levels of risk or with similar levels of genetic vulnerability, for example, could end up with a very different illness or recovery outcome. If that makes any sense at all. [laughs]
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Chris Sandel: It does, definitely. At what age did you develop anorexia, and how long did that go on for before you – I don’t know how you think about the word ‘recovered’, but until you somewhat came out the other side?
Emma Louise Pudge: I developed anorexia when I was 15. Rather than experiencing a gradual progression into the illness through dieting or through weight and shape concerns, I had a very unusually sudden onset. Within the space of about 12 weeks, I went from having what we might consider a fairly ‘normal’ relationship with food and being in good physical health to rapidly deteriorating to the point where I was admitted to an inpatient unit for the first time.
Looking back, I realise that that inpatient stay marked the start of an experience of medical trauma, which again, didn’t cause my eating disorder, but that experience of trauma that is deeply tied up with having had an eating disorder was one of the biggest obstacles to recovery for me and has had a lasting impact on my health and wellbeing.
That admission was about eight weeks in length, and it was really focused on short-term stabilisation. But when I was discharged, I was probably psychologically and behaviourally even slightly worse off than before. And, as is often the case, I struggled to access a continuum of care, so I deteriorated once again, had quite a severe relapse, and several months later was admitted to a different specialist eating disorders unit, this time for a longer admission of about six months – which did take me to a point of full physical recovery, but there was a lack of psychological support. There was a lack of preparation for reintegrating in the social world.
And the experience itself was traumatic. I came out of that and – again, it’s a cliché to say that’s where the real work of recovery begins, but it really opened my eyes to the fact that there is a lot missing from mainstream treatment. Medical treatment certainly plays a role in instigating recovery or in resolving certain symptoms, but ultimately recovery is, at least in my eyes, a process of learning to live in your body and live in the world. And that’s not what treatment typically equips us with.
So it’s been in the months and years since then, as I’ve matured, as I’ve established new ways of living and being in my body and ways of going about my life, that recovery is an ongoing an embodied experience for me of living a life that isn’t dictated by eating disorder symptoms, behaviours, and everything that comes along with that.
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Chris Sandel: What you described there in terms of the recovery process is actually what I’ve heard from a number of other guests who I’ve had on chatting about this, and it’s also been my experience when chatting with and working with other clients. For those who went into inpatient, the focus is very much on “How do we keep this person alive? How do we stop organ shutdown?”, etc., and basically “How do we get the food in?” But in terms of the relationship with food piece, the relationship with body, the understanding coping skills, the real bulk of it is not dealt with, but it’s more “How do we keep this person alive?”
Emma Louise Pudge: Absolutely. I think that is a very widespread experience. I think it would be helpful if in general, treatment would acknowledge more explicitly that that is the goal and the area of expertise, and that they’re not providing adequate psychological, social, even nutritional support. It’s not tailored, it’s not individualised, it’s not integrated with the home environment and the outside world so that families and people affected by eating disorders have a more realistic expectation of what they can expect from treatment and also to really mark out the space for other practitioners and other professionals who are able to offer something different.
I think one of the problems in seeking treatment is that this approach – there’s something of a double standard where on the one hand, we say that we address eating disorders holistically, and we’re often conflating things like physical, nutritional, and psychological health and creating these very linear narratives such as restoring nutritional health will restore physical health, which will restore psychological health, which will restore social wellbeing. There are links between those, and they’re important links, and that’s not to dismiss them.
But at the same time, it’s a vast oversimplification to say that re-nourishing someone will resolve all of the physical consequences of their eating disorder and that a restoration of brain function will automatically lead to better emotional coping mechanisms, and that in turn will allow someone to re-join this ‘normal’ social and developmental trajectory if we haven’t also given them other kinds of support to assist those links being made.
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Chris Sandel: I’ve done a previous podcast on the Minnesota Starvation Experiment, which I think is a really important thing to understand, but I feel that often what gets taken from that – and let me just back up a sec and explain the Minnesota Starvation Experiment in very, very short detail.
Basically, it happened towards the end of the Second World War, and there were I think 36 men who were starved for six months to see what would happen. The reason for it was they thought there was going to be huge amounts of famine and rationing after the war, so they wanted to see what would happen. When they starved these men, they had all of these symptoms that started to come up as part of it, whether that be physical, mental, emotional, etc. Then when they were able to let them eat freely, they ate a lot of food, they went to a higher weight, and then everything started to come back to normal. I think basically a year after the experiment, they were pretty much back to where they started.
I think that’s often used as the basis for “Well, if we can just get people to eat, that’s going to have the knock-on effect in terms of the physical that knocks on to the mind,” etc., as you explained. But the difference is those men all came in being psychologically sound in mind and didn’t have the issues around body image, etc., that someone with an eating disorder often has. So I think there’s a lot more baggage that is there for someone with eating disorders that’s not there for those men.
And I know I’m making some big generalisations here, but that’s where I think that often falls down when people use that piece of evidence as the sole thing driving their understanding of how recovery works.
Emma Louise Pudge: Absolutely. I think it speaks to a larger problem with how we interpret and generalise research findings in general because these studies aren’t representative of the lives of many of the people who are presenting in clinical practice. They’re not illustrative of the social world as it unfolds at this particular moment, at this particular time, with influences that are specific to this week, this month, this year.
Those studies are looking at specific variables, which, yes, may show meaningful changes, but we need to contextualise and situate those variables within the broader context of someone’s life and also think about whether they apply to the specific individual we’re talking about. Because again, those men are not women; like you said, they didn’t have psychological comorbidities going into the starvation experiment. The setup was very artificial. It was very carefully controlled – even though there are some problems that I’m sure people can read about if they’re interested in the study.
But again, I think science reporting the interpretation of data – those are very real problems that affect how we think about any scientific phenomena, and in particular eating disorders and eating disorder recovery in this conversation. And those have to be part of the conversation. We can’t ignore the effect that media reporting, science reporting, the translation of research into clinical practice, has when it ripples out into popular opinion of what eating disorders are, what causes eating disorders, and what leads to recovery. Those things are all part of the conversation. They’re all part of the landscape, really.
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Chris Sandel: That is a lot of what your paper is about. Let’s get on to that. As I mentioned in the beginning, a lot of the basis for these questions now are going to be based on that paper. You get the prize for making me read out the longest and most wordy title for a paper on this podcast.
Emma Louise Pudge: [laughs] Thank you.
Chris Sandel: It’s called ‘Theorising Anorexia Nervosa as Biopsychosocial Entanglement: Re-reading neurobiological and genetic research on anorexia nervosa through Karen Barad’s onto-epistemological Framework’. [laughs] Don’t be put off by the title. We’re going to make this accessible and relevant.
There are lots of different things that the paper touches on that I want to dive into specifically, but to start with, do you want to give an overview of what the paper is about?
Emma Louise Pudge: Yeah, of course. Thank you for saving me the mouthful of that exceptionally long title. And I’m aware that will probably put people off, but I will throughout this discussion hopefully break down what I mean by those different terms and make it a little more digestible.
Essentially, at the broadest level in this paper, I discuss how there’s generally this quite broad agreement that anorexia nervosa is biopsychosocial in nature, which is to say that there are biological, psychological, and sociological aspects of anorexia and that a person’s biology, their psychology, and both their physical and social environment all play a role in the development of the disorder.
But in practice, in both research and treatment settings, these tend to be treated as very separate areas to be addressed by separate researchers or practitioners specialising in just one of these areas, with very little overlap or communication between them. As I reviewed the literature on anorexia in writing this paper, it seemed to me that approaching anorexia this way, in very stratified biological versus psychological versus sociological terms, was actually shutting down some of the most interesting questions about anorexia and didn’t provide us with a model that could do justice to the complexity we were seeing.
This led me to develop a theoretical model of anorexia as biopsychosocial entanglement, in which biology, psychology, and sociocultural factors not only interact with one another, but at a more fundamental level, are deeply entwined in such a way that they are entangled, that there is no real division between what is biological, what’s psychological, and what’s sociocultural. Instead, I argue that these are distinctions that we make, that these are rhetorical distinctions as much as anything.
I challenge this in my paper by re-reading some of the neuroscience and genetics research through this lens of entanglement because I really believe that it offers us a more empirically and theoretically accurate model of anorexia, and one that’s more likely to be cynically effective and therapeutically useful and resonate with people’s lived experience of anorexia, in which we don’t experience the mind, the body, and the world separately.
But there’s also another layer to my argument, which is that this model of entanglement, of things that we usually think of as separate actually being bound together, also applies at a more abstract level to the relationship between our beliefs about what anorexia really is, what causes anorexia, and the knowledge-making practices that inform these beliefs. So we need to think more carefully about how our understanding of what anorexia is shapes how we think about what causes anorexia, and this in turn drives the kind of research we’re doing and the questions we seek to answer in a fairly self-sustaining cycle.
So really, this model of entanglement works to describe both anorexia itself and the intellectual landscape that shapes the conversation about anorexia.
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Chris Sandel: There’s a number of terms that you use throughout this paper that would be useful for you to define. Some of them you’ve already touched on, so I’m going to leave them to the side, but you talk about ontology, epistemology, and aetiology. Listeners might not be familiar with those terms, so could you explain what they are and the importance that they hold to your argument?
Emma Louise Pudge: Just to briefly recap with the two before of biopsychosocial and entanglement, with biopsychosocial we’re obviously talking about biology, psychology, and sociology or sociocultural factors. With this term ‘entanglement’, as I’ve introduced, it’s a descriptive term to describe the set of relationships as a tangle, as a kind of knotted entity. But in my paper, my use of ‘entanglement’ does draw very specifically on the work of feminist philosopher/physicist Karen Barad, who uses the example of quantum entanglement to develop a theory that describes relationships between scientific facts and how we come to accept those things as fact.
Quantum entanglement comes from the realm of physics. It’s a physical phenomenon that occurs when particles are generated, interacted, and share space with one another in such a way that the state of each particle cannot be described independently of the state of the other. So they really are, at a very fundamental level, inextricably tied up with a process of measuring them.
This distinction that I’m making between what things really are and how we come to know about them is this distinction between ontology and epistemology. Ontology is what things really are; epistemology is how we come to know about them. Karen Barad creates a framework of onto-epistemology that really denies any separation between them and suggests that whenever we investigate the nature of things, we simultaneously need to be asking how and why we come to see them that way.
I know that’s a bit of a philosophical detour, but what does this mean in the context of anorexia? What this means when it comes to anorexia is that although we’ve got decades of research into the illness, we still don’t really know what anorexia really is. Which is to say there is an ontological question that remains unresolved. If you ask a range of educated people, “What is anorexia?”, you could get a range of responses describing anorexia as a mental illness, a mental disorder, a mental health condition, a psychiatric illness, a brain-based illness, a coping mechanism, a symptom of underlying distress.
Whilst on the surface all of these definitions respond to the question of what anorexia is, they also conjure up different ideas about what causes anorexia. This is where we have to think about how cause fits into the equation. This third dimension of cause is called aetiology at a philosophical level. In the case of anorexia, not only do we not know what anorexia is – we have this unresolved ontological question – we also don’t know the exact causes of anorexia, so that’s to say we don’t know the exact aetiology.
What I try and do in my paper is acknowledge the contributions of Karen Barad’s discussion of the relationship between ontology and epistemology, but I add in this third dimension to look at how our understanding of what anorexia is, is tied up with our understanding of what causes anorexia, and these are both simultaneously influenced by the scientific practices that we use to study anorexia.
I’m aware that’s quite complicated, but essentially we’re talking about this difference between what anorexia is, what causes it, and why we think that way.
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Chris Sandel: Let’s see if we can address each of those, then. I know, as you’ve alluded to there, there aren’t complete answers to any of these things, but starting with anorexia, what is anorexia? You can give a clinical definition and then whatever broad definition you think is appropriate, if you can answer that.
Emma Louise Pudge: Sure, I can give it a go, the eternal question. If we take the latest edition of the Diagnostic and Statistic Manual of Mental Disorders, the DSM-V, for example, they include anorexia under the category of feeding and eating disorders and set out three main criteria.
The first is restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. This was the first edition of the DSM to remove a specific weight criteria in order to reflect the fact that serious restrictive eating disorders can occur at any weight and reflect people at a higher weight who previously would’ve been bracketed as atypical or received an ‘eating disorder not otherwise specified’ diagnosis.
This is a really important point because, as I said, people at higher weights often experience equally if not higher levels of distress, symptom severity, they’re medically compromised, so weight just isn’t an accurate gauge of the severity of an eating disorder. That’s just an important point to make.
Chris Sandel: Definitely.
Emma Louise Pudge: But within this criteria, the second part is an intense fear of gaining weight or becoming fat or behaviour that interferes with weight gain, and the third criteria is disturbance in the way in which one’s body or shape is experienced and undue influence of weight or shape on self-evaluation.
What the DSM gives us is a definition of anorexia as a mental disorder, specifically a feeding or eating disorder. It’s characterised by a physical state of negative energy balance that is brought on by restrictive behaviour, and that reflects a negative psychological state. So we have those three criteria – broadly, a physical criteria, a behavioural criteria, and a psychological criteria.
But what’s particularly interesting about the DSM-V is that just a few weeks before its release, the largest mental health funding body, the NIMH, revealed it would no longer be funding research based on these categories because they couldn’t actually identify psychiatric biomarkers that matched up with these symptom-based categories. Really, the aim of DSM-V was to create a biologically validated framework in which we could identify mental disorders at the level of physical biology. This just wasn’t possible in advance of the release of DSM-V, and it was considered a failed project.
Instead, the NIMH announced it would go on to develop a new framework called the Research Domain Criteria that would emphasise biology, genetics, brain circuitry, and neurochemistry. So that was what was going on in the background at large when we began to think about eating disorders in recent years.
But there was already a shift underway in the field of eating disorders towards adopting this biopsychiatric approach when the Academy of Eating Disorders published a position paper in 2009, in which they defined eating disorders as biologically based serious mental illnesses (BBMI) according to a definition of BBMI, as a condition the current medical science affirms is caused by a neurological disorder of the brain.
What the Academy for Eating Disorders does is provide a definition or an ontological statement of what anorexia is – it’s a BBMI, it’s a brain based serious mental illness – that cannot be disentangled from their assertion of cause, that it is caused by a neurological disorder of the brain. So that’s where we’re at with a definition of what anorexia is according to the Academy for Eating Disorders. They’re defining it in very narrow biopsychiatric or neurobiological terms.
Chris Sandel: With this, there’s a big distinction between the brain and the mind. Are you able to explain what that difference is? Because I do think it’s relevant here.
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Emma Louise Pudge: Yeah, this is really interesting. The Academy for Eating Disorders’ assertion that eating disorders are specifically brain based illnesses, a neurological disorder of the brain and not a disorder of the mind, follows the premise of neurobiology that mind is what brain does. What that means is that if we want to understand the mind, if we want to understand aspects of mental life, we need to look to neuroscience for the answers.
On this account, psychological distress, debilitating symptoms, and behaviours or processes that maintain anorexia should all be able to be traced back to pathological differences in the brains of people with anorexia, and if these are causal, then it’s presumed that these differences precede the onset of the disorder rather than being consequences of self-starvation.
This distinction between brain and mind is at once scientific, but it’s also representative of a number of social, political, economic interests that come into play surrounding the presumed importance of physical biology versus mental health or mental life, and this really has ripple effects onto what kinds of conditions insurance coverage will apply to and where our research funds are going. The mind has been deprioritised against this new enthusiasm for all things related to the brain and the interest in the brain as very physical matter rather than this abstract or intellectual entity that exists separate from the physical materiality of the body, of biology, of life, really.
Chris Sandel: You pointed this out in the paper, which I found really interesting: over the last decade, funding for brain studies have been the most generously supported and spending in that area continues to increase, whereas for basically every other possible cause, funding has gone from very small amounts to almost drying up. This is where the funding is going, and this is then obviously how it shapes how we think about anorexia. Is that correct?
Emma Louise Pudge: Yeah, absolutely. Research funding is always a reflection of a number of social, political, economic priorities. Given that research findings stretch outward into the public sphere through media reporting, science journalism, etc. to shape how the general public think about anorexia, and in turn shape how institutions and agencies such as governments and funding bodies respond with their policies and with further financial investment, we have this self-sustaining cycle in which narrowly biological understandings of eating disorders are naturalised by this alignment of funding priorities, research outputs and science reporting.
In my paper, as you said, I cite research by Harris and Steele, who analysed National Institute of Health funding trends over the past decade depending on whether clinical trials of anorexia used exclusively biological framings of the disorder or biopsychosocial formulations. What they found is that brain studies were the most generously supported, and the spending continues to rise, whereas biopsychosocial formulated studies start out as the very lowest funded, and this is further decreased.
Given that one of the aims of the Academy for Eating Disorders in defining eating disorders as BBMI was to increase their funding, their commitment to framing eating disorders as BBMI even in the absence of really reliable or really uncontroversial evidence that would validate this model has to be understood in this sociopolitical context, because there are very real social and political motivations for framing eating disorders this way, even if the science hasn’t yet progressed to a stage where it is entirely valid.
00:48:00
But I realise I haven’t really discussed how biology does or doesn’t differ from these other factors in anorexia, so that might be useful.
Chris Sandel: Yep, definitely.
Emma Louise Pudge: I think the biological basis of eating disorders takes for granted a lot of assumptions about – or it makes very bold claims about what we know about the biology of eating disorders.
Currently there’s increasing evidence in support of neuroanatomical, biochemical, hormonal correlates of anorexia and genetic variations that are found in people with anorexia, but we haven’t actually identified any biological factors that we can say with certainty have a causal role. This is really important because correlation doesn’t equal causation, as the saying goes.
But many scientists will use this argument to dismiss the importance of sociocultural and environmental factors as being relevant when we have substantial evidence to show that these are also correlated with anorexia in very much the same way as the biological and genetic variations that we’re finding are correlated.
What’s more, in general we’ve seen a shift away from thinking about the cause of a disorder as the thing that brings about the outcome. This shift has gone from looking for cause towards looking at risk factors and vulnerability. But there’s again a bit of a double standard playing out, because whilst many neuroscience and genetics researchers will recognise that biological, psychological, environmental, and sociocultural factors are all implicated in the development of the disorder, they continue to give precedence to genes and biology as the core causal factors, whereas the environment is given a more limited role as a trigger, which is contained in statements such as ‘genes load the gun, environment pulls the trigger’.
The assumption, again, is that decoding the biology of anorexia will enable us to develop these really targeted, effective, individualised treatments. But even if a biological formulation is proven to be completely valid – which currently it’s not – it doesn’t necessarily follow that this is going to be the most appropriate site of intervention. I think a lot of this comes down to a really artificial division that we’re drawing between what is biological versus what is sociocultural or environmental.
Ultimately, all aspects of the social world, all aspects of life experience, everything from physical and psychological stressors to experiences of stigmatisation, are registered in the body at a physical level because that is what it is to be an embodied being, to be a biological organism living in the world. Our brains and our biology are situated and sustained in this environment. So these nature versus nurture dichotomies really aren’t helping us actually carve nature at its joints, as many of the geneticists will be keen to argue.
Chris Sandel: I actually did a whole podcast roundtable on genetics and talking about really how little we know at this stage, and even what we do know, it’s looking at risk factors. It might increase it by twofold or tenfold or whatever as opposed to being causal. At this stage we just don’t know very much about genetics, despite what often gets presented about “We can take your genetic code and we can tell you the best diet for you to eat or all these different things.” At this stage, we can’t do any of that. We might get to a stage where we can never do that because, as you say, it’s not just what the genes are; it’s how that interacts with the environment, life experience, etc.
Emma Louise Pudge: Yeah, absolutely. Again, I think one of the most interesting things we’re contending with here is that the popular uptake of these genetic explanations of eating disorders is in part a kind of backlash against these really reductive messages that have contributed to the stigmatisation of eating disorder sufferers and their families – messages such as families cause eating disorders, that media influences, beauty ideals, thinness ideals, etc. cause eating disorders.
These messages are taken to be representative of the sociocultural perspective. They’re taken to be entirely nonbiological. But actually, first of all, these messages are generally not coming from sociocultural researchers themselves, but are instead coming from journalists and science reporters who are equally likely to misrepresent the findings of either sociocultural or biological research by assigning a causal role to these variables that we actually can only demonstrate are correlated as risk factors.
But it’s also interesting that I think it’s here that we have space to question the division between what is biological versus sociocultural at a more fundamental level. If we take what might seem on the surface to be a purely biological explanation of eating disorders, such as eating disorders are principally caused by energy deficit, that cannot be disentangled from the sociocultural family and environmental context that would lead someone to enter a state of energy deficit in the first place, whether or not that energy deficit was intentionally sought out through dieting, for example, or the inadvertent effects of low energy availability whilst engaged in competitive sport or during a period of illness or experiencing poverty and food insecurity.
So whilst the biological reality of energy deficit is very real – it may have a genetic basis as to who is more likely to fall into energy deficits and for whom this will cause a problem – if we want to reduce the likelihood of people entering energy deficit, if we believe that this is the mechanism that causes eating disorders, it’s likely that the most appropriate level of intervention is not going to be in identifying people with this particular vulnerability.
It’s going to be in intervening at the level of the environment by reducing media exposure to messages that encourage restrictive diets or unhealthy exercise habits, by reducing weight bias and the prescription of diets by doctors, empowering parents to promote body acceptance, Intuitive Eating, and ensuring that schools and athletic contexts are set up in ways that allow people to nourish their bodies and that food is accessible for people across the socioeconomic spectrum. There are endless ways that we can intervene in the social environment to reduce the dangers that are posed by a biological risk factor such as energy deficit – not just for the individuals who are at highest risk, but for everyone who is harmed to a greater or lesser extent by these kind of social injustices.
I think it’s there that we really lose a meaningful distinction between what is biological versus what is sociocultural and the appropriateness of intervening in either of those.
00:57:00
Chris Sandel: You touched on a number of different vulnerabilities or risk factors as part of that. Are there others you want to mention?
Emma Louise Pudge: Yeah. In my paper I draw quite a lot on research by Cynthia Bulik, who looks at the perpetuation of anorexia across generations. One of the main arguments that emerges surrounding the genetic basis of anorexia is this link to heritability and that genetics is what causes its perpetuation within families, rather than there being an emotional/psychological dynamic to the family itself that’s to blame. If there is a perpetuation across generations, it’s presumed to be strictly biological in nature.
This is very well-intentioned and it’s designed to reduce harmful parent blaming, which has a long and dark history and really has no place in building supportive recovery environments. But when we look very closely at the data surrounding the perpetuation of anorexia across generations, we see, for example, that factors such as maternal undernutrition result in epigenetic changes. These are changes that occur between the genome and the environment. We see that epigenetic expression in the foetus is in response to a state of maternal undernutrition.
When we think about what maternal undernutrition is, it becomes quite ambiguous whether this is a purely physiological state or whether this is an environmental state. It’s likely that a pregnant mother who is in a state of low energy availability has probably got a social or psychological motivation for being in that state. There is a reason why she is restricting her food intake.
That neonate is not only being exposed to the risk factors of maternal or neonatal undernutrition when in the womb; they’re probably being born into a household in which the main parent, or at least the mother, is possibly more vulnerable to perpetuating messages about dieting, about nutrition, and may inadvertently express their own anxieties.
And that is not to blame – this is often taken as a parent blaming exercise, which really isn’t the role of identifying that as a risk factor at all. Rather, I think it’s a really wonderful opportunity for us to think about how we can intervene in postnatal support, for example, and prenatal support, to help mothers ensure that they meet their nutritional needs during pregnancy, that afterwards they are in a psychologically stable state, and that they feel equipped to raise their children using non-restrictive feeding practices and that they’re supported both with their own struggles and the potential vulnerability that may be conferred to their child through both genetic and environmental factors and the interaction between them.
So I think we really need to be moving beyond this strictly biological versus environmental division and think about biopsychosocial approaches that are likely to intervene at a biological, psychological, and social level, both individually and collectively, to intervene for specifically vulnerable individuals, in their family systems, and for our society at large.
That’s where this model of entanglement really works to expand the conversation and at the same time hold it all together, bring it all together, and insist that we take anorexia seriously as biopsychosocial entangled phenomena, if that resonates with the listeners at all.
01:02:15
Chris Sandel: Yeah. One of the things you were talking about there is – I’ve done a podcast before on cognitive dietary restraint, and I’m working on another one on the topic. Basically, it looks at how the desire to restrict your food, whether or not that happens, has an impact on the body’s physiology. It has an impact on a woman’s cycle. It has an impact on their ability to think, etc., and it’s not just coming from the restriction of calories or being in an energy deficit because it happens whether someone actually fulfils that energy deficit or they don’t.
So it just made me think about both when the child is around and seeing that versus when the child is in utero and how it’s probably not just the level of calories, but can also be the mother’s thinking as well during that stage.
Emma Louise Pudge: Absolutely. We have this in other areas when we look at how poor health outcomes are perpetuated across generations in other marginalised communities, in communities that experience racial oppression, for example. Epigenetics is really leading the way in this area.
Again, in relation to eating disorders, I think weight stigma is another really interesting example of something that we think about as being a set of beliefs or attitudes, something that’s mental or intellectual in nature and doesn’t have any real physical consequences. But actually, when we think about how weight stigma operates in the world, it is biologically embodied through the behaviours that weight stigma may lead to such as dieting, weight suppression, exercise abuse or exercise avoidance, but it’s also biologically registered in the effects of stress – the effects of stress that are caused by the social and psychological experience of weight stigma.
So we see these kind of mental or abstract entities becoming embodied in very real ways through this interplay of the body, the brain, and the environment. So our discussion really has to include every level, every aspect. There isn’t a strict division.
01:05:00
Chris Sandel: The final question I want to ask, because I know we’ve covered quite a lot here, is in our exchange as preparation for this podcast, when we were working out what we’d like to cover, you said, “A lot of my work is challenging the very concept of recovery and what it means to be recovered.” I know we touched on this a little bit in terms of your comments earlier on, but I would love to hear how you think about this and how you think about recovery.
Emma Louise-Pudge: Sure. I think my frustration with the concept of recovery is less scientific and it’s more motivated by a sense of social injustice. I think it’s a real privilege to be able to identify as recovered. To be able to identify as recovered according to the versions of recovery idealised in research means that you have to belong to a very limited group of people who the medical community first of all recognised as having an eating disorder in the first place, and who they’ll then also recognise as having re-joined a very normative physical health, weight, psychological, and developmental trajectory that assumes that there is a correct, a better, a healthiest way to be in one’s body or to be in the world.
And then also, the versions of recovery idealised by recovery communities, although they’re often used to inspire people’s recovery and create a more hopeful image of recovery, I think these communities set up an expectation that eating disorder recovery is the endpoint of suffering for people. Obviously, the idea of eating disorder recovery is it’s the end of their suffering relating to food and their body and exercise, etc.
But people who’ve experienced eating disorders may also be subject to other kinds of psychological and social suffering because of medical comorbidities, because of trauma that they experienced and possibly led to the eating disorder, and maybe because they live in a marginalised body. Those things may not necessarily get better with recovery, as I spoke about earlier.
I think it’s really important to make space for those narratives too and really allow people to define recovery for themselves in more flexible ways rather than imposing definitions of recovery onto people that assumes very normalised and very idealised standards about what it means to live a good life and to be well.
So I think that’s really why I wish to challenge the concept of recovery and make it something that people can offer their own lived experience on.
Chris Sandel: I think it also links into what we talked about in terms of recovery after an inpatient experience versus recovery in a different, broader sense. I find that just because people get over their issues around food – and ‘get over’ along a continuum, whatever that really means – that doesn’t necessarily take away struggles they have with their family or in social situations or all of the other things that are the messy parts that make us human.
I do think that, again, too much gets tied up into “Once I get over this eating disorder, everything else will be repaired and recovered,” when actually they are, yes, part of the same issue, but they’re also separate issues.
Emma Louise-Pudge: Absolutely. I think that’s why we again need to expand the continuum of care and recognise that our current models of eating disorder treatment are limited and that people may need to access other kinds of support. That’s not necessarily medical support; that’s social support, that’s family support. Other, broader social and political changes are necessary for people to live their best lives. Not everything can be resolved in the doctor’s office or in a therapist’s office.
We live in a world where there are very real structural problems, and I think we really do a disservice to people when we tell them that they’re essentially failing at recovery because they continue to be impacted by structures and negative experiences and messages that are not confined to their individual biology, psychology, or social attitudes. This is where a broader perspective allows us to move beyond blaming individuals and is, I think one of the key contributions of moving away from seeing individual biology as the target for our treatment and prevention efforts towards addressing systems at large.
Chris Sandel: Perfect. This has been a fantastic conversation. I’ve really loved getting into the details with you around this stuff. Before we finish up, where can people be going to find out more information about you, whether that be on social media or a website? Is there any way you want to direct people towards?
Emma Louise-Pudge: Yeah, of course. I’m very active on Twitter @TakeonEDs. You’ll find me tweeting there about all sorts of things related to eating disorders, related to food culture, social justice issues. I’d be very happy for anyone to engage me on that platform.
I can also give you a link to my profile on Academia.edu, which is an open access site where I publish some of my papers. Again, these aren’t papers that are published in journals; I’m only a Master’s student midway through their degree. But I’d be very happy for people to read those and to contact me about them. I’ll give you my email address as well, which you can include in the show notes.
I would really like to thank the community of people who are interested in eating disorders and issues related to food, bodies, and weight for being a very open-minded space on the whole and being open to conversations across disciplinary borders and between patients and researchers, between parents and advocates, etc. I’d love to continue the conversation with anyone from any background, really, and would encourage them to reach out to me.
Chris Sandel: Perfect. As I said, this has been a fantastic conversation. Thank you so much for coming on the show.
Emma Louise-Pudge: Thank you so much for having me. It’s been a real pleasure.
01:12:30
Chris Sandel: I hope you enjoyed that conversation with Emma Louise-Pudge. As I mentioned at the top of the show, I am taking on clients again. If you’re interested in finding out more, head over to www.seven-health.com/help. There you can read more about how I work with clients and apply for a free initial chat.
Thanks for listening to Real Health Radio. If you are interested in more details, you can find them at the Seven Health website. That’s www.seven-health.com.
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