Episode 180: In today's episode, Chris chats with Dr. Jennifer Gaudiani. Their chat centers around eating disorders and being "sick enough" for treatment, orthorexia, values-driven recovery, the overlap between substance use and eating disorders, and more.
Jennifer L. Gaudiani, MD, CEDS-S, FAED, is the Founder and Medical Director of the Gaudiani Clinic. Board Certified in Internal Medicine, she completed her undergraduate degree at Harvard, medical school at Boston University School of Medicine, and her internal medicine residency and chief residency at Yale. Dr. Gaudiani has been a leader in the eating disorders field for over 10 years and served as the Medical Director at the ACUTE Center for Eating Disorders prior to founding the Gaudiani Clinic which is a Denver-based outpatient medical clinic dedicated to people with eating disorders and disordered eating. The Gaudiani Clinic is a HAES (Health At Every Size)®-informed provider and embraces treating people of all shapes and sizes. The Gaudiani Clinic is licensed to practice in over 32 US states via telemedicine and offers international professional consultation and education.
Dr. Gaudiani has lectured nationally and internationally, is widely published in the scientific literature as well as on blogs, is a current member of the editorial board of the International Journal of Eating Disorders and the Academy for Eating Disorders Medical Care Standards Committee, and is a former board member of iaedp. Dr. Gaudiani is one of a very small number of internal medicine physicians who is certified as an eating disorders expert. She is also a Fellow in the Academy for Eating Disorders. Dr. Gaudiani’s first book, Sick Enough: A Guide to the Medical Complications of Eating Disorders, was released by Routledge in October 2018 and is available on Amazon.
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Chris Sandel: Welcome to Episode 180 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/180.
Real Health Radio is presented by Seven Health. Seven Health works with women who feel obsessed with and defined by their bodies. Using a non-diet, weight-neutral approach that combines science and compassion, we help clients transform your physical, mental, and emotional health. We specialize in helping clients overcome disordered eating, body dissatisfaction and negative body image, regain their periods, balance their hormones, and recover from years of dieting by learning how to listen to their bodies.
We’re currently taking on new clients. If you’re ready to put an end to your diet struggles and heal your relationship with food and your body, please get in contact. Head over to www.seven-health.com/help, and there you can read about how we work with clients and apply for a free initial chat. The address, again, is www.seven-health.com/help, and I’ll also include that in the show notes.
Hey, everyone. Welcome back to another episode of Real Health Radio. I’m your host, Chris Sandel. I hope you are settling into the new year. At the time of recording this intro, it’s just after Christmas, and by the time you will be listening to it, I should be arriving in Sydney, Australia as part of a much-needed holiday. This week on the show, it’s a guest interview. I’m chatting with Dr. Jennifer Gaudiani.
Dr. Gaudiani is the Founder and Medical Director of the Gaudiani Clinic. Board-certified in internal medicine, she completed her undergraduate degree at Harvard Medical School, at Boston University School of medicine, and her internal medicine residency and chief residency at Yale.
Dr. Gaudiani has been a leader in the eating disorder field for over 10 years and served as the medical director at the Acute Center for Eating Disorders prior to founding the Gaudiani Clinic, which is a Denver-based outpatient medical clinic dedicated to people with eating disorders and disordered eating. The Gaudiani Clinic is a Health at Every Size informed provider and embraces treating people of all shapes and sizes. The Gaudiani Clinic is licensed to practice in over 32 U.S. states via telemedicine and offers international professional consultations and education.
Dr. Gaudiani has lectured internationally and nationally, is widely published in the scientific literature as well as on blogs, is a current member of the editorial board of the International Journal of Eating disorders and the Academy for Eating Disorder Medical Care Standards Committee, and is a former board member of IAEDP. Dr. Gaudiani is one of a very small number of internal physicians who is certified as an eating disorder expert. She’s also a fellow in the Academy for Eating Disorders.
Dr. Gaudiani’s first book, Sick Enough: A Guide to Medical Complications of Eating Disorders, was released by Rutledge in October 2018 and is available on Amazon.
I’ve known of Dr. Gaudiani for a number of years. I think I first came across her through Tabitha Farrar’s podcast. She’s been a guest on it multiple times, and then more recently, she wrote the book Sick Enough, which I read and enjoyed, so I wanted to invite her on the show to chat about it.
As part of this episode, we start off by talking about Dr. Gaudiani’s background and how she ended up working in the eating disorder field. While she never had an eating disorder herself, she counts herself lucky, considering she has many of the personality traits that are often associated with developing an eating disorder. We spend a bit of time chatting about this.
We then just spend the majority of the time touching on topics and ideas based on her book – why she called it “sick enough,” values-driven recovery, the caveperson’s brain and her house on fire analogy, misconceptions around pulse rate and bone density in athletes with eating disorders, weight stigma and binge eating disorder, eating disorders in older patients and in male patients, orthorexia, the overlap between substance abuse and eating disorders, and conversations to be having with teenagers to protect them from eating disorders.
I really enjoyed this conversation. Dr. Gaudiani has a really warm and lovely nature to her, and just having this chance to spend this time with her and chat about such an important topic was wonderful. Let’s get on with the show. Here is my conversation with Dr. Jennifer Gaudiani.
Hey, Dr. G. Thanks so much for joining me on the show today.
Jennifer Gaudiani: Thank you so much for having me, Chris.
Chris Sandel: Your book was released at the start of this year, the start of 2019 – at least, that’s when we’re recording this. It’s called Sick Enough: A Guide to the Medical Complications of Eating Disorders. I’ve read it. It’s a fantastic resource. What I want to do today is use many of the ideas that are touched on in the book as the basis for our chat, and then we can see what other rabbit holes and directions we go down as part of that.
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But as a starting place, do you want to give listeners a bit of background on yourself, a bio of sorts, like who you are, what training you’ve done, that sort of thing?
Dr. Gaudiani: Yeah, I’d love to. Thank you. I grew up in northern California, the oldest of three girls, and went off to college, where I was an English major and a pre-med. In medical school, my middle sister arrived in college and had developed an eating disorder. I knew nothing about them except that I loved her infinitely and was confident that would be insufficient. She got a therapist and struggled with her eating disorder for many years, finally getting fully recovered in her mid-twenties.
But I will tell you that witnessing and walking that journey with her was really scary. It was also inspiring to me to see her recover. I think that it particularly impacted me because I felt there was a shift in me. I have many of the temperamental traits that my patients also possess. It is I think a fluke and somewhat mysterious to me why I didn’t myself develop an eating disorder.
But I think that as somebody who had the privileges of white, cis, hetero, thin, able, and all of those things, I was certainly experiencing body pressures and self-assessment based on body appearance myself. I think as my sister went through her disorder, as I gave her my love and my inexpert support, I spoke the words to her enough that I came to deeply believe them at an early age, which was: “Don’t take your emotions out on your body. Whatever you eat is okay. It’s all going to be all right. Trust your body.”
I think I said it to her enough that I recognized a shift in myself as I was in medical school, thinking, huh, I’m a little bit less aware of this or bothered by it in myself now. What I’m telling her is probably right. So that was an interesting inspiration to me, and her courageous journey and willingness to share her story has been remarkable.
I did my internal medicine residency then at Yale, and my chief residency, and loved taking care of the whole person. Actually, I was also inspired by a dear family friend who developed Type I diabetes as a child and then a few years later, began to develop anorexia concurrent with it vis-à-vis floating her blood sugars or not taking enough insulin.
I watched, even at a much younger age than medical school, as the Western medical institution systematically failed her. When she was brave enough to say to the endocrinologist, “Hey, the reason I’m running A1Cs that are extremely high is because I’m afraid of gaining weight and this is a thing for me,” invariably the older white male endocrinologist would give her a virtual pat on the head and say, “Let’s just start by getting your blood sugars under control,” and really failed her.
As I progressed as a young doctor, I thought, I wonder if I can use these two inspirations to be the kind of doctor that really feels congruent with my values. What if I can invite the patient to share their narrative with me, and I can, in turn, meet them halfway with my medical knowledge, and together we can find a common language to make whatever they’re dealing with a little bit more manageable on terms that they care about?
That was the ethos that I went into my residency with, never thinking that I would specialize in eating disorders because I was an internist and there are no internists who specialize in eating disorders. [laughs] When I moved to Denver 12 years ago, I had the opportunity to become a leader at a hospital-based unit here that specializes in multidisciplinary medical stabilization of critically ill adults with anorexia nervosa and helped to run that unit for 8 years, and published and learned and spoke to various different audiences. That was it for me. It landed in my lap unexpectedly, but that was it. I fell in love with the field.
Then 3 years ago, I left on warm terms to open my own outpatient medical clinic because I wanted to see that full story. I wanted to be with my patients and with a much more diverse group of patients through all the chapters of their lives, not just during hospitalization. So that brings me to this day.
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Chris Sandel: Nice. There’s a lot that I want to dig back into. The thing when you talked about with your sister and you said a lot of your temperament is the same as hers and it’s almost like a fluke that you weren’t the one that ended up in that position – maybe talk a little bit about your childhood, your upbringing. How was food in your household?
Dr. Gaudiani: Thanks, that’s always a really interesting question. There were strong positives and there were some interesting negatives. On the positive side, I’m of Italian heritage, and there’s a really strong culture of food and food with family in Italian culture, even several generations of Americanization in.
I think there was quite a lot of structure around food in my family. I came from a well-to-do family. There was always plenty of food, and family meals kept relatively low chaos around food, by counterpoint with what some of my patients do experience. That was protective – as was the cuisine that my mom, and then eventually my dad as well, cooked, which had no orthorexic tendencies to it whatsoever. Fats were used in delicious abundance, and thankfully at the time, it would’ve been utterly bizarre to suggest, in the ’80s and ’90s, that carbs were an issue. [laughs] So that didn’t arise on my horizon. We ate delicious food, plenty of it, and usually in a family setting. Those were protective things.
I was athletic. Not to say I was necessarily an athlete, but I think my relationship with movement was one of joy and confidence, on the whole.
The negatives were that my dad came from a really fat-phobic family and brought that into our home in myriad unfortunate ways, in retrospect. My mom, who is as brilliant and accomplished as she was gorgeous, was coming of age professionally at a time that feminism was just dawning, and she had a lot of self-doubt. I think that it wasn’t popular for women to be super capable and super bright, so the easy out was to put herself down, especially her physical appearance. There was just endless chatter around “Oh, I shouldn’t eat this, I’m being bad” or a relationship between food and exercise and body size. Or the fact that I even knew my mother’s weight growing up is super bizarre.
So I think there was a lot of that swimming through my head and it definitely programmed me to realize not just in society, but also at home, there was clearly being power and privilege ascribed to certain body types more than others.
Chris Sandel: Did that then play out as well with school friends? Was it “in” that everyone was dieting when you were a teenager? Is that your experience?
Dr. Gaudiani: I ran with the nerd crowd. [laughs] I was not amongst the popular girls who maybe were a little bit more aware of their appearance. But nonetheless, if a friend of mine lost weight, either incidentally or perhaps with some intent, they got attention. Interesting attention, for a teenager. Attention from boys. And that all influenced me. That was definitely in my heart.
Chris Sandel: Did you have a strong period where you were dieting and going from one diet to another that you can remember?
Dr. Gaudiani: Interestingly enough, I love food too much to have ever gone too far down atypical eating. As a teenager, absolutely, every couple of days, here and there, thinking about it too much. But I think I’ve always really loved food. And again, by quirk – I can’t explain it now, how this didn’t happen, but I never restricted sufficiently that that binge urge became more prominent. It always stayed relatively moderate.
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Chris Sandel: In terms of your sister, was there anything that was different as part of her experience than your experience? Was there more pressure on her from friends, or was there anything that you can point to towards why it was her and not you?
Dr. Gaudiani: I could postulate. She was definitely in a somewhat more popular group of friends. She’s naturally built curvier in a society that does not honor that. I think that her temperament was such that she had just that little bit more of sensitivity to life’s vicissitudes and to social interactions that I think were harder for her to sit with. She was so passionate and caring and so influenced by a social relationship that was going awry that I think it may have made her more vulnerable to everything that restricting calories meant, and that eventually purging meant as well.
Chris Sandel: As sisters, was there ever any dieting talk amongst you guys? Or that wasn’t the relationship?
Dr. Gaudiani: Never. Not for a heartbeat. Even before she arrived at college, when she started talking about, “Hey, I’m worried about my weight and I can feel myself eating less,” I would continually give her the good messages. Eat all the good food. Get all of your meals in. Get all of the snacks in. Your body needs all of this energy. Fortunately, there was not a competitiveness. There was a great tenderness and a feeling of protectiveness, recognition that there are certain things that are good for you and certain things that clearly won’t do you any good.
Chris Sandel: Given that this is the profession you’ve now ended up in, was the care that she got as part of her recovery something that was luckily very good, was unluckily very bad? How did it play out for her?
Dr. Gaudiani: It was luckily very good. She had a series of terrific therapists as she finished school and moved on to graduate school and work that I think were great. She never had to step up to a higher level of care. I look back and wince at my own super uneducated attempts to support her, like, “If it would help you, I can listen to everything you’ve eaten that day” – I mean, goodness, mercy, that was not my role.
On the positive side, I didn’t screw it up in the sense that I was always giving her what I now know to be fundamentally sound advice. But wow, that was not my place. If I were to have my current wisdom back when I was in my early twenties, yep, I might’ve done some things differently myself. But she got good care.
Chris Sandel: Good. At that time as well, because of what she was going through, did you start to read books or websites or material around eating disorders at that stage? Or that came a little later?
Dr. Gaudiani: Actually, I never did, I’m embarrassed to say. It’s a great question. It really wasn’t until I had the opportunity to get into the field and help to grow and run this hospital-based program that I threw myself into reading and learning.
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Chris Sandel: How was it when you first started in that hospital-based program? If I speak for myself, there’s so much that, as a layperson, you just don’t understand about eating disorders in terms of how they work, how they affect the body. So to go from being someone who really doesn’t understand it, to be thrown into that, how was it?
Dr. Gaudiani: It was fantastic, and I made lots of mistakes. I loved it from the very get-go, and I think I was probably benefited by the fact that when I joined, it was a two-bed program, and then when I left it was a 15-bed program. So it’s not that I jumped into a completely full service. I learned. I really enjoy learning from my patients themselves and then from a multidisciplinary team. So it’s information that I feel I absorb pretty quickly.
But gosh, I made a zillion mistakes. I continue to make important mistakes on at least a weekly basis, and just try to not respond to my innate fragility reaction of defensiveness or defeat and instead say, “How fortunate I am. Thank you for teaching me this. I apologize that I made a mistake. I’m going to do better next time.” It was really with that attitude that I came into it, and I just – the whole deal, I absolutely loved it.
Chris Sandel: Was Health at Every Size a part of that practice?
Dr. Gaudiani: Oh my goodness, no. [laughs] I was late to the Health at Every Size party. Really, not until I opened my outpatient clinic and knew that I wanted to see patients of all genders, ages, body shapes and sizes, and all eating disorder diagnoses, that I realized I needed to do some fast learning. I can’t even remember the first time I heard about HAES and weight-inclusive care, but it was early on in the course of my outpatient work, and as soon as I heard about it, I was like, “Of course. Of course.”
But I benefited tremendously from some very patient, wise, thoughtful teachers who really helped me understand where my years of medical training and practice, no matter how kindly intended, had done harm, had not helped people, and were based in a system that is as archaic as it is useless.
Chris Sandel: Were you reaching out to these people and saying, “Hey, I’ve discovered this concept, and I know you know a lot about it; can you give me more help on this?” Or it was more in terms of interactions where they came across something you’ve read and were trying to correct what you were talking about?
Dr. Gaudiani: It was both. I really sought out experts to try to get myself up to speed. But interestingly, there are almost no physicians practicing under a HAES model. I was fortunate enough to be learning HAES from wonderful dietitians and therapists, but still, there was not the kind of supervision that could be like, “Here’s how to practice outpatient medicine through a HAES lens.”
I had to bring the concepts in, and again, make a couple of public mistakes and be like, “Whew, okay, gosh, clearly did not get that. Let me try again,” and get corrected, and push myself. I mean, my uncomfortable learning edge was being really challenged over the last few years. But at the same time, I felt so excited about it because all of my work in eating disorders had left me with this deep desire for a concept that would unify care across the entire spectrum, not one type of care for one group of people and another almost opposing type of care for another set of people.
Chris Sandel: At this stage, do you speak at medical conferences where HAES is not the norm? Is that part of what you do at this point?
Dr. Gaudiani: Traditionally, I’ve done most of my speaking at eating disorder conferences. I think although HAES is finally becoming more and more mainstream thanks to resources like you and others that you’ve had on your show, the actual universal application of it remains non-mainstream, even in eating disorder circles, lamentably.
I think when I speak at eating disorder conferences, I’m still, I hope, helping to educate people on how weight-inclusive care can truly be applied and how much more beneficial it is mentally and medically for individuals of all body sizes, as well as bringing social justice awareness, broadly speaking, into my practice.
But I am going to start to do a little bit broader medical conversations. What’s interesting about – do I speak to physicians? Primarily, they’re not interested. They don’t want me. They don’t want to hear it. And I say that as a profound generalization. There are some wonderful physicians who are curious and open and intrigued, like I was. But there’s a lot that just think, “Nope,” and there’s a lot of resistance still.
Chris Sandel: Yeah. I was reflecting on this, and it feels like because of the kind of work that we do, and you’re on that frontline of seeing how destructive dieting and complicated relationships with food really are, it feels like we would be the first group of people to get HAES as a concept, and then it moves out to places where there isn’t so obvious this connection between why this would be a good idea.
Dr. Gaudiani: Absolutely. I really have hope that because HAES does make so much sense and because some of the early data – I’m in the process of compiling early data that I’ll try to publish next year with my co-authors – because the early data look so sensational as far as medical outcomes, radically better than the diet culture focused ethos we’ve got currently, my hope is that it will be adopted. I think there’s also little pools of medical students here and there who are like, “Hey, we’ve heard of this. This sounds right,” and they’re starting to demand more inclusion in their curricula.
So I am hopeful, but we’re in early days. And I say that respecting the fact that the true progenitors of HAES and weight-inclusive care have been waiting decades for any movement and momentum.
Chris Sandel: Yeah. You mentioned about setting up your own clinic more recently, and it’s an outpatient clinic. Was there any thought of you setting up your own inpatient facility – I’m thinking of someone like Carolyn Costin – or doing something of that ilk?
Dr. Gaudiani: Carolyn Costin is a beloved friend, and I’m inspired by the folks who created some of the first IP residential programs. I’m really interested in what happens when people stay in their own lives and have the benefits and motivations of seeing what they care about while also seeking treatment.
Now, for the people who need a higher level of care, 100%, I have referral relationships all over the country and routinely send patients to a higher level of care when necessary. However, the way that U.S. insurance works, at least, it’s becoming more and more difficult to get comprehensive benefit from the higher levels of care because insurance is reluctant to approve someone. They are having a tendency to cut services way too early. They then put patients who are in the baby stages of a recovery back into their home environment, with just enough care to be in that no-man’s-land of mental and physical challenges. And then patients think they can’t get better.
So I think what I’m really interested in doing is helping people within their outpatient world medically, as long as it’s appropriate, working with a multidisciplinary team that includes a dietitian and a therapist, and trying to help them here. Having taken care of some of the most medically compromised patients in the country for quite a long time, I’m interested in what can happen, the needs medically of everyone else who either doesn’t require that higher level of care or who’s been failed by it or who just can’t bear to go back to it. I think this is a really fun setting for me in which to live my clinical values.
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Chris Sandel: You said values there, and you alluded to it as well – one of the things I took from your book is how big values are and using a client’s values as part of the recovery piece. Do you want to talk a little about that?
Dr. Gaudiani: I’d love to. I am not a therapist. I never play therapist. But to the extent that I understand the basics, I’m really interested in ACT, acceptance and commitment therapy, and its values basis. It was what was broadly used on my prior program, and it appeals to me as a pragmatic, thoughtful approach.
When I first meet a patient, because all of my patients need to come to me in person for a two-hour initial assessment, and then I can follow them up by telemedicine around the country, I invite them to share with me as the first piece of information they speak what are their goals and values.
It’s so easy in a hierarchical, power-infused medical system – even in the dyad of me as a friendly, laidback, nice physician, there’s still power in the room. So for me to work on decreasing my assumptiveness by asking patients what they want for themselves and then using that as my roadmap, not making assumptions about what their outcomes should be or what they’d want or what feels possible to them, that’s such a powerful start for the two of us.
And then their naming their values – the things that matter to them in their lives – begins to help me understand them as a whole human. I don’t think I can provide good medical care without that.
Chris Sandel: That’s actually the place that I will typically start with clients as well. I prefer to do it as a writing assignment, just so they have more time to think about it. I prefer to have more time to go through it, so getting them to do a writing assignment on what’s your identity, what’s your values, what’s your priorities, and there’s questions with all of those. I find it really helpful.
The one thing that comes up a lot when I get them to do that writing exercise for values is there’ll be things like compassion and caring for others and all of these values, and I’m always like, and how do these values apply when you turn them inwards? Because people seem to be a lot better at having values that they have for others than being able to hold themselves to those same values. So that’s always an interesting conversation to have.
Dr. Gaudiani: Isn’t it? I think that’s such a lovely point. I find it helpful when I do have somebody who’s struggling with whatever I’m encouraging them, inviting them to do next for their recovery work medically, to bring it back to their values. “Listen, what you told me really mattered to you was this. Let’s just take a quick check-in, because I know the eating disorder is being such a jerk right now and it’s so powerful, but is it taking you toward that value, or is it indeed taking you away from that? Because if it’s taking you away from that, then your values and my recommendations are congruent with each other. Let’s find a way to try to push through.”
Chris Sandel: Yeah, because there’s a difference between lived values versus aspired to values.
Dr. Gaudiani: Right.
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Chris Sandel: One of the other bits that I wanted to talk about is just how difficult it can be for people to get a diagnosis, and this then feeding into the title of the book, of people not feeling sick enough to warrant care. Do you want to talk a little about that?
Dr. Gaudiani: I would love to. I think on a fundamental level, we’re up against a lot of huge obstacles. We have physical symptoms caused by eating disorders that intermingle with diagnoses that occur alongside eating disorders, like anything from Type I diabetes to migraines to substance use disorder, but that themselves are worsened by the eating disorder. And then those get mixed up in symptoms that get worse due to stress and anxiety.
Then we end up in a medical system where only that which is measurable is true, and where mind-body connection are not honored or seen, and where dietary restraint is the new defining behavior of virtuosity in our society, and where we have a society-wide epidemic of restriction that triggers groupthink, and that as long as there’s such a thing as “looking healthy,” medical providers are going to miss and harm patients.
That’s, in a nutshell, the challenges that our beloved patients are up against when they walk into the clinic, besides all of the systematic challenges of access to care and the like. So it’s a big challenge. But what I’ve really tried to do in my personal one-on-one care, in my writing, and in my podcasting, is to offer a model in which one can actually, with time and relationship and thoughtfulness, slowly make progress on how all of these factors interact.
I named the book Sick Enough because – well, you’ve written about this yourself, of course, brilliantly – so many people just don’t feel that they’re sick enough, no matter what phase of their eating disorder they’re in. With the internet, they can always find someone who, on terms that they arbitrarily point to, appears to be sicker than they, and they conclude, because of this being a mental illness, “I’m not worthy of going and spending resources or finding expertise, or even just taking on the demands of my eating disorder. It’s not worth it because I’m not sick enough to do that.”
My message to patients is: anyone who has a disordered relationship between food and their body is sick enough to get care.
Chris Sandel: Yeah. When I wrote about it, my take was just, do you want things to be better than they currently are? If that is the case, then it doesn’t matter whether you’re “sick enough.”
Dr. Gaudiani: I thought that was such a great point, yes.
Chris Sandel: Yeah. You want to get better. You have a really great analogy for this in terms of the house on fire analogy. Could you share that with people?
Dr. Gaudiani: I’d love to. The house on fire metaphor is one that I will introduce relatively early on if I suspect that a patient might benefit from it. I really like speaking in metaphor, A) because I was an English major, and B) because I think sometimes speaking in stories gets around that part of the brain that’s guarded by the eating disorder and ready to leap defensively.
The house on fire story goes as follows, and I’ll just happen to use a female pronoun for the character in this story. There’s a young woman standing outside her burning house, and the fire department comes roaring up, and the firefighter jumps out and says, “We’re here to put out your fire!” She goes, “What fire?” The firefighter says, “Your fire. I see the flames, I feel the heat, I smell the smoke.” She goes, “Oh, no, if I had a house fire, it would be so hot that the pavement would be bubbling. Because the pavement’s not bubbling, I couldn’t possibly have a house fire.” The firefighter understands that this individual is mentally ill and puts out her damn fire.
The message that I give to my patients, when they say, “But Dr. G, I’m getting a 4.0. My potassium’s okay. My weight’s not that bad, my weight’s not low at all. My vital signs are normal. My labs are normal,” I’ll just look at them and say, “Oh, pavement bubbling.” [laughs] Then they laugh and they’re irritated, and we move on.
Chris Sandel: The other analogy or the thing that I think about is when people talk about hitting rock bottom. You hear someone’s story and you’re like, how is rock bottom now two years prior to this? The point at which someone typically thinks “okay, now I need to do something about this” – you don’t want someone to end up at that place. That is such a difficult place, mentally, emotionally, but also physically. That is just so dangerous, and you’re then still hoping that someone’s going to hit that point of recognition.
Dr. Gaudiani: That’s right. I think the concept of rock bottom can be used internally as an excuse to proceed with the disorder, and you can end up in a really dangerous game of chicken with mortality. “Well, I didn’t feel too hot yesterday, but I’m going to do the same thing today, or maybe go a little tighter, and let’s just see, because I might not have hit rock bottom yesterday.”
Well, you know what? Rock bottom might be your coffin, friend. It might be permanent physical or neurological damage. Past experiences don’t predict future physiologic responses, so what you were able to tolerate 3, 10, 20 years ago, gosh, you might not be able to now.
Very often – and you mentioned this in your blog on the concept of sick enough as well – when patients compare themselves presently to a prior state of illness and conclude they’re not as bad as then, so why make any changes or why do something different, what I encourage my patients to think about is: let’s not compare you to your “worst day.”
Let’s compare you to the vision of your future that you’ve told me matters to you, where you’re working, you’re in school, you’re enjoying your dog, you’re having fun with your children, your sister. Let’s compare you today with that future vision. The delta, the difference between today and what you actually fundamentally wish for yourself – that’s what makes room for change. That’s where we say, “Oh my goodness, I’m nowhere close to that.”
That’s where patients say, “I’ve eaten well for a week, so I figure I’m now fine.” Well, hmm, no, because, honey, here’s what “fine” is going to look like. Fine is going to look like XYZ, and not thinking about your weight 15 times a day, and not being unkind to yourself, and not pushing yourself when you need to rest, and not choosing food based on some theoretical moral valence of it instead of what sounds tasty to you in the moment.
When you go over some of those features of “fine,” each one individual of course, the patient can be like, “Oh yeah. That’s right. I’m nowhere close to that. I see.”
Chris Sandel: I think that’s really important to use that as the comparison, as opposed to just “I was so much worse X number of months ago or X number of years ago.” For a lot of clients that I work with, they will have had a point where it worse, and it’s that thing of, “Things are obviously better now, so do I really need to try? Maybe this is as good as it gets.”
The analogy I’ll often use is previously you were at a 1 out of 10. Now you’re at a 2 out of 10, and you just don’t understand that you’re at a 2 out of 10 because that’s become your norm. But you’ll see when you’re at a 10 out of 10 just how much of a difference there is between where you’re currently at.
Dr. Gaudiani: That’s a really powerful point. I think as well, I talk to my patients sometimes about sick exceptionalism. Like, “Sure, that’s all fine for everyone else, but it doesn’t apply to me.” Let’s say that I have a patient who is a beloved dog owner, and they say, “Dr. G, why do I have to make changes now if my labs look okay and … also looks all right?”
I say, “Look, it makes intrinsic sense to you that you would never wait until your dog’s potassium was abnormal or until their vital signs were abnormal to give them their supper and their water. They get those because they’re mammals, period. That actually applies to you too.” Inevitably it’s, “But I’m different. It’s different for me because…” And my answer is, “You’re a mammal. If we can keep it in the simplest terms possible, it isn’t actually different for you.”
00:43:25
Chris Sandel: Let’s then use that – you talk a lot in your book about the caveperson brain and making reference to being a mammal. Let’s talk about that for a little bit and what the caveperson brain is trying to do, but also how the body is then damaged as part of restriction and all the components that that starts to have a knock-on effect to.
Dr. Gaudiani: Absolutely. I use the concept of the “caveperson brain” with my patients – which is about as neuroanatomical as I get because I almost failed neuroanatomy in medical school – as a reference to the part of our brain that runs us as a mammal without any conscious intervention. It’s the part that regulates our temperature and our metabolism, our digestion, all of the elements of our bodies we can’t consciously control.
What I tell my patients is, this caveperson part of our brain has evolved exquisitely over the millennia to save us from death by starvation. That’s the only reason the human race is possibly alive, because we evolved much more during a time of want than of plenty. So this part of our brain is exquisitely attuned to malnutrition. I always pause and say, malnutrition means when for any period of time, your body is not getting the energy intake that it needs, regardless of what body shape or size you happen to be in. Malnutrition does not refer to someone with a visibly emaciated body or who’s lost weight.
When the brain senses even a day or two of malnutrition, it jumps into action. It says, “Oh, I’ve gotcha.” Our magnificent, beautiful, miraculous brains do what they were evolved to do, and they begin profoundly changing our body’s physiology to save us from famine. Because that’s all the brain understands. It doesn’t understand it’s a diet, it’s a fast, it’s a cleanse, it’s an eating disorder. It just knows its mammal is being underfed.
As a result, the brain changes physical processes in the body to use less energy and get you through the famine. Everyone’s body is going to do this differently in the sense that one person, in the face of malnutrition, might get cold hands and feet and low energy, but their heartrate’s always normal and their tummy works fine. Another person might instantly develop constipation and bloating, but their heart rate is fine and their hands are warm. Exactly what turns on or turns off in the body is really related to our individual genetics.
But here’s a quick list of the things that the brain may alter in order to save energy in someone who’s not taking in enough. They may slow the heart. That’s what happens to bears in the winter when they hibernate, and that slowed heartbeat is a result of increased vagal tone in order to save calories.
That same person with a slowed heartbeat at rest, when they walk down the hall, their heart rate may actually get quite a lot faster, which is the difference between someone with an athletic heart and someone with a starved heart. A great athlete who’s well-nourished and well-rested may have a slower heart rate at rest, and then just walking down the hall – I mean, that’s nothing for an athlete’s heart who’s well-rested and nourished. Heartrate’s not going to change much. But somebody who’s malnourished, regardless of body size or shape, may have a low heart rate at rest to save calories, and then as that malnourished body asks something of itself, walking down the hall, even if the person is an over-exerciser, the heartrate may really go up. Say it goes from 45 or 55 up to 90. That’s a very considerable change. That’s a starving person’s heart.
Another example would be slowed digestion, which can result in gastroparesis or stomach emptying, constipation, bloating, abdominal pain. That, in turn, can trigger any number of other complications, like bacterial overgrowth.
People’s hands, feet, and overall body temperature gets cool because the body doesn’t want to spare those extra calories on keeping your body warm. So it makes you feel cold so you seek a sweater and a hot cup of tea rather than make it keep your body temperature up.
It also changes sex hormone production. You’ve talked a ton about that before. It can result, but not necessarily, in the absence of menstrual periods for women and in the absence of erectile function normally for men.
So there’s a lot of different ways in which the body can change in response to malnutrition. It’s just a question of your genetics as far as which ones you’ll manifest.
Chris Sandel: I think that’s a really important thing for people to get, for a number of reasons. We have this stereotype of what “an anorexic” looks like, and that is really damaging because it means that for the very small percentage of people who fit that stereotype, they’re going to be more likely to get help, and then for everyone else, it just doesn’t work that way and their disordered eating behaviors are often congratulated as “Wow, this is the thing that you need to do to try and fit into society’s body preferences.” So it’s a real problem from that side.
But also, I’ve talked more recently about RED-S. The focus was so much for the Female Athlete Triad on people having issues with their bones and then losing their period, and what we know now is that’s just not what happens with everyone. For a lot of people, they would be completely missed because for whatever genetic reasons, even under starvation, their bones stayed relatively good and they were able to keep their periods.
Dr. Gaudiani: That’s completely right. It can mess with people on either side of the equation. My patients who say, “Gosh, I used to be able to do a lot more of my eating disorder without my body falling apart, but now I can’t,” it’s frustrating to me. Also, on the other side of the spectrum are the people who say, “Man, I’ve been doing this a long time, and my body seems to be really hanging in there and not showing that much medical problems.” That’s frustrating to me.
So either way, there’s no winning. It’s a matter of really understanding an individual’s personal body responses, naming them as emerging from the eating disorder, and as oftentimes being reversible with nutritional rehabilitation, with or without weight gain, depending on the eating disorder, and then being able to live their values better.
Chris Sandel: Yeah, definitely coming back to that values piece – because it’s like, even if for some miracle reason your body doesn’t appear to be falling apart, even though maybe behind the scenes it really is, is this the life that you really want to be having? Is this allowing you to be with friends the way that you want to be, or be with your kids, or to be having relationships, or to be able to eat in the way that you truly want to be eating? As you said, match that back up to values.
Dr. Gaudiani: Totally.
00:51:30
Chris Sandel: I made reference there to the Female Athlete Triad and bone density and that not being so great for people who are restricting or with eating disorders. There was a bit in the book that I didn’t really know about in terms of how someone’s – it was either Z scores or T scores will differ if they’re an athlete versus not an athlete with an eating disorder. Can you talk about that? That wasn’t something I’d heard of before.
Dr. Gaudiani: Oh, great. Yeah, absolutely. When we do the bone density scan, called a DEXA scan, we get two different types of scores back depending on people’s ages. For those over 50, it’s a T score. For those under 50, it’s a Z score. A lot of patients who are under 50 – and I used to do this wrong, too, but now I’ve got the right of it – mistakenly go around thinking they’ve got a diagnosis of osteopenia, which is the intermediate diagnosis between normal bones and osteoporosis. However, formally speaking, osteopenia does not exist as a diagnosis for those under 50. It’s only for those 50 and up.
So then we really have to burrow in and say, what harm is done by medical systems that lack a recognition of eating disorder physiology and the fact that you have to put the patient’s narrative story and whole-body picture together with the bone density results to get the proper diagnosis? This is what I mean.
In somebody under 50 – I’m just going to focus on that population exclusively for a moment – a Z score of -2 or worse equals a diagnosis called “low bone density for age.” That means that any Z score greater than -2 – it’s an awkward scoring system – are listed on their sheet from the radiologist “normal bone density for age.” A lot of patients think, “Well, great, I guess I’m fine.”
But here’s the interesting trick. Less than -2 on the Z score in addition to a history of low sex hormones, as evidenced by either a low testosterone score or erectile dysfunction in a male, or absent or irregular periods or low estradiol level in a female, equals osteoporosis. That makes the diagnosis. You have to know the patient’s whole story, because those are what’s called a secondary cause of osteoporosis, having those low sex hormone levels. And malnutrition itself definitely prevents bone formation normally.
So if I’ve got anyone who has a Z score of -2 or lower and they have a history of an eating disorder, especially with this history of hormone imbalance, at any point in the past, they don’t just have “low bone density for age.” They have osteoporosis. As a result of that diagnosis, we may need to treat them more emphatically or more aggressively.
What’s really interesting, and what you referred to, is that the International Olympic Committee, or IOC, has identified that young athletes under 50 should have better bones than we mere mortals because the act of exercising puts electro strain on the bone that signals to them, “Hey, we’re under heavy use. Become stronger.” So a really good athlete – really, anyone who’s athletic under 50 – should have 5% to 15% stronger bone density than their age-matched peers.
Thus, let’s say that I’ve got somebody who’s under 50 – and many of my patients, by no means all, but many of them have an athletic past – if their Z score is -1 or less, that reflects meaningful bone density loss. There’s a lot of folks out there who have a -1.3. Their test came up “normal bone density”; their GP said, “Gosh, good news, your bone density’s normal,” and we missed the opportunity to name it, diagnose it, and treat it in order to prevent bad complications down the road.
Chris Sandel: I think that’s a really important thing to know, and it’s definitely going to be something that I’ll be looking out for because so many of the clients that I work with who have issues around food also have issues around exercise. If I’m thinking of the client population I end up working with, I would say 80% to 90% have over-exercise as part of their picture.
Dr. Gaudiani: Absolutely.
00:57:00
Chris Sandel: One of the other things I wanted to talk about was just care. You made reference there to clients who are under 50 and over 50, so how much of your population that you’re working with would be over 50? Or what would be considered “older” for having an eating disorder? I don’t know what the cutoff is for someone to be “younger” or “older” with an eating disorder. Is there an agreed upon cutoff?
Dr. Gaudiani: There isn’t, and it’s a great question. You’re right, they deserve their own focus because they have a lot not in common with the younger patients. Eating disorders in adults who are older – let’s say over 40, over 50 – are really, really common. We know that the gender and body image study confirmed really a high prevalence of chronic use of weight loss strategies, body dysmorphia, and a really close connection between emotional distress in body perceptions in women over 50 years old.
On the whole, eating disorder prevalence in women over 40 is estimated at 3%, and in men at 1-2%. Certainly, at my former program, a quarter of the patients were over 40, and over 40% were 30 and up. In my current practice, I see patients from all over the age spectrum, from preadolescence all the way into their seventies.
I think it’s really important to say that while there might be slightly different expectations of recovery rates or even what recovery might be allowed to look like, between the patient’s own stated goals and toleration and what the team feels “yes, at least that will keep you from dying, that’s better than nothing,” it’s really an important message to say that anyone, at any age, can get relief from their eating disorder and can meaningfully improve and fully recover.
Chris Sandel: I want to second that as well. With the clients or the patients that you have who are in their forties or fifties or sixties, is it typically that that has been going on since they were in their teens? Or there’s been some life events later on that’s meant that they’ve started to diet and then end up down the eating disorder end of the spectrum?
Dr. Gaudiani: The literature would indicate that most people with eating disorders in their forties and up had some body stuff probably going on during adolescence, during the commonest inception years of an eating disorder. But I have a number of patients who say, “Well, I guess I was influenced to the extent that all of my peer group were somewhat influenced, but really my eating disorder didn’t begin full-blown until this particular time of life transition.”
I think especially with regards to the narratives of women with eating disorders – and I suspect this is true of men, too; I just don’t have quite as much personal experience – it is those times of life transitions. It’s graduations, marriages, divorces, menopause, children moving out of the house, illness in a parent, illness in a child, which can be the flint off which that spark of the eating disorder is struck.
Chris Sandel: And the flint that is struck because those are times that will typically lead to either intentional or unintentional restriction, or this is how people are then starting to use this as a coping mechanism, or a combination of both?
Dr. Gaudiani: A combination of both indeed sounds right. Is that your experience as well?
Chris Sandel: Yeah, typically. Especially for people who have had eating disorders, the unintentional relapse is really something that I talk with clients about and I watch out for because it is so common when people are at a point in recovery where they’re so strong in the fact that “I do not ever want to go back to that place. I really am striving to get to that values-driven place that I want to get to. I’m so close,” and then a son will get sick or there’ll be this thing that happens with their mother, or something will just throw them off where, for whatever reason, food couldn’t have been their priority, or wasn’t their priority as much as it’s been more recently.
That happens for a number of weeks or a month or whatever, and then before they know it, they’re like, “Wow, I am now back in this place.”
Dr. Gaudiani: I think that’s such an important point you make, especially because that same tendency to underrate the importance of the moment that somebody finds themselves in, in relapse, can be worsened by saying, “But this time I don’t want to. This time it’s not like I have a drive for thinness. This time it’s not like I want to be purging and getting that high and that release. I don’t even want it anymore. Not like X number of years ago, so it can’t be that bad, right?”
You say, no, once again, your body doesn’t know the difference. We risk reawakening those very same gremlins you say aren’t present just by your beginning to have inadvertent vomiting because you’ve been really anxious or inadvertent weight loss because your IBS has been acting up, and even if you don’t want it, unless you are aggressively going after solutions to make sure you get enough nutrition, etc., we risk tumbling all the way down to the bottom of the chutes and ladders board.
Chris Sandel: Definitely. What I have found with clients is if they then can catch it and they put in the work to get back, the recovery process there is much, much quicker. It’s not like we’re starting from all the beginning again. But it is very amazing how quickly someone can get back to that place of being in an eating disorder when there was no intention of trying to get there.
Dr. Gaudiani: 100% agree.
01:04:10
Chris Sandel: With your older clients, then – and I’m not using the word “older” pejoratively, but just as a descriptor – are there things that are different with them in terms of how you would work with them versus someone who is younger?
Dr. Gaudiani: Yeah, there’s a number of differences – if they wish there to be differences. I think I should qualify.
Let’s say that I have an 18-year-old individual versus a 42-year-old individual who comes to me with a similar level of anorexia nervosa or bulimia nervosa or binge eating disorder, any of them. I will say pretty clearly that with the 18-year-old, that outpatient team and I are going to have pretty clear expectations of momentum, forward progress, behavioral reduction, really aiming for complete wellness and recovery as quickly as possible, because the less amount of time that beautiful brain is exposed to malnutrition, the better.
I’m going to use the term “malnutrition” across the eating disorders because we know that every single one of the eating disorder diagnoses can come with a meaningful element of caloric restriction.
Then when it comes to the 42-year-old, let’s say they often – not always – have been sick longer. They’ve been through a lot. They have sacrificed a lot already. They might say, “Dr. G, here’s my values, but I’m just not sure how I can get there. It feels so daunting.” As we get to know each other, I might suggest a slower pathway towards wellness if that’s what the individual can tolerate. I might suggest harm reduction outcomes, where the individual says, “I think I could probably commit to nourishing myself enough on a daily basis to meet my needs and maybe to gain some weight,” if it’s anorexia nervosa, “but I cannot commit to do more than that, at least now. In that person, I would be much more likely to say, “Okay, let’s start there and let’s see how you go from there.”
Now, if the person says, “Dr. G, I’m ready to get better. I want to get all the way better. I want it to be fast. I hate this” – great! I’m in. But I think that one must be a little more gentle and compassionate.
And really, I’ve had to work on my own distress tolerance, because I absolutely adore each one of my patients, and watching them struggle and suffer physically and emotionally is sad. But it’s not about my struggle. If I need to do that work, I can do it elsewhere. It’s about my holding a space to provide really thoughtful, informed medical evaluations and to be a quarterback of a treatment team so that their dietitian and their therapist feel comfortable saying, “All right, let’s go slowly. Let’s go slowly and see if we can inch you back towards what you say matters.”
I think a lot of individuals, especially if they’re younger in the field, might think, “If I allow this person to go slowly, I’m just colluding with their eating disorder,” when the answer is we’ve actually got to move away from that hierarchical, parochial structure of “this is what recovery looks like” and be creative, and meet patients where they are, and try to find a way forward that’s creative.
01:07:55
Chris Sandel: Are you saying that there is less of that when you’re working with someone younger, where you feel like “I feel like I can push this a little more” or they should have a slightly quicker trajectory?
Dr. Gaudiani: Yeah. In my younger patients, I’m going to push for clearer outcomes-based recovery work, because they’re relatively newer to the disease, and the faster we can get their brain nourished, the likelier that they will end up in a meaningful remission from their eating disorder.
But even then, it takes creativity. I have really come to learn – it’s been a humbling and also an exhilarating process in the course of running this clinic – for me to realize that it is actually the rarer patient who meets all their benchmarks right on time and proceeds linearly without backtracking. It’s sloppy. It is messy and hard, and things happen, and our patients are already perfectionists. So if I can help guide them and walk with them and set a pace, but meet them when they trip and help them up if they slow down, to me, that’s the sort of relationship that induces trust and that can help allow patients to give up the behaviors that have seemed absolutely necessary to hold onto.
Chris Sandel: I would agree with everything you’ve said there. I think with time, doing this with more and more people, I’ve learnt that things are really messy.
I think sometimes if things aren’t going to plan or aren’t going as well as I had hoped, there would be some ego of mine getting in the way, like “I’m obviously doing something wrong. Maybe I need to be doing this better. What more can I read?” All of those things can definitely be true, but there’s also just things don’t always look like the nice, neat, linear “things are getting better” that you would imagine. So yeah, I’ve definitely adopted more of a “if things are at least trending in the right direction, then we’re good here” and just trying to find ways of keeping that person to be progressing.
And even when there are times where things slip back or things don’t go as we’d hoped, how can that be a learning experience? It’s like, “Okay, cool, next time this thing arises, we know we’ve been through it before. You know you can do this thing, or that thing made it much worse.” The whole journey can be further understanding their reactions, their body, their perceptions, etc. Then it is still moving in the right direction.
Dr. Gaudiani: I love that. You and I are completely aligned on that. I do think that it takes practitioner maturity and practitioners doing their own work, whether that’s casually with their teammates or their colleagues, or more formally in supervision, to really exorcise the demons of our own perfectionism, our own imposter syndrome.
There’s plenty of times that one of my patients is struggling and I have this moment of thinking to myself, “You’re supposed to be Dr. Gaudiani. You’re supposed to be able to make this better. That’s why they’re paying you. That’s why they’re here to see you.” Then I just have to really, like you said, check myself and say, I’ll be really introspective and think about what I could do better personally, and realize that there is no alternative universe in which the optimal doctor is giving the optimal sentence at the optimal moment and the patient’s able to respond to it and move forward necessarily. We’re just all muddling through together.
It can be agonizing, for parents especially, to watch their kids have this halting, starting/stopping, regressing, slipping, moving forward pathway, because so much feels like it’s at stake. But indeed, that is the nature of eating disorder recovery.
Chris Sandel: I think partly, it’s freeing to come to that realization as the practitioner, but I also think it makes me a better practitioner because it means that I don’t feel like I have to constantly be pushing, and it doesn’t set us up as adversaries when things aren’t going the way that it should. You can then be much better at walking with that person and seeing the struggles and being okay with it, without feeling like “I’m the responsible person for this.”
Dr. Gaudiani: I love that. That reminds me that the way that you’re practicing, the way I’m trying to practice, really does hew away from the patriarchal, “I’m in charge, I’m the expert, you’ll do as I say and then we’ll know what’s gone right.” There is not actually a role for that mentality in there. Unfortunately, that remains, even when it’s done in a pleasant way, a lot of what Western medicine is grounded on still.
Chris Sandel: Definitely. And maybe there is some level of a role for that in an inpatient place, where you’re like, “This is life and death, you need to do this.” But in terms of the clients that we’re working with, it just doesn’t work.
Dr. Gaudiani: Completely agree.
01:13:35
Chris Sandel: What about, in terms of the population you’re seeing, how many are identifying as males?
Dr. Gaudiani: In my prior practice we had about 10% of our patient population were males. It just so happens by I think selection bias, accidentally – and we’re still only 3 years in – I’ve got fewer than that male patients now. But I think that probably speaks to ongoing stigma in society around identification, diagnosis, and treatment of men of all body shapes and size across all of the eating disorders, because they are out there. They’re being missed. In fact, they’re being praised for their orthorexic eating habits and their intensive workout regimens. They continue to suffer from constructs of toxic masculinity and what maleness is supposed to be like. They suffer just as much as the rest of people do from those societal constructs.
Chris Sandel: Yeah. Do you feel like in the next 5 or 10 years, as things shift, we’re going to have this real big increase in male eating disorders? And not an increase, but just it’s going to be identified?
Dr. Gaudiani: I hope so, because they’re out there, and they think they’re living healthily until it becomes obvious that things aren’t going so hot. We’ve got a good friend in the field who’s recovered from an eating disorder and is a former elite athlete. He has expressed that he thinks the vast majority of the guys he played collegiate and professional sports with have disordered eating or frank eating disorders – all under the guise of “Let’s get an edge. What can we do to decrease our body fat X amount? What can we cut out of our diets to give us the edge as we play?”
The irony being, of course, that as they speak amongst themselves and draw from media reports of what bizarre diet so-and-so follows, they’re actually not nourishing their bodies. They’re ending up in RED-S, relative energy deficiency in sport, or a florid eating disorder because once again, our caveperson brains will respond in knowable ways to inadequate fueling.
Chris Sandel: Yeah. I was chatting with Aaron Flores around this in a recent podcast. It hasn’t been released at the point at which we’re recording this. I was saying how much it gets changed in terms of the language. So rather than talking about dieting, it’s talking about “biohacking.” It gets shifted into something else that becomes really glorified. And then when you really strip it all back, you’re like, no, this is just eating disorders.
Dr. Gaudiani: Correct. And I think always asking ourselves the question, who stands to benefit from making you feel bad about your body and maintaining the systems of oppression that broadly speaking keep you quiet? When you elevate your brain to that level, it becomes less about an individual “do they have good enough self-esteem, do they have enough body love, do they have enough bootstrap, go-get-’em individually?” Really, we’re all tucked within the intersections of various systems that try to keep us quiet, try to keep us insecure, try to keep us buying products. That’s always so important to keep in mind, and that absolutely affects people of all genders.
Chris Sandel: Definitely. With the men that you were either seeing at the previous place you were working or at your current place, is there anything different in terms of how you work with men versus how you work with women? Or there are different things that affect men differently, whether that be from a physiological perspective or some other way?
Dr. Gaudiani: There’s a few things that I certainly think about. One of them is that there should be no assumptions that the driving force or the “if not the eating disorder, then…” What fills in the “…” for men might be quite different than for women. It may be similar, but where there may be a drive for overall thinness in women patients, there may be more of a drive for muscularity and leanness in men.
They’re being influenced and pressured in different ways by society. We always have to keep that in mind. Again, that’s why I try to really hear my patient’s perspective before I imagine upon them what might be going on.
Additionally, a lot of men are not appropriately worked up for low testosterone levels or for bone density problems. I don’t know whether that’s because of provider lack of knowledge, because men don’t happen to have periods to make providers think about sex hormones in them, but for every one of my male patients, I talk about erectile function. When it comes to dieting, with or without weight loss, many of my patients can remember the week that their erectile dysfunction occurred. They’re like, “Oh yeah, things stopped working right around 6 weeks ago,” or stopped working normally.
So having frank, open, unembarrassed conversations about these vital topics is important – and then checking free testosterone levels. Two different morning checks before 10 a.m. are what’s required in the U.S., two weeks apart, for insurance to agree, “yeah, this guy does have clinical low testosterone levels that require replacement.”
Because, as with females, absence of sex hormones in males causes more bone resorption – that is, the natural process by which our bones are turned over; bones are always, a little bit’s being made, a little bit’s being taken away. When you don’t have sex hormones, more is taken away, and then, when you’re not nourishing yourself properly, you’re not making enough bone.
I’ve seen individuals who should have been the slam dunk obvious, classic anorexia nervosa for 10 years, in and out of programs, and the guy’s never had a bone density ordered for him. Ever. And you check it and it’s like, oh my gosh, what a disaster. We have 10 years of bone density loss that could have been prevented with appropriate use of testosterone or other medications.
Chris Sandel: Wow. How reliable is looking at morning erections for men as a proxy for low testosterone?
Dr. Gaudiani: Sexual function comes in a bell curve. I think it’s asking men to compare their own previous function to their function while undernourished and over-moving. It’s not a standard for all; it’s like, compared with you normally, how’s your sex drive? How’s your sexual function? And a lot of guys are really quite attuned to that.
01:21:20
Chris Sandel: One of the big things that you talk about in the book that I’d really like you to talk about today is weight stigma and binge eating disorder and the problem that it causes.
Dr. Gaudiani: I would love to. Perhaps in another edition of the book, I will separate out those two categories, because it is very important people hear me say that not everyone with binge eating disorder is in a larger body, and not everyone in a larger body has binge eating disorder. However, I do talk about them in the same section of the book because there can be overlap there.
But by the same token, I have tons of patients who have anorexia nervosa that I hate to call “atypical” anorexia nervosa, because the weight stigma of the DSM-V is so ridiculously obvious in that diagnosis. But that’s anorexia nervosa that occurs in people who don’t happen to be visibly malnourished, visibly emaciated. But there’s plenty of my patients presently, and millions more, unfortunately, who have anorexia nervosa and who live in larger bodies, or body sizes constructed as normal. By the same token, I think that when I talk about binge eating disorder, certainly it can result in higher body weights, and so those individuals experience stigma.
Probably the best thing that I can say is that when I talk about weight stigma, I’m referring to a reality that influences and affects not only my patients in larger bodies, regardless of diagnosis, but also my patients who are in more emaciated bodies, because everyone in society is aware that thinness is preferable and holds power. That’s not saying in any way that that is my personal belief, but that is what is foisted upon us by everything from media to commercial business to medical practitioners.
So many patients are harmed by this dangerous, gross exaggeration. It is just a nonscientific reality. It’s a way of society to segregate itself and make sure that some people have less power.
I think a lot about weight stigma. I think a lot about internalized size stigma, that innate experience all of us have within us that we’ve been inculcated to believe this and that we have to identify and fight against as we provide care. For instance, it would be the kind of thing that would make me, when one of my patients with anorexia nervosa would be really anxious about gaining too much weight, in the past I might’ve said, “Don’t worry, you’re not going to get fat.” Oops. Nope. That’s not what we say, because I don’t know what’s going to happen with your body, and my saying that implies that I think there is something negative about fatness as a descriptor. So we always have to be looking at this in ourselves.
The reality is that people in larger bodies experience profound stigma in medical settings. They are continually being asked to lose weight with regards to things that they present to their GP for that have absolutely nothing to do with weight. They are underdiagnosed, they are under-offered really nice modalities that help, like physical therapy when it comes to, say, knee pain. They are shamed, and ultimately they are ostracized from a sense of comfort that they can reach out and connect comfortably with their medical provider.
I personally believe that the number one medical problem associated with being in a larger body is the inadequate and often harmful medical and surgical care offered to those individuals.
Chris Sandel: Was any of this taught to you at medical school? Was there anything mentioned about weight stigma as being a thing?
Dr. Gaudiani: Not even a sentence. I mean, not even a sentence in my prior program either. This is really, I’m sorry to say, learnings that I have finally come to in the last 3 years, and now I am all on board.
Chris Sandel: Was this basically Health at Every Size and weight stigma came to you as a package?
Dr. Gaudiani: It did. I was aware at a high level – obviously, it was body pressures and this and that. But constructs of social justice as they intersect with medical care, especially of those with eating disorders, really are newer for me, and yet now, part of the fiber of my soul.
Chris Sandel: Is part of the connection as well between the weight stigma and binge eating disorder that binge eating disorder happens proportionally more likely with people in a higher weight body because they’re in a higher weight body, they’re then told to do things to lower their weight to “help their health,” they then go on said diet or restriction, which then makes it much more likely that they end up binging, and you’re then in that position?
Dr. Gaudiani: Most definitely. There’s no doubt that one of the brain changes that occurs due to caveperson brain is that when we restrict food, our brain clicks into a frantic fantasy of the food that we need and that we’re denying ourselves. That type of a mammal that is starved is not playful, creative, or cuddly. It is rigid, rule-bound, and anxious because it is seeking food.
Invariably, people who restrict certain food groups, absent a true allergy – like, say, carbohydrates, which is one of the most absurd food groups one can skip – become somewhat obsessed with them. That’s not because there’s an “addiction” to sugar or carbs; that doesn’t exist. It’s because they are being driven by their caveperson brain to go seek out the thing that they’re lacking, and when they have access to it, like “Oh, I guess I’ll have something,” they go straight to the bottom of the box because that’s what their body has been yearning, and that’s how we save ourselves from starvation.
If you’re in the desert and then you come to a little patch of woods and you find a honey hive, you’re not going to be like, “Mm, that’s a nice little taste of honey. Okay, on we go.” You are going to eat the whole damn honey hive. And that is not willpower. That is biology, friends.
Chris Sandel: This is the problem, because what gets mislabeled is that the binging is the issue. When talking to people about this, I’m like, no, the binging is a symptom. The restriction is the issue.
Dr. Gaudiani: 100%.
Chris Sandel: If there wasn’t the restriction, you’re most likely not going to end up at that binge stage. But that’s just not what is typically told to them. They think, “I’m at this higher weight because I’m binging, so that must be the problem,” and there is this misfocus with what they should be doing as a way of remedying it.
Dr. Gaudiani: Exactly right. People think “I’ve got a problem with willpower, with control, etc. If I could just rein that in, I’d be all right.” And the answer is, no, my love, you are controlling everything far too much. If you order your favorite binge food and have it for supper and have the leftovers for lunch next day, you’re much less likely to eat five servings of it. You’re more likely to enjoy exactly what you want of it and realize there’s more tomorrow. No restriction. You have access to it. No food has a higher moral valence than another. So I couldn’t agree more with you.
Chris Sandel: I guess the difficulty with that is because in the beginning, they almost prove the point of “but when I bring in these foods, I eat more of them, so the food is really the problem.” It’s like, yes, it feels like that at this point, but with time, that is going to change. But it can be difficult in that very short-term place because it feels like “I’m really proving why I need to avoid these foods.”
Dr. Gaudiani: Exactly.
01:30:40
Chris Sandel: Another one I want to talk about is orthorexia and just how common this is with your clients, because it feels like – and I don’t know if this is really the case, or the media has just moved on – for 3, 4, 5 years there was this real focus on clean eating, and that seems to have disappeared. At the time when the clean eating movement was going on and then there was a lot of backlash around it, there was talk around “this is leading to orthorexia” and what orthorexia is about. I just don’t seem to be seeing articles like that in the same way, so I’m just wanting to get your reading on what you’re noticing.
Dr. Gaudiani: My fear is that it’s because orthorexia, which does not yet exist as a DSM diagnosis, but is well-defined as an obsession with “healthy” or “clean eating,” with a series of arbitrary rules that differ from one orthorexic to another, my fear is that that kind of eating is actually no longer being highlighted as being a gateway to more significant malnourishment, vitamin deficiency, poor athletic performance. It’s just become what people think is the right way to eat.
I was in an interesting email correspondence with a colleague who said that a mom and her spiritual congregation recently told her daughter, “We would never eat pasta in this household because that is just so unhealthy. Who would ever eat pasta? Surely no one does.” I mean, that’s just jaw-droppingly horrifying to me, A) as an Italian, B) as somebody who personally loves and frequently eats pasta, and C) it’s just spellbindingly crappy nutritional advice.
We need carbs, and lots of them, to fuel our bodies because they’re the only things nutritionally that can be broken down to the glucose that runs our brain. It’s like putting something in a car that might make the tires turn, but doesn’t actually make the engine start, and being like, “I wonder why this engine is so messed up. I’m putting plenty of tire juice in this car.”
This is a huge problem. I actually think it’s not that it’s gone away; I think that everyone has absorbed it as a norm, that carbs are bad, that sugar is evil, that – gosh, there’s a million to name. That preservatives will ruin us all.
I can’t say enough that I am an omnivore who constantly preaches to my patients – and then encourages them to talk to their dietitian about the details – eat all the things. Eat plenty of them. Eat the things that satisfy. Eat the things that will make sure to give you the energy you need to do what you’re doing. And that’s pretty much it.
I always get trolled when I talk about HAES or weight-inclusive care in broader news types of things, and people say, “What, you should just eat junk food all day and that doesn’t matter?” Well, no. [laughs] It just means that there’s no moral valence to any given food, and of course nice fresh fruits and vegetables are a lovely part of getting in the vitamins and minerals you want – and all the other things too.
Chris Sandel: Yeah. I remember when I wrote an article about this years ago, where the response was like, “So you’re now telling me eating healthy is not the right thing to do?” I’m like, you’re missing the point. The analogy I used was there’s a difference between washing your hands and washing your hands 5 hours a day because you have OCD.
Dr. Gaudiani: What a brilliant one. That’s great.
Chris Sandel: We don’t look at the person who washes their hands for 5 hours and think they’re the epitome of cleanliness. We’re like, this is now a problem. It’s no longer serving them. It’s creating a real issue. I think the same way about orthorexia. It’s not that healthy eating is bad; it’s you’ve taken it to a place where it’s actually not healthy at all. We’re missing the context. We’re thinking these foods are healthy, but how it is being constructed and put together and how someone is thinking about the food is leading them to not a healthy place.
Dr. Gaudiani: I love that metaphor, and with gratitude, I will use it.
Chris Sandel: Definitely. The other part of it as well is I think orthorexia feels like it came into prominence while the clean eating movement was going on, so it’s become brushed with the stereotype of what we thought of as clean eating back in 2014, 2015, etc. We think of someone orthorexic when they’re spiralizing courgettes or whatever, but it could be just as much you’re orthorexic if you’re following Carnivore, even though that doesn’t present in the same ways we thought of as orthorexia.
Dr. Gaudiani: Correct. I think anything that has to do with hewing rigidly to an arbitrary set of rules that if you follow them, you feel a sense of higher purpose or superiority or moral win – any of those are orthorexia. It’s not just the rabbit eaters (that is, those who eat like rabbits). It’s those who eat in any weird way, and which, if you say, “Hey honey, let’s go out for date night,” the person would immediately freeze and be horrified at the prospect of what their options would be.
01:36:50
Chris Sandel: One other area that you mention in your book that I wanted to touch on as well was substance abuse and eating disorders and the overlap between these two. Tell me, in terms of the clients you’re seeing, how often is that occurring?
Dr. Gaudiani: Very highly. There is tremendous overlap between substance use disorder and eating disorders. Unfortunately, these are some of the patients that get I think the most missed – although I’ve got a pretty long list of people who get missed – because it’s very hard to treat one and not risk symptom substitution with the other.
That’s particularly true in higher levels of care. Somebody’s in day treatment for their eating disorder, they’re now nourishing, they’re not purging, but ooh, look at that, their alcoholism really kicks in again. Or you have somebody who enters substance use treatment, they’re now clean from drugs, but they’re able to get away with eating disorder behaviors because it looks like how everyone else is talking about wanting to eat, so they’re flying below the radar.
There’s also a lot more treatment withdrawal and early termination of treatment from eating disorder care of those who have substance use disorder. So it’s tremendously hard, and it requires really a multidisciplinary team and a lot of attention to both at the same time.
Chris Sandel: I think it might be also difficult as well because you’re getting mixed messages from the ways that you deal with them. From a substance perspective, I would imagine it’s much more of an abstinence model. You’ve got to stop having these things, and stop having them for the rest of your life. With food, you’re kind of trying to encourage the opposite in terms of a real openness.
So there might be those mixed messages of “but then I’m going to turn into a sugar addict.” It’s these approaches where you’re going in different ways and talking about things differently, even though the substances that they may think of, “Aren’t these things the same?”
Dr. Gaudiani: That’s exactly right. I also think the ethos of the substance use treatment world – of course, which I’m not nearly as well-versed in as the eating disorder world – oftentimes mistakenly recommends orthorexic behaviors. Like, “Hey, in this sobriety house, we’re also sugar-free. We’re also white flour-free. Let’s get all of the bad substances out of your life.” And unfortunately, that A) is scientifically incorrect, B) is going to trigger binge eating, and C) is going to radically contribute to eating disorder behaviors and perpetuate those myths.
Chris Sandel: I guess also, OAs, or Overeaters Anonymous, follows very much the same principles as Alcoholics Anonymous, and I’m yet to have a conversation with someone who’s adopted the OA model where it’s genuinely worked for them. It just doesn’t seem to do what it does for alcohol.
Dr. Gaudiani: That’s exactly right. Because it can’t, because that’s not how our brains are set up. Our brains are set up perfectly well to be sober from alcohol and drugs. Great. We didn’t evolve to seek those out and make sure that we had them at all times. But we sure as shit did for carbohydrates.
So we’ve got to really remember how our brains are biologically set up and really try to thread that needle very delicately with a full abstinence model with regards to the substance in question and supporting our sensitive, lovely patients around how frustrating it is that some can use in moderation without problems and they cannot, as well as giving the message of moderation and all-inclusivity with regards to how they subsequently eat.
Chris Sandel: With the substance abuse that you’re seeing, is it mostly alcohol? Is it prescription drugs? What are the things that are most commonly coming up?
Dr. Gaudiani: For me, I have most seen cannabis and alcohol, but a good study of women with anorexia nervosa looked at different drugs of abuse, and in the anorexia with purging group, the risk for drug abuse or dependence was six times higher than with restrictive anorexia. In that particular group, actually 32% of those with anorexia nervosa purging subtype also had drug use or dependence. Cannabis was the most commonly used drug; however, stimulants, cocaine, sedatives, and alcohol were all studied and were quite common too.
Chris Sandel: With that research, do you think a lot of that then can come down to temperaments that can then lead to where someone ends up in terms of what type of eating disorder they end up with?
Dr. Gaudiani: Yeah, I think that’s probably right. I think broadly speaking, there are temperamental subtleties, differences amongst those who purge, for instance, versus those who never purge. It does seem apparent from the literature, and from my own clinical experience – I suspect yours as well – that those who purge seem to be more likely to be at risk for concurrent substance use disorder.
Chris Sandel: We haven’t had the change in laws over here around cannabis that is coming to the U.S. Has that got better or worse, just from your experience, now that it’s so much more readily available?
Dr. Gaudiani: Yeah, here I sit in Denver, Colorado, where it’s freely available and quite legal. I think my feeling around cannabis use is that by comparison with alcohol, there are probably fewer physiologic risks in some ways, as long as someone is of age and using moderately. That’s always the big point, isn’t it?
I have reservations and concerns about my patients who are under 25 years old, which is well over the legal age, who are using cannabis regularly just because some of the data we have about how that impacts brains, especially brains that already have a propensity to mental illness, is not great. But the jury is still out on that in the greater scheme of things.
On the whole, I would rather my patients nourish themselves, do great therapy, and consider well-overseen psychiatric medications than self-medication. Mainly because I just want to make sure we’re not muddying the waters about what’s really going on. But I’m not a stickler by any means. I’ve got plenty of my patients who do regularly use marijuana.
01:44:25
Chris Sandel: Dr. G, is there anything that we haven’t gone through that you really wanted to chat about today? It feels like we’ve touched a lot of different topics, but I just want to give you this opportunity in case there was something that we didn’t go through.
Dr. Gaudiani: I think the one thing that I’d love to talk about briefly is empowering kids and parents of kids around the time of adolescence, when they start going into the pediatrician’s office and we start hearing some weight stigma comments come in, like, “Oh gosh, you gained a lot of weight since last time.” I wonder if we could talk a little bit about that because I think I’d like to lend my medical credentials to some ways that we can reframe those sets of conversations, which can be so damaging to kids.
Chris Sandel: Yeah, I’d love to hear about that. Just in terms of your own experience around this, you’ve got two girls – is that right?
Dr. Gaudiani: I do, yeah. I’ve got two daughters. One is 14 and the other’s almost 11 at the time of this recording.
Chris Sandel: Is this also coming from experiences that they’ve had or that you’ve noticed with them as well?
Dr. Gaudiani: The ones that I talk about with my patients that are quite prevalent haven’t shown up in my kids’ pediatrician’s office yet, but the conversations that I have with my kids about changing bodies and about size and shape, absolutely. This is a topic of regular conversation in our household.
Chris Sandel: Cool. Yeah, by all means, share with people what you want to say around this.
Dr. Gaudiani: Thanks. It is necessary for kids to gain a ton of weight in order to successfully move from a child’s body to an adult’s body. It is almost never the case that a child progresses through adolescence in perfect equipoise, with not an awkward moment to be seen. I would love to hear from one of your listeners for whom they were like, “Nope, it was all really smooth sailing. No problem.”
Chris Sandel: [laughs] There is no amount of money that could be offered to me to want to be a teenager again.
Dr. Gaudiani: [laughs] Yeah, exactly. What we find now, though, in this overly thin-focused world, is that from the ages of – depending on when puberty starts in your kid – say 8 through 15, there are going to be years – and maybe forever – where your kid is going to have gone from a certain body type to a thicker body type. They’re going to have years where they gain weight a lot faster than they grow in height.
It may be that that presages the fact that they are destined, properly, healthily, to be a bigger-bodied person – in which case, great. The best thing a parent can do is not lament their fat child or worry that their kid is going to get teased and therefore engage in dieting talk in the home, but rather, to celebrate their kid’s body and everything about it and to make home a safe place for all body types and to help prepare their child for what society may be slinging their way.
Or it may be that a kid just goes through those thicker phases and higher weight gain as they prepare to enter their adult selves.
What’s commonly found is that a pediatrician will take a look at a growth chart and make a comment. “Uh oh, your weight’s quite a lot up this time” or “I see you’re thicker around the middle now. We’ve got to be really careful that that doesn’t continue. Let’s watch out on the sweets there.” These I suppose well-meaning, very common comments that then just strike a kid straight in the heart and set up, if they hadn’t gotten any commentary already, a real conundrum.
Because that pediatrician has a lot of power, and when we speak about power in this moment, it can be very hard as a parent – where you rely on the pediatrician to prescribe the insulin or prescribe the asthma medicine or to take care of your other child – to stand up and say, “Hey, doctor, I prefer you not speak that way to my child. That doesn’t seem right.” That can be very difficult.
So the first thing is to make sure that the parents and aunties and uncles and grandparents listening to this know how necessary and normal it is for kids’ bodies to go through any number of awkward years or heavier years as they go through adolescence. For some, that will be the body they occupy, and for others, it will sort out into proportions that are more familiar later on. Either of those are fine.
What should not happen is familial comments about the body, teasing, differential eating patterns – “You can’t have dessert tonight, but your sister can have ice cream” – or any undue focus on this, and instead to say to kids, “Your body is about to go through miraculous changes. It’s not always going to be fun, but it’s doing incredible work right now. Nobody knows exactly how they’re going to be shaped during that time. In our family, we honor body diversity, and we also know that we eat what we want, we eat delicious foods, we eat to make sure that our taste buds are satisfied and that we have the energy we need to do the fun stuff we do in our life.”
What I think is helpful is briefly to talk to the kid in advance of the pediatrician appointment and say, “There is a chance that your pediatrician is going to make some silly comment about your weight. But you and I both know, because I have educated myself on this, that that has nothing to do with your health or wellness. We understand, because we listened to Chris, that that kind of talk doesn’t help anybody.”
Chris Sandel: As you’re saying all of these things, I’m reflecting on many of the clients that I’ve had, and their journey towards an eating disorder or disordered eating was because of the kind of interaction you’re talking about. They had that interaction, and that was the thing that made them make changes, and it was changes that they were then praised for, and were told that now they’re looking after themselves, or “aren’t you good?”, etc., that then continued on and spiraled, and then they ended up in the place that they ended up in.
I think it’s really important, as you say, to have that conversation beforehand. But I also see how difficult it is because of how many people just aren’t on board with this message and how what can on the surface appear like “this person’s making some healthful changes” can then turn so nasty.
Dr. Gaudiani: That’s absolutely right. Medical practitioners have not yet internalized the reality that health cannot be ascertained by appearance. Period.
Chris Sandel: Yeah.
Dr. Gaudiani: When I talk about this, I get pushback from some who say, “Okay, but Dr. G, what about if my kid is really gaining weight fast, has never been able to regulate their appetite, and is having trouble breathing when they run in Physical Education now and is not able to do the things that they want to do?”
The answer remains – and this is the core of how HAES gets practiced by an internist – we do not focus on the weight and we do not recommend dieting. Behavioral change can absolutely occur when seeing a wonderful dietitian and a therapist around, “Can you tell me what it is that makes you want to eat, feel hungry to eat fourth and fifth portions of dinner at night when you’re actually physically full, but you’re driven to want to eat more? All right, let’s start from there. Let’s work through that.”
It’s never “We’re going to cut sweets. We’re going to cut carbs. We’re never going to eat this, we’re never going to eat that.” Because you and I both know, as we’ve talked the whole time, that is guaranteed to set off the caveperson brain, to cause a transient (maybe) loss in weight, which will get roundly positive attention in society, which only contributes to the greater likelihood of body shame and an eating disorder ongoing, and then to greater weight gain afterwards.
Because your caveperson brain says, “Gosh, we’ve already gone through at least one desert. We might be raising this human in a time of scarcity, so let’s make sure that next time we come through this desert and we have access to food, we push their body weight above whatever their prior set point was by some, just to safety them for the next desert.” That is how we are built. It is how we are wired. There is no way around it. So dieting can never be part of the solution.
Chris Sandel: Definitely. I think in the scenario that you just gave, what is pushed upon someone is that the skill that you want to learn is weight loss. For me, the meta-skill you want to learn is how to listen to your body. How do you listen to hunger and fullness? How do you listen to satisfaction? How can you start to work out how to structure your eating in a way that supports you? The meta-skill should be about how to live and eat in a healthful way in the broader definition of what that means, not in an orthorexic way of what that means.
Dr. Gaudiani: Exactly
01:54:40
Chris Sandel: In terms of your daughters, is there any specific conversations that you’re having with them? Or even when they were younger, were there other things you were doing with them in terms of books to read or resources that you were sharing with them?
Dr. Gaudiani: Well, I have a lot of theories, but it’ll take until they’re a decade along to see if any of them were right. [laughs] They come loaded for bear as far as their genetic predisposition towards eating disorders and the temperamental traits, of course, and yet I am passionate about what I do and talk about it all the time, and have really enjoyed inculcating in them my feminist perspectives on this, my social justice perspectives, and certainly my weight-inclusive perspectives – to the extent that if an ad is shown on TV where someone’s talking about weight loss, they’ll both be like, “Uh oh, Mom’s gonna freak out.”
So they definitely get the message, and they understand the messages about the broader picture of avoiding orthorexic tendencies.
I think that there are a couple of inflection points where one can be thoughtful about this. One, not talking about your own body or other people’s, either really praisingly or negatively. Just don’t say. If you’ve got to talk about your body, go to your therapist, go to your dietitian, and talk about it. But don’t talk about it in the home. “Oh, I’m so happy my body is X, Y, and Z” or “Oh, I’ve lost weight” or “Gosh, doesn’t that person look strong or healthy?” Nope. Just leave bodies as neutrality.
When I exercise, I’ve been really thoughtful since they were quite young to make sure that they heard me say, “Mommy’s exercising so she can stay strong to play with you” and really disconnect it from a body appearance, have it be a functional piece. Movement has everything to do with ability and interest, and there’s a lot of issues with how people are encouraged to move when that’s not an option for them.
I think talking through adolescence and talking through what’s going to happen with their bodies, talking through appropriate birds and bees topics can be really nicely done in not necessarily heteronorming ways, in ways that honor body diversity and imagine the diversity of people and experiences out there.
And just the way in which we talk – and ultimately, my belief is that children are going to be exposed, chronically, to the kind of societal ills we’ve talked about. We can’t protect them from those, but we can to a certain extent inoculate them from some of the harms by making sure that home is a place where they can feel safe in their bodies and unconditionally loved and safe in their relationship to food.
Chris Sandel: Yeah. You are a good decade in advance of me in terms of your daughters. I’ve got a two-year-old son. At this stage, we’ve got a book called The Body Book which we’ll often read, and it talks about different shapes and all bodies being good. We’re just very conscious of not talking about bodies and weight loss and everything you’ve talked about there.
Even when Ramsay will grab Ali’s tummy, just being conscious of what we say around that. She’ll be like, “Yeah, that was where you were.” Just having this real neutrality around bodies or being very positive about what they can do and never badmouthing bodies or other people’s bodies. Yeah, we are very conscious of that, even though he’s only just becoming verbal and only two.
Dr. Gaudiani: I love that. I think we’ve got to be really cautious when kids say, “Mom, am I fat?” or “Mom, are you fat?” Take a breath, because oftentimes the thing that people say is, “No, honey, you’re beautiful.” Whoops. You’ve just put fatness at opposition to beauty. Instead, answer questions with questions. “Tell me what that means. Who’s talking about fatness around you? Everybody has fat on them. That is for sure true.” Things like that. I think those are all important little messages one can give.
Chris Sandel: Yeah. This has been wonderful. Thank you so much for all the time that we’ve had today. Where can people be going to find out more about you?
Dr. Gaudiani: They can go to my website, www.gaudianiclinic.com. On our website, they can learn about what we do, they can see podcasts that I’ve done. There’s a link to my book, which is also available on any online resources where people get books. I would be delighted for them to take a peek.
Chris Sandel: Perfect. Thank you so much for coming on the show and for everything you do. As I said, I really loved your book and I would recommend that people check it out.
Dr. Gaudiani: Chris, thank you so much for having me.
Chris Sandel: That is it for this week’s show. As I mentioned at the top, Seven Health is again taking on new clients. We specialize in helping clients overcome disordered eating and eating disorders, body dissatisfaction and negative body image, regaining periods, balancing hormones, and recovering from years of dieting by helping clients learn how to listen to their bodies.
If you’re interested in working together or finding out more, you can head over to www.seven-health.com/help.
Next week, and actually for the next two weeks, the podcast is going to be hosted by Lu and then Amanda. I hope you enjoy these episodes. I’ll personally be back for the last episode in January, and I will catch you then.
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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