296: Autism and Eating Disorders with Livia Sara

Chris Sandel: Welcome to Episode 296 of Real Health Radio. You can find the show notes and the links talked about as part of this episode at www.seven-health.com/296.

Hey, everyone. Welcome back to another episode of Real Health Radio. I’m your host, Chris Sandel. I’m a nutritionist and a coach, and I help people to fully recover.

Before we get on with today’s episode, I have an announcement. I mentioned this on the last episode as well. I’ve recently expanded my team, and I now have some extra spots available for working with new clients. I made a similar announcement to this back in March time, and the spots were snapped up very quickly. I’m slowly creating more space in my calendar to have more spots for this kind of private coaching, but at this stage the spots are limited.

The thing I want people to understand is that change is possible and that I’m an advocate of full recovery and that people can get there, and I believe everyone can get there. You can have a life where you call the shots, not the eating disorder. You can have fun and joy-filled days where thoughts about food and weight and exercise no longer dominate your mind. As I said, full recovery is possible, and after working with clients for over 15 years, I’m very good at helping people to achieve this.

So if you’re tired of living with an eating disorder and are ready to do what it takes to reach full recovery and complete freedom, I would love to help. You can send an email to info@seven-health.com with the word ‘coaching’ in the subject line, and I can then send over the details to you.

With that announcement out of the way, let’s get on with today’s show. Today on the show, it is a guest interview. I’m chatting with Livia Sara. Livia is an autism advocate and eating disorder survivor that now helps others to overcome their own mental health barriers through her courses, coaching programmes, and books. She is the creator behind the blog LiveLabelFree.com and the host of the Live Label Free podcast. Liv is a lifelong learner that loves listening to audiobooks, going on walks, and reading the latest science on all things neurodiversity and eating disorders.

I’ve been aware of Liv for the last year or so, and we’ve been working on having this conversation for a long time now. I read Liv’s book, Rainbow Girl, and I love the content that she’s putting out about eating disorders and recovery and autism. That’s what today’s episode is all about.

We chat about Liv’s story and how her eating disorder began, her various attempts at recovery and the things that finally made the difference for her. Connected to this, we talk about special interests in autism, demand avoidance, and the importance of choosing recovery. We cover how eating disorders look different for autistic people and how they won’t necessarily match up to the criteria in the DSM. We also talk about the overlap between autism and eating disorders, existential loneliness, metabolism – and this is a really interesting conversation on this area and on science that I had been looking for, so I really loved getting to chat about this. We talk about body image, eating variety and its importance in recovery, the fear of weight gain, hunger signals, interoceptive awareness, and how intuitive eating does and doesn’t work with autism, and much more.

I also want to add that it’s difficult when we talk about the experience of a group of people, like talking about the experience of autistic people or autistic people in eating disorder recovery, because there is just a variety of people. In the same way that we have neurotypical people, we have neurodivergent people, and their experiences are going to be very different because they’re individual people. I remember hearing recently on a podcast, “If you’ve met one autistic person, you’ve met one autistic person.” I think this is a really useful thing to keep in mind.

Even though we’re talking about certain commonalities, there’s going to be times when what we’re saying is really broad brushstrokes and it’s not going to capture everyone’s experience. So I just wanted to mention that at the top.

I think Liv is doing fantastic work with recovery and what she’s doing, and I know that you’ll benefit from this episode, and that’s true even if you’re not autistic. Let’s get on with the show. Here is my conversation with Liv Sara.

Hey, Liv. Welcome to Real Health Radio. Thanks for doing this with me today.

Livia Sara: Thank you for having me on. I’m delighted and excited to be here.

Chris Sandel: Nice. I want to talk about your story and your recovery, and so much of your brand and what you talk about now is around autism and autism’s connection with eating disorders and maybe neurodivergence more generally. I think that’s really what the conversation today is going to be about: what recovery can look like for different people where we may get recovery wrong and we have to do these things differently because of autism or neurodivergence. You have such a great message on this. I love going through your Instagram; I love all the stuff that you share on this. I want to be able to share this with the audience.

Livia Sara: Thank you so much. That means a lot to me. I completely agree; I think especially now, there’s a lot more acknowledgment of, okay, we can’t keep hiding anymore behind the fact that we’re going to try to ‘treat’ people who are autistic and neurodivergent in the same way that we treat neurotypicals, because we’re seeing over and over and over again not only that the treatment isn’t helpful but that it’s actually inflicting harm and trauma on a lot of neurodivergent folks just because we process differently, and we have a different way of being. So if you’re going to approach that in the same way as someone who has a different way of being, it’s not going to work.

Chris Sandel: Yeah. We’ll get into it. In terms of the diagnostic criteria, that doesn’t necessarily match up from many people’s experience.

Livia Sara: Yeah, the diagnostic criteria, that’s where the start of Live Label Free comes up. I feel like this entire Diagnostic Statistical Manual of Mental Health Disorders can go straight in the bin because what it’s trying to do is it’s trying to take complex, unfathomable beings and squeeze them into boxes. Even if a certain diagnosis (for example, anorexia) is going to resonate with someone, there’s always going to be something about that person that doesn’t completely fit into the diagnosis or there’s going to be something about the diagnosis that doesn’t necessarily reflect in that person.

I think then what happens is you start feeling like a fraud, first of all, like “I can’t have anorexia because I’m not severely underweight. I can’t really have an eating disorder.” On the other end of that, you have medical professionals that are like, “I don’t know what to do with this person because they don’t fit in my pamphlet that I received and that’s on my desk.”

So yeah, when it comes to eating disorders in and of themselves, something that I’ve been talking about more is that I believe we should eliminate this term ‘eating disorder’ in general and replace it with ‘adaptive eating spectrum’ because ultimately, what is an eating disorder? It’s an adaptation. It’s an attempt to find safety and trust and control in circumstances that feel unsafe and that feel out of your control.

When we look at any single human adaptation, we’re trying to find safety. We’re trying to evolve in our current environment, and I think especially in the society we live in, with the judgment and the fatphobia – and I mean, the fact that we’re still fricking using BMI even though we have these AI robots taking over half of what we do online. [laughs] I mean, it’s ridiculous, right?

But anyways, that’s my stance. I see both autistic behaviours and eating disorder behaviours as adaptations, and when we look at it from this perspective, it opens the doors to have more compassion for the individual and to start seeing the person as a person rather than a label or a diagnosis.

Chris Sandel: I am definitely in agreement with you on that.

00:08:54

What food was like for Liv growing up

Let’s back up a little and go through your story and your background connected to this. If we go back to you as a little kid, what was your relationship with food like? What was food like in your household growing up?

Livia Sara: I’m really happy you zoned in on the food piece because I was going to spit out every single detail. Growing up, I would definitely be a ‘picky eater’. That’s definitely how I would have seen myself and how others saw me. Looking back, I can totally see that was me being autistic and me just having safe foods.

Basically my entire diet consisted of what would now be called ‘junk food’, so it was sugary cereal for breakfast, I would eat very American macaroni and cheese for dinner with chicken nuggets and broccoli, and I would eat peanut butter and jelly sandwiches on white bread, and it had to be a specific brand of peanut butter and a specific brand of jam. And desserts and cookies and ice cream. That was me growing up.

This is already where I feel – I don’t know if I feel grateful or not, but because I have the genetics to not have a fat body, the way that I was eating was just accepted. I was never told that I had to eat differently, whereas I think if I had been in a larger body eating that, I would’ve been told as an eight-year-old, “You need to go to Weightwatchers, you need to go on a diet”, whatever, whatever. But because I was always very petite, I was always on the lowest point on the growth chart and stuff, and I naturally have a very high metabolism, I could ‘get away’ with eating all this crap and nothing happened.

Chris Sandel: Were people or your parents concerned the other way? I think this can happen; there can be the worry about “You’re eating too much and your body’s too big and we need to restrain you”, but also there can be the worry of “You’re not eating enough. Come on, have another chicken nugget” or “You need to have more of the bowl of cereal.” Was there any of that pressure on you?

Livia Sara: I’m happy you brought that up because I was eating a lot of food, and I stayed really small. I think that’s why my parents didn’t really want to do anything, because they offered. “Livia, have a potato, have a brussels sprout, have a piece of steak.” But I would be like, “No, if you do not give me exactly what I want, I won’t eat.” They were like, “Okay, she has to eat.”

And I am so stubborn. If you are going to tell me what to do, I am going to stand my ground. I could’ve gone on a hunger strike if they didn’t give me what I wanted. And again, I think looking back, it all makes sense. That was definitely just my autism being like “This is how I want it and the only way it’s going to happen is if I get it this way.” Which later on worked to my disadvantage during my eating disorder because it was like, “I’m going to do this weight loss thing and nothing’s going to stop me.”

But before all that, when I was around 11, I was in fifth grade in the US. I don’t know what the school system is like in Europe. It’s different.

Chris Sandel: I live in Europe and I still don’t know what the school system is like. I grew up in Australia and I understand the school system there, but in the UK I still haven’t got my head around it.

Livia Sara: Right. Australia, I don’t even know. I know it’s different in the UK. I lived in the Netherlands, it’s different there. But yeah, when I was around 11 years old, we started learning about health and nutrition in school. I think that’s also the age where you have to do these fitness tests. You have to run before the beat and stuff.

00:12:34

How she spiralled into an eating disorder

That is when the whole eating obsession and healthy eating interest started for me.

There’s a term in the autism space called ‘special interest’, and that’s if someone is really very passionately interested in a topic. For me, that’s what ‘eating healthy’ and fitness and exercise became for me. In school we learned “If you eat too much sugar, you’re going to get diabetes.” We learned about BMI and how becoming obese is the worst thing you ever want – even though it’s complete bullshit. “If you are hungry, you should have something nourishing like an apple, and junk food is only for rare occasions.” Just basically everything so, again, diet culture infiltrated into the school system.

My autistic brain took all of these ‘recommendations’ so literally that I was like, “If I eat sugar, I’m going to get diabetes. I’m going to become obese. I can’t have this happening.” I implemented this really strict exercise regimen, because it was like “You have to move X amount of minutes per day to have a healthy heart.” It became so obsessive. I had this black-and-white, ironically, composition notebook, and I wrote down all the rules I had to have.

And that quickly spiralled into a full-blown eating disorder because the moment that I lost a bit of weight – because I wasn’t eating my usual sugary stuff anymore – I dropped off the growth chart. I went into energy deficit, and we know how that works. Once the energy deficit is sparked, it’s downhill from there.

I remember my mom being so worried, taking me to the paediatrician, and the paediatrician saying, “Livia, you need to eat more. You need to eat full fat dairy.” And I just remember sitting there and being like, “You cannot be a doctor if you’re telling me to eat full fat dairy because clearly, skim milk products, that’s what’s healthy.” I didn’t believe what anyone was saying. I was like, how is everyone so stupid? That was my view at the time.

Fast forward, I was tossed in and out of treatment centres to gain weight and to eat. I was the perfect patient because I knew, “Okay, if I just eat and I follow the rules, I can get out of here as quick as possible, I can go home and return to my ways.” That just kept happening. At one point – I think it was in 2015 – I still had to gain weight but I didn’t want to gain weight, so I manipulated my weight. I drank water and put coins in my underwear and did all this crazy manipulative shit just to prove that no-one could tell me what to do.

And then I got caught, because I peed all over the scale at the doctor’s office. I got caught and I had manipulated my weight very extremely. This doctor said, “I’ve been a doctor for 20 years and I’ve never seen someone manipulate their weight to this extreme before. This just shows us how sick you are, how much you need help.”

So I went back to treatment, and then in 2015 we moved to the Netherlands – and I grew up in Boston, for reference, which is where I am now again. In the Netherlands I went to a clinic again. They didn’t care about anyone. And then when I was 15, I was basically told, “You are so manipulative, you are so complex, you’ve done all these treatments and nothing helps, so you’re just going to have to accept the fact that you are never going to get better.”

For a 15-year-old, that is like, “What? What’s the point of life?” I think that’s for me where the further downhill started, because the eating disorder for me had been my purpose in life, almost like an existential, like “If I just do this one thing right, I’m following the right path. I can’t mess up at life.” And that existential thinking, I’ve learned, is so incredibly common in autistic people; we are constantly questioning the purpose of life and why we’re here.

Life is freaking hard. The options and opportunities are endless. In that sense, again, seeing an eating disorder as an adaptation makes a lot of sense because it creates such a small little box for yourself that the rules, the answers, are always there. You always know what to do as long as you follow the eating disorder. How can you be wrong if you’re just doing that?

I know I’m talking a lot, so I don’t know if you want to pause and go into any…

00:17:24

Why people don’t always fit neatly into diagnostic criteria

Chris Sandel: A couple of things that come up connected to that. One, in terms of that final piece that you said there, “There are so many options, there are so many things, and actually the eating disorder really simplifies things. It gives me a sense of control, it gives me something to focus on.” I made the comment earlier about the fact that the DSM and diagnostic criteria often don’t make sense for people on the autism spectrum – again, I’m generalising here, but I’ve had many people who have suffered with anorexia, and it’s through discovering that they’re autistic that they’re like, “Actually, this makes sense, because it was never really about weight. It was never really about thinness. That was not actually the drive for me. This was about something else.”

It could’ve been about the “I never felt like I fit in” and there was the loneliness piece connected to it, or it could be about “Once I got hooked on the numbers piece, there was something very calming in being able to know the calories or being able to know my weight or being able to have this thing be very precise, so I got locked into that piece.” But the focus so much, if we’re looking at anorexia, is about thinness, it’s about that being the driver. It’s like, “There became later on this fear about gaining weight, but actually that’s not the main thing that was going on. It definitely wasn’t what got me into this in the first place.”

Livia Sara: Right. Clearly, I’m floored. I’m like, wow, clearly you have so much experience with this. I think that is so important also, because it’s very clear to me also that you stay humble and you stay open to lifelong learning. I have no doubt that you are an incredible coach for your clients and teacher, which we need more of, because for me, that doctor / psychiatrist telling me, “You have to accept the fact that you’re never going to get better” – that wasn’t because that was a fact or that wasn’t because that was true, but that was because she didn’t want to take responsibility. Because by saying I’m the problem, I’m never going to get better, then she’s off the hook. She didn’t mess up as a provider.

I think when we can acknowledge there’s no ‘messing up’, it’s just about are you willing to learn from your patients / clients, yes or no? If you are taking responsibility for learning, then you can’t mess up. You can’t fail, because failure cannot coexist with responsibility.

I did want to say something about the fear of weight gain, because I never feared gaining weight and becoming fat because I never saw myself as fat, but I think that the fear of weight gain can be part of especially the anorexia – but again, I hate that label – but even in ARFID, which is classified as fear of weight gain not being present, for autistic people, gaining weight, gaining body fat, can be very sensory overload. For me, if I gain weight or my clothes feel tighter, I want to crawl out of my skin. And that is not just unique to anorexia. Any autistic person can feel that way.

That’s why, again, these diagnostic labels – like “Oh, someone who has anorexia wants to lose weight but someone who has ARFID doesn’t” – it’s like, no. It’s so unique to the individual. I was diagnosed with anorexia because before 2013, when ARFID was added to the DSM – that was in 2011, so I couldn’t have even been diagnosed with ARFID. But that diagnosis always felt wrong to me because I never looked in the mirror and saw a fat person looking back at me and all the stereotypical things they say about anorexia.

Then later on, when I started talking more about my eating disorder and autism, a lot of people have been asking me, “Okay, then did you have ARFID?” But I’m like, no. It wasn’t either of them. It was an eating disorder that doesn’t have a label because I, as a being, cannot ever be squeezed into a box. Like I said, we’re unfathomably deep. We don’t even necessarily know what it means to be human. Before I even go down there, I’m just going to stop myself. [laughs] Way too much philosophy. But I think you know what I’m getting at.

Chris Sandel: I don’t think this is just for people with autism. The amount of people who are like, “Yeah, I’ve got a little bit of that one, I’ve got a little bit of this one, but I don’t really fit neatly into the boxes here” – and if we’re sticking with anorexia, the percentage of people who have atypical anorexia is a very, very, very slight percentage of the people who actually have anorexia. And the people who have ‘typical’ anorexia are a very small percentage of people who have that diagnosis.

So I think for many, many people they’re not falling into these neat boxes. And this is a real problem because they then look at this and they’re like, “I can’t obviously be sick enough, I can’t obviously have a problem because this thing only happens once a month instead of twice a month so I don’t follow that criteria” or whatever it may be. So I definitely think there is an issue with that.

00:22:38

How demand avoidance impacts recovery

But in terms of the thing you were told where, “You’re never going to recover, this is something that is lifelong” – there’s two things out of that. One, it’s horrendous that someone your age is being told this. If someone is 75 and they’ve been in treatment for the last 50 years – I am forever the optimist, and I am always like, no, that 75-year-old is still going to get there. It is about them making the changes. That is not off the cards for them. I will be like, no, forever they can make that change.

But I can at least get on board more if that was the information that was given to that individual. For someone who is not even 20, who is being told this information, it angers me to no end because that information then gets relayed to the parents and friends and people then get treated differently. Everyone changes their mind about “What do we need to do in this situation? She’s never going to get better, so we’re not going to keep doing this. I’m sick of this.” It changes everyone’s perspective around it.

The one thing I would add, though – and this is point two – it sounds as though this actually helped you. It didn’t in the beginning, but it sounded like this actually took the stubbornness that led you into the eating disorder, like “You can’t tell me what I can do. I’m going to keep doing this.’ You kind of reverse-engineered that comment to be like, “Oh, no, you can’t tell me that I can’t recover.” In a lot of ways it felt, when I read through your book, like this was a quite important thing that actually helped you. It was a really shitty way to get you to recover, but in your situation it seemed like it actually did the thing they weren’t expecting it to do.

Livia Sara: Yes. I love that you brought this up because I’ve thought about that a lot, and I think it was my demand avoidance being like, “You’re going to tell me I can never get better? Well, I’m going to show you.” I feel like for a long time I was afraid to admit that because it made me think that this lady who said that to me would be like, “Oh yeah, that was my plan all along. I was going to say that.” But I was like, she’s not at that level. [laughs]

So I completely agree. At the same time, I want to do a disclaimer – to any professionals listening, do not tell your patients that. Even if they have demand avoidance, that is not the way. It’s just important, especially with the demand avoidance, to phrase any kind of treatment protocols to make sure that the client or the patient always feels like they still have autonomy. I think that’s where the danger of the tube feeding and the coercion and the tying people down to beds – that is, to me, the most horrendous thing ever, and it’s so fricking Middle Age practices, tying people up. I’m like, what the hell?

The thing is, also, that it kind of works in the same way as someone who’s on life support, someone who is brain dead and is still breathing because the machine is allowing them to breathe. The moment they come off the machine, they’re gone. I honestly feel like that is literally what professionals are basically doing or replicating by force-feeding patients and tying them down against their will. Okay, their life’s in danger, but if you’re going to take away their control mechanism, the moment that they have freedom again or feel autonomy, the eating disorder is just going to be exponentially worse because that’s the one thing that allows them to feel safe in unsafe, traumatic circumstances.

Chris Sandel: I agree. I think with eating disorders, they’re biopsychosocial, so there is this biological component, as you talked about. “When I got into this energy debt, in a sense it turns on the eating disorder.” So it’s not that there’s not a biological component, but I don’t believe that you can then force-feed someone against their will back to a place of not having an eating disorder.

I think this then becomes that misconception because then you’re missing all of these other components that are important as part of recovery. I’m not against inpatient, but I think one of the problems with inpatient is if someone is going there, they have to (1) be choosing it and (2) actually want to get better. Because otherwise, all that happens is, like you did, “I will be compliant. I’ll be compliant until I get out of here and then I’m going straight back to what I was doing.”

You can eat the exact same meal, but there’s a big difference between someone’s metaphorically got a gun against my head and making me do this versus “I’m choosing to do this.” I can get in the same amount of calories, but it reacts very differently within my body. That’s why I’m always like, you don’t choose an eating disorder, but you have to choose recovery.

Livia Sara: Right. It’s that taking responsibility. I completely agree with you when you said it has to come from the person. The person has to choose, because for me, I did go back to treatment in 2017, and I gained weight there and did all the DBT and CBT and whatever – not that that necessarily helped me. I think DBT and CBT can help when they’re individualised to the person, and the person actually wants to engage with them, but I’m pretty sure you read from my book – I hid sudoku books in the DBT book because I was like, what the hell? I’m not going to do this.

But again, it was the demand avoidance. I was like, “You’re telling me I have to engage in therapy? I’m not gonna.”

But for me, when I went to treatment in 2017 and I did gain the weight, when I got out of treatment, I was like, “I am recovering. I’m doing this.” A lot of people ask me, “What was different about that treatment centre?” and my answer is, absolutely nothing. The difference was me. I actually chose to go. That’s why force doesn’t work and why allowing the person – creating an environment that is safe enough for the individual to do the work, that is the absolute foundation of recovery: that you feel safe enough to make changes, because change is scary.

You can’t change the fact that change is scary, but you can do everything else to make that change a little less scary. I think that’s where working with a coach or working with you or working with me or – we were just talking about our friend Victoria Kleinsman earlier – there’s infinite coaches and therapists and whatever out there that are absolutely fantastic. I think the best helpers or teachers, as I like to call them, are the ones that don’t give advice. They don’t tell you what to do. They say, “I’m here for you. We’re going to go on this journey together, and it’s safe. You are safe with me.” That feeling is probably way more important than anything that’s ever being said or done with the client.

Chris Sandel: I’m definitely on board with you with that. It does need to be a collaborative effort. It’s not that I won’t ever give advice or I won’t give suggestions; I will check first. I’m like, “Would you like to hear my thoughts on this? Can I share?” because I want to be sure that someone is okay with that. But yeah, I think the relationship is important.

I guess the one caveat I would add with this is that as a coach and as the person – I see it as very important for me to have a belief in the person even if they don’t have that belief in themselves. I can have a belief that “I know you feel like this is scary and I know you feel like you’re going to be unable to do this, and I believe that you have the capacity to do this. I believe that you can tolerate doing this thing.” Not where you’re then forcing someone against their will to do it; I think it’s important for someone to have that belief in them when the eating disorder really is getting in the way or constraining their perception of what they think they’re actually capable of.

I also am not afraid to say, “I think the goal you’re choosing is actually not going to be that helpful. There’s going to be a ton of anxiety with making this change, and the upside is really small for you. You get to choose the goal. If you want to do this, fine. But I also want to be honest with you, because I don’t want to go on for months and months and months and you’re making all of these changes that are getting you nowhere.”

I think you can say it’s never a failure or people can learn from these things – true. And there’s a lot of burnout that then can happen, where you’ve spent all of this time, all of this effort, all of this energy on something that, no matter if they did every single one of those things, was never going to get them anywhere. So when I think about a strong therapeutic relationship, yes, there’s collaboration, yes, there’s working together – and there is also honesty from both people about that.

Livia Sara: Absolutely. Even as you’re sharing this, I’m like, yeah, but it’s still collaboration. Because nowhere in what you just said is like, “You can’t do that, I’m not going to let you.” [laughs] You’re pointing it out to them. You’re saying, “I’m going to be honest with you, I really don’t think this is going to work”, but ultimately you’re still leaving it up to them to decide whether or not they do it. So they still maintain that autonomy.

I did just want to add that on. Again, it all comes down to the same thing and that foundation of trust and safety. It doesn’t mean, like you said, that you don’t give them recommendations, that you don’t share your thoughts, because that would defeat the purpose of us if we were just sitting there like, “Yep, you’re safe with me.” [laughs] Obviously that doesn’t make any sense. Ensuring that you’re not placing demands on them, especially when they have demand avoidance.

00:33:03

What Liv’s recovery looked like

Chris Sandel: What did your recovery then look like from the point at which you said, “Yeah, I’m actually going to do this”, and what do you think are the things that really made a difference when you committed, made this a non-negotiable and then started on that journey? And I know it’s not lovely and linear and everything just changed overnight. What were some of the most crucial parts of that for you?

Livia Sara: For me, obviously the weight gain piece. I had been pretty much underweight my entire life, and now I was at a point where I was actually in overshot weight. So not only was I above my setpoint weight range, but I got there from like 0 to 100 in pretty much a few months. I had to completely get rid of all my clothes. I had to buy new clothes. Clothes shopping for autistic people – not all, but for me at least, absolute nightmare. I hate shopping, still do. So the weight gain piece was so, so hard.

And I do have to be honest: the moment I got out of treatment, there was that part of my brain that was like, “We can’t do this. We can’t handle being in this body. We need to lose weight again.” It was like, “Yeah, I’m not going to lose that much weight that I go back into the eating disorder, but I’m just going to lose a little.”

Chris Sandel: ‘Restriction lite’, as I like to call it.

Livia Sara: Right. We know that that doesn’t work. I don’t like the word ‘relapse’ at all, but I would say that my weight definitely went up and down for the first few years. Then what happened – I think this was in 2020 – I wasn’t underweight, but I wasn’t overshoot weight, but I definitely was restricting. I was like, “Yeah, I allow all food, but only at that time, and only on the weekend. I’m allowed to eat bread, but only twice per day.” I still had a lot of little rules, but I think it’s so easy to justify them because of the world we live in. Because my friends had the same rules. So I’m like, “Oh, I can’t have an eating disorder.” I was almost invalidating that ‘recovery lite’ or whatever you were saying because it’s so normalised in our society. The fact that it is normalised is so problematic.

I remember coming home from school one day and I hadn’t eaten breakfast that day because I was in a rush, and I got home from school and I was really hungry. And then I had the first time ever in my life that I had an – I don’t like to say binge, but I would say extreme hunger episode or a feast episode. That was my very first meeting with extreme hunger.

That threw me for a freaking loop because I was like, “Okay, I’ve got this whole new diet of mine that I’m not in the eating disorder, but I’m at a ‘healthy’ weight. I’ve got this perfected. I have a new life purpose. I’m going to be this perfect recovery model.” And then extreme hunger happened, and anyone who’s gone through extreme hunger knows all choice goes out the window. You have to just eat and eat and eat and eat until you feel full and freaking nauseous that there’s nothing else you can do.

So that caused a lot of weight gain for me. I went into overshoot again. I fell into this binge-restrict cycle because I developed this fear, “I’m swinging to the other side, I’m developing binge eating disorder” – which is such a common fear. I was like, “This cannot happen.” So I would restrict the whole morning, and then in the afternoon I’d be like, “Okay, at 3 p.m. I can eat my oatmeal”, but then it would be like, “Screw this, I’m so hungry” and then I would binge all over again on Nutella and ice cream and whatever.

After a few months of that, I was to the point where it was like, okay, clearly my body has adapted and it will no longer tolerate me to go into energy deficit and have a famine again. I think in that sense, I’m so grateful for extreme hunger because it really showed me that your body’s going to show up for you no matter what. You can treat it like a bag of garbage, but your body loves you so much and its sole purpose is to keep you alive, and that’s what it’s going to do.

I don’t know when this episode is coming out, but my next book, How to Beat Extreme Hunger, is actually coming out in August, and that sheds light on my whole story with extreme hunger. I also talk about coping with the weight gain, but also the stuff that happens that no-one really talks about. Not just the digestive issues, but I think for me, the hormonal changes were a huge thing that I could have never expected. I got my first period when I was 18 or 19, and then when I was in this ‘eating disorder lite’ mode, I didn’t have my period again for a few years, but then when the extreme hunger happened, I did.

But then I was like, “I can’t have extreme hunger anymore because I’m weight restored. I have my period. This has to stop.” I tried to make it stop again, but then it wouldn’t.

Anyways, I don’t even know where I’m going with all this, but I think for me, the answer to your question was yeah, it came with lots of ups and downs. [laughs]

Chris Sandel: On that piece in terms of the hormonal changes, I definitely think for someone going through recovery, especially if they have lost their period or they’ve never had their period, it can be like going through puberty for a second time, or for some people for the first time.

Livia Sara: Absolutely.

Chris Sandel: There are all these changes that happen connected to that, and we can frame them in a ‘bad’ way because they’re uncomfortable or “My body is changing in a way that feels different to how I would like it to change or what I would expect.” But if we look at what happens in real puberty during your teenage years, that’s what happens. There’s not many people who are like, “I went through puberty. It was awesome.” That’s like, said no-one. So if this is then happening again in your twenties or thirties or forties or whatever age you are, you could go through a lot of those same things. I think what you’re describing is actually really common.

Just on the period piece, this is something I really want people to know because I think what often happens is the period gets thought about as “This is the line in the sand that tells me recovery is over.” I want to just say that that is just not true. There are some people who get their period back very early in their recovery, and there are some people where they get it back and it’s one of the last things to get back. But just because you’ve got your period, does not mean you’ve now eaten all the food that you need or you’ve now done all of the recovery you need to do or you’re now out of energy debt. All it means is your body is now starting to prioritise reproduction in a way that it wasn’t before. That’s all it means.

Livia Sara: And I think it’s so important to highlight that because not only people who get periods get eating disorders. If we make this ultimatum of like, “Oh, getting your period, that’s the final sign of recovery” – well, what about guys? What about people who are nonbinary? What about people who are transgender? And I work with a lot of clients who are part of the LGBTQIA+ community because there’s such an overlap between neurodiversity, eating disorders, and being queer or nonbinary or trans.

I think from the puberty perspective, that can pose an extra challenge for people who are transgender or nonbinary because part of the weight suppression is due to the gender dysphoria. I think that’s so important to highlight that, because so many of these books about eating disorder recovery and dieting and recovery from dieting – I feel like they’re all aimed towards women, and that’s just not fair. For anyone who’s listening to this who doesn’t fit that stereotype, your struggles are valid.

00:41:17

The harm reduction model vs full recovery

I think, again, it’s worth also mentioning – I’m curious, Chris, your thoughts on the harm reduction model of eating disorders. I have worked and work with a few clients that when they reach a certain weight and go higher than that – excuse my language – it fucks up their gender dysphoria, beyond feeling like they can handle that. I think it’s so important to respect that in an individual and not to be like, “Well, you’ve just got to suck it up and deal with that if that’s what your body is doing” because they need to handle living this life, and they feel like they can only handle living this life if they’re under that weight.

Obviously it still has to be within a healthy range for them. Again, you can’t strip that autonomy from someone. And at the same time, going back to what you said earlier, it’s believing in them and saying, “I think you can do this, even if you maybe don’t.” And at the same time, also I do think that they believe in themselves even if they say they don’t; otherwise they wouldn’t even be listening to this or talking to you or talking to me, if there wasn’t that little tiny piece inside of them that believed they were capable of everything that they want to be capable of.

Chris Sandel: In terms of your question about the harm reduction model, I think with everything there are shades of grey. I’m never going to say, “This is the only way.” But in terms of my messaging and the way that I talk about recovery, I am a proponent of full recovery. That’s what I do with people and what I want to focus on and where my expertise is.

So if someone is from the very beginning like, “I want to go down a harm reduction route”, I’m going to put my hands up and say, “I’m not your guy.” That’s just not the way that I practise, and I don’t want to then be half doing something that I’m not well-versed in. I’m like, find someone who is the harm reduction person that you most resonate with and work with that person, if that’s what someone’s telling me from the outset.

I want to be very specific about, how do I think about eating disorders and what is the way that I want to focus on them? And just because that’s the way I want to do them, doesn’t mean that’s the way it has to be for everyone. You find your person that resonates with you, and I’m putting out this message because that’s how I think about it.

In terms of that example that you’ve given, again, there are shades of grey. But I’m very much of the opinion – the way I frame eating disorders is I think of eating disorders as being anxiety disorders. With anxiety disorders, anxiety is about avoidance. Avoidance of events, it could be avoidance of food, it could be avoidance of certain senses or feelings or emotions. If we’re looking at what helps in terms of avoidance and getting past that, it’s exposure.

Exposure where I learn to tolerate that “This is really uncomfortable for me to have rest days, and now I’ve done it enough times that I’m able to tolerate it.” Or “I feel really uncomfortable any time I eat peanut butter on a toast, and I’ve done it enough times and now I’m able to tolerate it.” I’m very much, when I work with clients, it’s coming at it from that angle of “How do we look at exposure?”

And this is impacted on because of a number of different things. The more you get into an energy-depleted state has an impact on your brain and how it processes food or movement or different things as being a threat. So being in that state means that you’re going to be more propelled towards avoidance because this thing becomes more scary to do. We’re trying to do the neural rewiring and the unwinding of all that.

Livia Sara: I love that you brought that up, the exposure piece, because with the harm reduction – and the reason that I asked about it is because what happens with a lot of my clients when I start – I had one client a few months ago that honestly, I was surprised that she was still alive. She was really in an emaciated state. She came to me and she said, “I want to go down the harm reduction route. I’ve been struggling with this for 40 years. There is no way I’m ever going to get better.”

I was like, okay, we’re going to go down that route.” As she gained confidence in herself that she was able to do these things that she initially said “That’s never going to happen” – she now has committed to full recovery. I think that’s where it’s so important to acknowledge that there are shades of grey because just because you choose to do full recovery one time or harm reduction another time, it doesn’t mean that it can’t shift and evolve and change over time.

For me personally, I had this weight in my mind. I was like, “If I’m above that weight, I cannot tolerate my body. I will need to crawl out of my skin. I can never be that weight.” But when I kept going through extreme hunger because I was trying to suppress my weight, I learned about my body that my body actually needs to be above that weight; otherwise I will be fighting my body for the rest of my life. And now I have made full peace with that weight because I’ve been exposed to it enough times to learn, am I actually incapable of being at this weight? Or am I placing judgment around ‘this weight is bad’ or that I shouldn’t be this weight, etc., etc.?

This is obviously a whole other conversation, but I’m glad we’re having it because it has been coming up a lot more recently in the eating disorder space. So yeah, I’m grateful to be able to talk about it with you.

Chris Sandel: I also want to add that when I’m thinking about these things, it’s like Venn diagrams which are overlapping on different things. It’s not that I think healing an eating disorder heals everything. If you’re dealing with gender dysphoria or you’re living in a body in which you feel like “Actually, I’m in the wrong gender” – one, this is not my area of expertise. I’m not going to pretend it. If that’s what you’re dealing with, I’m not your guy. I know what I’m good at doing , and this isn’t my area. Find someone who’s very good with that.

And then two, doing all the recovery stuff doesn’t necessarily solve all of those things. It could be “I need help”, whether that be “I need to work with a specific therapist that is about this, I need to be having surgery, I need to be on these hormones, these medications” – there are all of these other options that then can come in to be able to deal with this. So it’s not that in every situation, exposure is the answer. There are certain situations where it’s like, that’s not the problem. That’s not what’s driving this.

So again, I just want to say that so that none of this is misconstrued like ‘exposure is the answer to every problem’ because I definitely don’t believe that is the case.

Livia Sara: That’s a good disclaimer to make. I completely agree. It’s about working with someone and evaluating, what’s the safety zone right now? What does this person need right now? And like you said, being honest and upfront and saying, “This is not my area of expertise.”

I work with a lot of LGBTQ+ people, but I will never say I completely understand when they tell me “I feel like I’m in the wrong gender” because I cannot completely understand because I don’t feel that way. Again, there’s so many nuances that we could go into.

Chris Sandel: To tie a bow and finish up on this harm reduction point, I guess part of the reason why I’m like, no, I really believe in full recovery is because I think for so many people, when they are in the depths of an eating disorder, they’re very constrained in what they believe is possible. I think so often, if you were to offer someone, “Hey, we can give you harm reduction or we can give you full recovery. We don’t really think you’re going to get to full recovery. We don’t think everyone gets to full recovery; it’s one of those things you’ve got to be pretty special to get”, then people will settle.

The really sucky thing for me is I don’t actually think it delivers someone that much of a better quality of life. You’re going from a 1 out of 10 to a 2 out of 10 and believing that the 2 out of 10 is best that you can get when I’m like, but you’re experiencing all of this discomfort, all of this anxiety, all of this worry, all of these physical symptoms. All of these things that don’t actually have to be there. You can get to a better place. And yeah, there’s some shitty middle bit in between that you’re going to have to go through, and I get that.

And when we go out longer term, in two years’ time, three years’ time, four years’ time. But if this stays as it is, we can fast forward 20 years and you’re still going to be in this situation. That’s the part for me where I’m like, I want to be really evangelical about the full recovery piece. I think it’s got better now and people are talking about it a lot more, but I think for a long time it wasn’t talked about a lot. There are so many people, especially who’ve been in treatment – I work a lot with people who are in their forties, fifties, sixties. When they started with their eating disorder, things were very different. There was no internet. Treatment centres were very different. The whole concept of it was completely different.

So it could be much later in life that they hear about the idea and the concept of full recovery, and no-one’s ever told that to them. That’s why I’m very much like, this is what I want to talk about, because one, I truly believe that people can get there, and two, I think a lot of people haven’t got this message when they really needed to hear it.

Livia Sara: I think it’s about the individual being open to the message. That’s why I mentioned that one client who came to me and basically said, “You’re my last hope. I’m only going to do this if we can do harm reduction.” I don’t want to turn someone away because, yeah, secretly in the back of my mind I’m thinking, “We can do this, but you’re going to realise through working together that you’re going to want full recovery.” [laughs]

I think it’s totally dependent on the situation, but I don’t believe that someone should tell someone, “Okay, we need to do it this way because full recovery isn’t possible.” I feel like it has to be coming from the person. It has to be their path.

I know we keep talking about this – the harm reduction can be almost like a low-barrier way to do the challenging stuff and almost give them a taste of like “Okay, yeah, I can do this. I am going to commit to full recovery now.” Again, it’s so unique to each person, but maybe it’s good to branch off of this. [laughs]

Chris Sandel: We can definitely transition off of it.

00:52:34

How she received her autism diagnosis

As part of your recovery, this is when you discovered about autism. I know we’ve been having this conversation and you’re referring your autism, and for some people listening, they may think you knew this from when you were really young and this has been part of your knowledge all through your life. But this isn’t the case. So talk about how you discovered this and then what came up, what happened after that discovery.

Livia Sara: This is so funny and typically me, talking all about this and then just being in my own story and not even realising, oh, they have no idea about when I discovered I’m autistic. So thank you for providing that objective perspective to me.

For reference – I think I already said this – I was diagnosed with anorexia and depression when I was 11, tossed in and out of treatment. When I committed to full recovery in 2017 – and that is when I willingly went to eating disorder treatment, gained all the weight and then had extreme hunger later on – there were parts of me all along that throughout my treatment happened to be labelled as eating disorder behaviours, but I was like, no, I know for certain this is not the eating disorder.

But I didn’t know what it was. I just chalked it up to “Oh, that’s my personality” or “That’s just the way I’ve always been.”

Chris Sandel: Can you give a couple of examples just so people know what you’re talking about?

Livia Sara: I remember this one example in treatment – with food, there has to be the perfect amount of spices and flavourings on food. I’m just very particular about the way food is presented. All the aspects: the way it looks, the temperature, if there’s a balance of crunchy and smooth, whether the foods are separated or together. I have to be in the mood for it at that moment in time. And when you’re in treatment and all the food is being made for you, that’s hard to do.

So I just remember so often, by the time we would be sitting down, my meal would be lukewarm and I’d be like, “Yeah, I can’t eat this. I need to put it in the microwave. I need to heat this up.” And then they would say, “That’s an eating disorder behaviour because the food needs to be special and it needs to be perfect. You need to appreciate that the food is just what the food is.” Definitely a point there, but for me, I would get so focused on the fact that it wasn’t the right temperature that it made the eating experience exponentially harder for me.

Another time – if I eat an apple, there needs to be cinnamon on it. That is the only way I can eat apples. I’ve always been like that because it’s the sensory input. I remember in treatment I was like, “Can I please put cinnamon on this apple?” They said, “You can put cinnamon sugar on it, but you can’t put cinnamon on it.” I was like, “Why? I just want cinnamon.” They’re like, “Definitely eating disorder behaviour, because if it was really about the flavour you would be fine with the extra sugar.” I was like, “But I don’t need extra sweetness, I just need cinnamon.”

So those are two examples. And then also, I can give one more just because I thought of it yesterday. I get up very frequently when I’m eating. I think that’s just my hyperactivity, my ADHD. I always have a stress ball with me; I’m always walking around. I need movement to regulate myself. And I know that a lot of autistic people need to move to regulate themselves. I think that’s also inherently part of the reason why the exercise component can get so out of hand during eating disorders, because of that mobilised energy, that fight-or-flight mode that we go into when we don’t feel safe.

Last night I was eating dinner and I took a bite of my potato and it’s like, “I need to put this back in the microwave.” So I get up, I sit down. “This needs some more butter.” Get up, put some more butter. “This needs some salt.” I keep getting up to make it exactly the experience that I want. In eating disorder treatment, you can’t get up. Once you’ve sat down, you have to stay sitting down for 30 minutes and eat your food, and you can’t get up.

I just remember that would give me so much anxiety because sometimes I would need a break from being at the table with all these people and the conversation and the food and the lights. There’s so much sensory input that I would want to get up and leave, but I couldn’t because that was an eating disorder behaviour. You were just trying to delay your food, you’re trying to eat slowly.

I hope that answers your question with the examples.

Chris Sandel: It definitely does.

Livia Sara: Obviously there’s so many more. These were just things that as I was on my own, I realised everything that they told me in treatment was an eating disorder behaviour, I was still doing them – but it wasn’t like “I’m doing this because I want to restrict or lose weight or have less calories.” It was just “This is what I need right now.”

So I kept wondering, what is this? In the meantime, I started one-on-one coaching. I believed I was recovered and this was as good as it was going to get, because by all the standards of what is recovered, I had the eating disorder thoughts but I wasn’t engaging with them. I was like, “Okay, guess this as good as it’s gonna get.” Which I know looking back, when you do do the full recovery thing, you’re like, “I cannot believe that I set the bar so low for myself.” [laughs]

This is my main introduction to autism: my very first coaching client was autistic. When I first started my coaching and I announced I was doing it, I got so many messages from people saying, “You can’t do coaching. You haven’t been recovered for long enough”, whatever, whatever. But I truly believe that if I hadn’t done it at that time and at that place, my whole story may have been different.

This first client, I was so nervous. I was like, “Oh my God, someone’s actually putting their trust in me to help them.” I just asked, “Who are you? What is your life like? What’s your personality? Why are you reaching out for help right now?” She was telling me about she did have the autism diagnosis – autism and anorexia – and that she really resonated with my “too complex, you’re never going to get better” story. She was basically telling me her whole life story about the food preferences and the temperature and the hyperactivity and that everything had to be lined up and symmetrical and she didn’t like small talk. And I was like, “Do you secretly know my entire life?”

That’s when I started educating myself more on autism. I read this one book called Aspergirls by Rudy Simone. I pretty much knew. I was like, “This is literally me.” I could get an official diagnosis and I could get all these things, but I had already decided in that moment, as soon as I read that book, “I’m autistic and no-one can tell me otherwise” – because finally, my entire life made sense. All these things that were ‘weird’ made sense. All these ‘eating disorder behaviours’ made sense.

And ever since that time, it’s really been about, okay, this is a huge overlap, prevalent connection that really not enough people (a) talk about and (b) understand. This is my life’s mission. This is my purpose. And that’s what I’m totally leaning into now.

Chris Sandel: That’s great. As I said at the start, you’re putting out really awesome content connected to this.

Livia Sara: Thank you.

01:00:06

Why there’s overlap between autism + eating disorders

Chris Sandel: Maybe this is something we’ve kind of touched on or answered, but I’d love you to specifically answer this: Why do you think there is this overlap in terms of eating disorders and autism? People who are listening to this, I don’t know how much you know about this, but there is a huge overlap between these two things.

If you look at the percentage of the population who is on the autism spectrum – if we’re just using autism and not talking about neurodivergence – the percentage is pretty low. And I think it’s way lower in terms of what they say in the percentage to actually what is true in the population. I think a lot more people are on the spectrum than actually know about it. But if we then look at the percentage of people who develop an eating disorder, there’s a very high percentage of people who are autistic.

So why do you think that is the case? What do you think is driving that overlap?

Livia Sara: There’s definitely a few main factors that I’ve found to be repeatedly coming up. I’m actually giving a talk for a school on Thursday about why autistic people develop eating disorders. [laughs] So I love this question.

Chris Sandel: So you can pull up the slides. [laughs]

Livia Sara: I actually just did, ha-ha. I was like, “I hope he can’t see my screen.” No, I’m just kidding.

I think it goes back to what I was saying all the way at the beginning about how I believe that autistic behaviours and eating disorder behaviours are adaptations. I like to describe being born autistic into a world that is not built for autistic people, and validates and shames and stigmatizes autistic people – this can feel very unsafe, this can feel very dangerous, this can feel very threatening. And what do we as humans, or pretty much any species, do when we feel threatened? We turn on our stress response. We turn on the fight-or-flight mode so that our body can mobilise the stored energy to escape the danger.

When you are in fight-or-flight mode, you become very hypervigilant. You become very aware. You try and conform, you try and fit in. That’s also where – I like that you talked about eating disorders being anxiety disorders, because ultimately, what is a lack of safety? A lack of safety is a lack of trust, and a lack of trust equals anxiety.

And when you are in this fight-or-flight mode, which goes hand in hand with having high levels of anxiety, you’re going to turn to something that you can trust, that does make you feel safe, that you can control. You cling to something. If we’re drowning in the ocean, we’re going to cling to a freaking life raft. We’re going to hold on to that for dear life, because otherwise we’re floating around this existential water of not knowing what’s going to happen. Because ultimately, trust is knowledge of the outcome. It’s having tangible certainty.

If you look at it from this perspective, if you feel unsafe, you feel threatened, and you need control, what is the one thing that every single person needs to do every single day, and hopefully we have access to and we have choice and autonomy around? It’s food. It’s eating. It’s how we move. When people get other addictions, like smoking and alcohol and sex addiction, this may happen later in life. There’s a huge overlap between autism and addiction in general, and I think that’s because of this clinging to something you feel you can control.

I think for younger autistic people – again, I don’t want to generalise here, but a lot of the time we see eating disorders start 7, 8, 9, 10, 11, 12, teenage years. Not to say they can’t happen later in life, but that’s generally – for me, the eating disorder starting at 11 – I’d definitely say over 80% of my clients, that is exactly when their eating disorder started. Around that time.

Like I said, that’s when you are a kid, you gain more control and choice over what you’re putting into your mouth because you don’t have to be spoon-fed anymore like a baby. And then you realise, “I can control this.” I think ultimately, it’s also a form of conformity and masking. If we’re engaging in diet culture and feeling like this is our purpose in life, that’s another great way to hide behind what you think the world does not accept. It’s like, “If I conform and do diet culture and become perfect at diet culture, I can’t be wrong. I can’t be weird. I can’t be messed up.”

And that transitions into another factor, which I think we talked about before, and that is that existentialism life purpose piece. Because for me, I literally feel like the eating disorder was a solution to an existential crisis. There were all these choices, all these opportunities, all these paths I could go down, and I didn’t know which one to take because I was so afraid of being wrong and failing and messing up that I was like, “Okay, if I do this one thing, then I’m fulfilling my life’s purpose. I’m on this mission.”

Autistic people, when we have decided we are going to do something, we are not going to let anything get in our way. We are going to do that thing so ‘perfectly’. I think that’s where this eating disorder spiral comes in. So many people will start a diet, but after a week they’re like, “I can’t do this” and then they stop. But when you’re autistic and you’ve decided that you’re not going to let anything stand in your way, you are going to keep going and going and going and going until basically you realise, “I can’t do this anymore” and that’s when you commit to full recovery.

So yeah, the fight-or-flight mode, the anxiety, the existentialism. Black-and-white thinking plays into it, but that falls under the umbrella of what I just talked about. And I think also the sensory stuff, too. I mentioned the fear of weight gain for me was less “I’m afraid of becoming fat or looking fat.” It was more like “I’m afraid of the sensory ‘blegh’ that comes from that.” And then with food, textures and temperatures and stuff, someone can just be a very selective eater because the food has to be like Goldilocks, basically. Which it isn’t always going to be in this world where everything is unpredictable and changing and uncertain. Does that answer your question?

Chris Sandel: It does. You covered lots of them. The ones that I would add – and piggybacking on the things you said – in terms of that sensory piece, which can then connect to tastes and textures and temperatures, it’s then so much easier to get into a place of energy debt. If you can eat 200 different foods, all these different variations of it, then there’s a lot of opportunity.

But if you’re like, “I can only eat these 6 things and it has to be this particular brand and I can only eat in this environment”, it makes it much more likely that there are going to be times where you don’t get enough food, where you miss out on things. What can often happen is that then with more stress, “I now can’t eat that type of food anymore. It used to feel safe; it now no longer feels safe.” So you get into a situation where what used to be 20, has now become 10, has now become 5, and it just keeps getting reduced more and more.

I would also say when you’re in that fight-or-flight state, you’re much more likely to have digestive issues. And for so many people, they talk about digestion as being the gateway into this thing. “I’ve had these digestive issues, so I was researching what I could do on digestive issues”, and in the same way you talk about, “this then became my special interest. I’m reading about all these different things I can do to heal my gut.” So you start removing and removing and removing, and then lo and behold, “I find myself in this place.”

Livia Sara: Yes.

Chris Sandel: Even just the fitting in piece – masking is such a big component of autism, but I would say neurodiversity in general. Especially girls. I think this is so much more common, and I think this is often the tragedy when people talk about what happens with autism. So many women are like, “Yeah, but that’s not what I’ve read about, or that’s not how I’ve seen it portrayed” because they haven’t seen –

Livia Sara: They think Rain Man, right? [laughs]

Chris Sandel: They think Rain Man, yeah, and they’re like, “That’s not me.” So there’s this very high percentage, or a lot higher amount of masking that happens in girls. I’m thinking of a client who was always in a thin body, and then her friends, at age 12 or 13, went on a diet. She was like, “I had no interest in actually going on a diet, but this was my way of being part of the group.” And her friends said to her, “It doesn’t count because you’re already thin”, so she was like, “But what if I lose even more weight?”

That was how she was able to be part of that pact and that thing that just completely spiralled for her. And it wasn’t because she feared certain foods; it wasn’t because she feared weight gain and it was about thinness or anything. It was like, “There was this thing that I did because I wanted to fit in, and then it turned into something I never expected it to turn into.”

Livia Sara: That’s such an excellent example, because when you are that age, many people do go on a diet. I remember creating this custom diet plan for me and my friend at the time, and I was like, “We’re going to do this diet. We’re going to do it perfectly.” Well, after a week she was like, “I can’t do this, Livia. You’re crazy.” [laughs] But I had made up my mind I was going to do this diet. I was going to ‘win’ at school fitness, which isn’t even a competition. But for me, everything. I had to be the best. If I was the best, that was “I am worthy in some capacity. I can’t be a failure at life” kind of thing.

You mentioned women, and I do again want to reiterate members of the LGBT+ community, because I have so many clients who were born a different gender and now have transitioned. Part of their eating disorder was not wanting to fully go through puberty and identify as the gender they didn’t want to identify as.

Chris Sandel: Yeah.

Livia Sara: So masking in their own way, I guess.

Chris Sandel: That’s another form of masking, yeah.

01:10:21

The role of metabolism in neurodiversity + eating disorders

I saw this on your Instagram, and I haven’t gone back to listen to the podcast that you did on this, so I want to ask you about it. There was a post you put up there about the role that metabolism plays in eating disorders and neurodiversity.

It really resonated with me because for a long time, I’ve talked about the fact that one of the things I’ve noticed with clients – I haven’t found any science to back this up, and maybe you’re about to tell me that you’ve found some connected to this, but so many of them who go on to develop eating disorders, when we look at “What was your eating like before you had this?”, it was “I used to out-eat all the boys. I was the one that used to come home from school and I’d eat four bowls of cereal.” There are all these stories, and it’s not just women who tell me this; it’s across the gender spectrum. “As a kid, as a teenager, before I developed my eating disorder, I always ate a ton of food. People would make comments about the fact that I could. It was something I was proud of.”

I know this is part of your story as well and you commented on it earlier. But it sounded like, at least from the post – and as I said, I haven’t listened to the podcast – that there was something that you found connected to that, and then connected to neurodiversity as well. So tell me more.

Livia Sara: I’m so fascinated that your clients have similar experiences, because as I was telling you, I ate so much ‘junk food’, and no-one said anything about it because I was so thin. I was eating so much, and I was so thin. Sometimes my dad would joke, “Do you have parasites in your stomach that are eating everything?” [laughs]

But even now, too, now that I am recovered, I eat so much more than my family members. I’m the shortest. We often joke in our family, “Where does it all go?” But it’s like, I don’t know. It just is used.

But there are two factors that I talk about in the metabolism piece. Number one is that fight-or-flight mode because when your body is constantly in a state of “It’s go time, we need to escape the danger, mobilise the glucose stores!”, your body is going to be using a lot more energy. I mean, the fact that we notice everything, we smell everything, we hear everything, we’re so sensitive – that means that we’re constantly hyperalert, and naturally, when the body is in that state all the freaking time, it’s going to be burning more energy. I think that is why burnout and shutting down is more common among the neurodivergent population.

Because when does shutdown, when does burnout happen? It’s when the body can no longer sustain mobilisation. So it reverts to its most primitive survival circuit, which is death-feigning in vertebrates, like “I’m going to pretend I’m dead, conserve energy.” That’s why a lot of people who experience sexual abuse do not remember, because their body went into shutdown.

So I think (a) the fight-or-flight mode is a huge piece, and (b) – there isn’t a lot of extensive research on this; I would like to see a lot more of it, especially on not boys. They actually have found that in the brains of autistic people, there are more neuronal connections, which means there’s more filing going on the whole time. In that episode, I actually found one study that – I don’t even know how they measured this, but they found autistic people had 67% more neurons in their brains, which is really significant considering that the brain uses 20% of our total energy.

So if you’re doing that times 167%, the brain is going to need a lot more calories to just maintain homeostasis. Like I said, the research is very slim, so I’d really like to see more on this, but there’s definitely something there. Because like you say, not all of my clients, but most of them are these big eaters. Like, we can eat so much food and not become fat, for lack of a better way of saying it.

Chris Sandel: Cool. That’s super interesting. It does then make sense from a brain perspective. As you said, the brain uses a ton of glucose. I constantly make reference, or over the years have made reference to this fascinating study that’s in Robert Sapolsky’s book Why Zebras Don’t Get Ulcers. He talked about chess grandmasters, and when they looked at how much energy they were using, they were going through between 6,000 and 7,000 calories a day when they were playing chess.

Livia Sara: They were probably all autistic. [laughs]

Chris Sandel: There’s that extra piece that I hadn’t even thought about. But there’s definitely that there as well, or could be there. But yeah, they’re sitting around, moving little bits of wood on a board. They’re not exerting energy in the way that we think about exerting energy, and yet to do all of the strategizing – the brainpower that is needed to perform at that level in chess uses an inordinate amount of energy.

So to hear about you saying there’s 67% more of these pieces or neurons within the brain, yeah, that’s a very good explanation for why this could be happening.

Livia Sara: Exactly. Even for me as someone who’s autistic and has ADHD – not officially diagnosed, but I suspect I have ADHD – I like to describe my brain as balls bouncing around the whole time. I never get a moment where it’s just quiet, like off. I’m always thinking about everything. And I love that you brought up that chess example, because I think we consider burning calories as physical activity, but you know, the brain only makes up 2% of the body’s entire mass, but it consumes 20% of energy. That is insane. That is burning more energy than if you would probably go for a run – just thinking the whole day.

I’m really happy we’re talking about this because I think that’s why it really validates also eating a lot of food in recovery and not exercising to compensate for it. That doesn’t mean you’re not using energy. You still are using energy, because (a) recovery physically, you need to do a lot of physical repair work, and (b) the brain is starved. The brain needs healing.

So not only does it need like 20% of the body’s total energy, it’s going to need way more. And it’s going to need a lot of glucose, a lot of carbs, a lot of sugar – which a lot of people are afraid of, but sugar and glucose and carbs, all the same thing, are so, so important to eat abundance of in recovery. Because your brain cannot use protein shakes as energy. [laughs] Even though you may want it to and that may feel safe, the brain’s like, “No, we want cookies and we want ice cream, because that’s what’s going to help us heal.”

Chris Sandel: I’m in agreement with you on that one.

01:17:29

Body image as a tree

One of the things that you had a post on was talking about body image, and there was this really great analogy of thinking about body image like a tree. I would love for you to share this, because it’s something I hadn’t heard before. It’s a great perspective shift.

Livia Sara: That’s actually another book that I wrote that’s just sitting there on how to get out of quasi-recovery. I kind of have too many books that are just sitting there. It’s my biggest passion.

But I’m pretty sure I start that chapter off with, “Do you love the air? Do you love the trees? Do you love the sand? No. I don’t love those things, but I do accept them. I accept that they’re part of Earth.” And that’s how I started seeing my body. I don’t love the way my hands look or the way my feet are or the way my stomach is, but I do accept that my body is part of the Earth, part of the universe, part of matter.

With the tree example, I don’t see my body as something that I possess, not something that’s mine. What I mean by that is the tree analogy. Say I planted an apple tree in my backyard. Would it be my tree because it’s in ‘my’ yard? I could say that. I could delude myself into thinking it was ‘my’ tree, but it isn’t really my tree. It’s the Earth’s tree, or rather, part of the Earth as a whole, part of its matter.

I think when we can view the body as that – like, the body is just a physical vessel, physical entity that makes our unfathomable existence possible. I think it really allows us to have compassion and treat it with the respect that we would treat a flower in our garden or a newborn baby. We don’t say, “You fat baby, I’m going to starve you for the next week.” [laughs] No. We treat these physical entities with respect because we acknowledge that a being needs nourishment. I don’t know why we think our own being doesn’t need it, but that’s different for everyone.

But for me, that has massively helped. Even though I don’t feel hungry or even though I don’t like the way I look, I don’t need to like the way I look – just like I don’t need to love the plant in my apartment to give it water. I don’t need to like the colour, but I still give it water because I know if I don’t give it water, it’s not going to be happy. So that’s my analogy.

I was on a previous podcast episode where they asked about this as well, and they titled the Reels snippet “An Ecological View of the Body”, which I loved.

Chris Sandel: I like that it gives this layer of detachment there. And detachment doesn’t necessarily mean – as you said, it’s not that you don’t care about this thing. You care for it, you show it respect, and you do the things to nourish it, but you’re approaching it from a different angle. It’s not just about the aesthetics, or it’s not getting to this place of overwhelming love for this thing. And look, if someone wants to go down that route, I’m not saying that your tree analogy is the way that everyone has to go.

Livia Sara: Exactly.

Chris Sandel: It’s just more of, this is one way of being able to think about this. And if I was to think about my body in the same way, what would happen? How would this make me feel differently or think differently about my body? If I think of it like a tree or like sand or something along those lines, how would I then feel about my body?

Livia Sara: Right. It’s about neutralising it. I think what neutralising does is it takes away judgment, positive or negative. Like you said, there are a lot of people out there that are like, “It’s all about loving your body and loving what it does for you!” but that just never resonated with me. That never worked for me because I’m like, “Why do I need to love my hands? No.” [laughs]

When I just see it as a neutral entity, then it loses any power to influence me. Because ultimately, even the scale – when we say “The scale has complete power over me”, it only has as much power as you give it the permission to have. When you stop seeing it as something with power and you say, “It’s just a scale, it’s just a number, it’s nothing more, nothing less”, then it doesn’t have power anymore. Just like your body. If it’s nothing more and nothing less than a body, then it can’t have power over you.

Chris Sandel: For listeners, some of you will really resonate with that, some of you won’t, but I just wanted to bring it up because I think it’s a nice way of seeing how it lands.

01:22:10

Hunger signals + interoceptive awareness

One of the other things you talk about a lot, and I’ve seen some different posts on this, is connected to hunger signals and interoceptive awareness. I think this is a big part of autism and has an impact on it, and it can also be a challenge then in recovery, or especially a challenge when we’re trying to go down certain routes with recovery or what our expectations are about what recovery and what a recovered body will be like. So talk about interoceptive awareness.

Livia Sara: Interoception, for anyone who’s not familiar – it’s also known as the eighth sense, because most of us are familiar with touch, taste, smell, the main five senses, but there are actually three more senses that no-one really knows about: proprioception, the vestibular, and interoception.

Interoception is responsible for telling us how we feel inside, whether we’re hungry or thirsty or if we’re too hot or too cold or tired or energetic or if we need to go to the bathroom. I think toileting difficulties are huge in autistic kids. Even for me personally, I had to wear a diaper till I was like 10 because I did not know when I had to go pee. Which is so embarrassing if you’re a 10-year-old, side tangent.

Obviously, interoception is responsible for communicating hunger with us. Autistic people and neurodivergent people in general tend to lack interoceptive awareness, so it may be really difficult for us to tell whether we are hungry or full, on the other side of the spectrum, or whether we do need to go to the bathroom. Also in terms of when we have surpassed our energetic limits. A lot of autistic people tend to fall into burnout because we just don’t know that we’re overdoing it. Our body is not communicating that with us, or we’re just not picking up on these signals.

In the anti-diet space and eating disorder recovery space, the ultimate goal is intuitive eating, that framework coined by Elyse Resch and… it’s something with an ‘E’.

Chris Sandel: Evelyn Tribole.

Livia Sara: Yeah, that intuitive eating framework doesn’t really work for autistic people. Personally, as someone who’s been recovered for over four years now, I do not eat intuitively. But I recently did have Victoria Kleinsman on the podcast and we talked about this and she introduced me to a term that I had never thought of, but she likes to call it ‘intuition eating’. You’re not listening to your body, but you are using your intuition from a holistic perspective, including your brain – because mental hunger counts – to decide, “Do I need food, yes or no, right now?”

For me personally, I have – I don’t like to call them rules because that makes me sound like I have an eating disorder. [laughs] I have guides around when I eat. And what I mean by that is if I wake up in the morning, I have a guide / rule that I have to eat breakfast within X hours of waking up. If I’m hungry or not. Because for me, if I wake up and I’m not hungry, “Oh, intuitive eating, I’m going to skip breakfast” – that’s just not good for me because then there’s no more boundaries, then there’s no more constraints, and then I get overwhelmed and then I get anxious and then everything is ruined and messed up, and I can’t go down that route.

It’s really nuanced because I do sometimes feel physical hunger. I describe it differently than what people say, like “Oh my God, I have a gnawing hole in my stomach.” That, whatever they’re saying or describing, is a completely foreign description to me. When I feel physical hunger, it literally feels like there’s this magnetic field between me and food, and I’m being pulled to eat. That’s what physical hunger feels like to me.

But most of my hunger that I honour is mental hunger. That’s so important to acknowledge, again, because I used to have so much judgment around mental hunger. Mental hunger was just me wanting to eat emotionally because that’s what diet culture tells us. “If you’re thinking about food, go on a walk, go distract yourself, drink a glass of water. You’re not really hungry.” But again, we are so unique, and our body communicates in a unique way.

I think part of achieving recovery – not only as an autistic person, but as anyone – is about giving yourself permission to discover, what are your body’s ways of communicating with you, and how can you lean into that and give yourself permission to honour and learn from those signs? And you’re not always going to get it right, but it isn’t about getting it right. It’s about learning and growing and moving forward. So yeah, I hope that answers the question.

Chris Sandel: It does. There’s a couple of things that come up connected to this. One, I’m giving intuitive eating a lot more credit than maybe what you’re giving it in that –

Livia Sara: Okay, I made it sound really bad, I’m sorry. [laughs]

Chris Sandel: Not that. It’s just that I’ve had conversations with Elyse Resch and I’ve had conversations with Evelyn, and their understanding of ‘honour your hunger’ isn’t just “Have you got a gnawing sensation in your stomach? Okay, cool, that means you’re hungry.” One, they are well aware of the fact that there can be many different hunger sensations that people can experience. And this isn’t just an autism thing. The point at which I get a gnawing sensation in my stomach, I should’ve eaten three hours ago.” It’s one of the last things that I get in terms of my hunger. I’m always fainting before I’m getting that sensation.

So for me, when I’m looking at hunger symptoms, most of them aren’t digestive. It can be I’m a little more irritable, I’m starting to think about food, I’m having a little more trouble concentrating. They’re all pretty nebulous, and they’re pretty vague, but I just know those are my hunger symptoms and I lean in and I go and get something to eat. I haven’t severed them because I keep ignoring them or I disregard them.

I think those are all valid hunger symptoms. It’s not like they’re mental hunger. They’re hunger symptoms. I think what we often do is we talk about physical hunger as if that’s real hunger, and then mental hunger is like its second cousin that we don’t really want to hang out with so much. It’s like, no, these are all the same things. These are all just cues that your body is giving you that you’re hungry. Within intuitive eating, these are all hunger symptoms.

But the other thing – and they also talk about this – is with honouring your hunger, it’s not just about “Am I feeling my regular hunger symptoms?” It can also be using my intuition of like, “Normally I eat this amount of food. Today I’m actually not feeling as hungry. I wonder if that is because I’m genuinely not hungry, or is there something that could be interfering with my hunger?” If I’ve got a really busy day of back-to-back clients and then I’ve got podcasts and all that, my normal hunger symptoms aren’t really strong. I can not feel as hungry until everything’s done and then I’m like, “Holy moly, am I exhausted now.” And again, I still might not feel hungry, but I can feel that I’m really drained from the day.

If all I listened to was, “What are my usual, obvious hunger symptoms?”, I could be like, “Well, I’m not hungry.” But I ‘m able to use my other knowledge of what usually happens – which I still put under the bracket of intuitive. I’m using my intuition around this, like “Sometimes I get better hunger signals, sometimes I get less good hunger signals, and I can still recognise, yeah, I’ve had a really busy day or I have a really busy day coming up; I need to be eating regularly throughout this day.” I do think that can still be considered intuitive eating, even if it’s not the way that we stereotypically think about as intuitive eating.

Livia Sara: I completely agree, because this terminology ‘intuitive eating’ is spot on because that’s exactly what it is. I think the fact that it’s been attached to these principles is what’s caused it to take on this new meaning that people twist up, like, “Oh, that’s not one of the principles so I can’t eat.” You know what I mean? Because also, one of the principles is ‘feel your fullness’. Again, there’s so many ways to look at that, but when I speak to autistic people who never feel full, don’t know what it’s like to feel full – to say to them “Feel your fullness” feels like an insult, almost. It’s like, you think I don’t already know that? That just feels so invalidating.

So in that sense, it might almost be more helpful to take the principles and translate them to neurodivergent-friendly. For example, instead of “Feel your fullness”, “Explore what satisfaction means to you.” We could technically say that’s still the feel your fullness principle, but then we get into this rabbit hole of what is language, what are semantics, what are words? Why is this even a jar? Maybe we can call it a laptop instead, and what I’m talking to right now is a microphone. We can mess everything up.

So in this sense, there’s nothing inherently wrong with intuitive eating or that it doesn’t work or that it does work. It’s just I think it’s really important that we continue to remember that everything that’s being said and everything that does have a framework isn’t one size fits all. There are nuances and there are shades of grey within whatever we’re talking about that you need to accommodate to your own unique being. Because nothing is ever going to work for you if you don’t adapt it to you.

Chris Sandel: Sure. I’m completely on board with that. The example you used in terms of feeling your fullness – in that situation, what are the physical sensations? What are some of the mental changes you notice with that? In intuitive eating, they separate satisfaction from fullness, so we can then have a conversation like, how do you feel satisfied? What is it about – and we can talk about this from a taste and texture and sensory perspective, but we can also talk about after a meal, what’s the difference between “I feel unsatisfied or satisfied”?

I think when you’re trying to summarise something like intuitive eating in “I’m going to use 10 words to sum everything up”, I think you completely run into trouble with that. And then when you’re able to use it in terms of let’s have a conversation about what each of these things truly means – what’s the point we’re trying to get across when we’re talking about ‘feel the fullness’, or what’s the point we’re trying to get across with understanding satisfaction? We can still get there, even if the decision with the hunger piece is “Yeah, I still just think I need to have a plan each day, and I still think I need to have a minimum set of meals that I’m going to have. And if I’m not hungry by this time, I’m going to eat.”

I am totally on board with that, and that’s what’s happened for a number of clients I’ve worked with who are autistic. They’re like, “Yeah, I’m at a place where I’m recovered, and I know that this is the thing that works for me. Not works for me to keep me out of an eating disorder – works for me like, this is how I have better energy. This is how I’m able to sleep. This is how I’m able to keep my period.”

Livia Sara: Exactly. Even for me personally, sleep is an excellent example. I don’t always go to bed when I’m tired. If it’s my bedtime and I know I need to get up at 7 a.m. the next morning, I’m not going to wait until I crash of exhaustion at like 3 a.m. [laughs] Because I know intuitively I need to go to bed at like 10:00 because I need this many hours of sleep. That doesn’t necessarily mean I’ll fall asleep that quickly, but I’m still going to do it. Just like if you have back-to-back client calls, you’re probably going to eat something before so you don’t halfway collapse of exhaustion. It’s all about the conversation.

And then specifically the fact that satisfaction and fullness are two separate components of intuitive eating – just for me personally, fullness isn’t even part of the way I eat because I never feel full. Fullness for me only occurs when I am so full that I cannot eat another bite. That is what I recognise to be fullness. And I think for me to eat and question, “When am I full, when am I full?” gives me so much anxiety that it’s a lot easier for me to just focus, “When am I satisfied? Okay, we’re done here.” It just takes the edge off, I guess.

Again, that’s not saying that for another autistic person, ‘feel your fullness’ may be applicable to them. It’s a conversation, and it’s an exploration and it’s discovery, because ultimately that’s what life is.

Chris Sandel: On board with that. I think that with intuitive eating – and look, it’s not like I’m wanting to die on this hill about intuitive eating. [laughs]

Livia Sara: [laughs] I know, I know.

Chris Sandel: It’s just I think there are a lot of people where they have this very stereotypical view of it, and it’s like, no, there’s a lot of nuance with it. And even the principles – they’re suggestions. So if you’re like, “Actually, fullness isn’t that important to me, or I never feel fullness” – it’s like, okay, great. Let’s not spend our time focusing here. Or in the same way as you noticed “My hunger symptoms are something else”, my fullness symptoms might be something else. You’re putting that in the same category as satisfaction, so maybe that’s all you need to pay attention to. That’s fine.

I would also say fullness doesn’t have to be like “I have a distended stomach.” Fullness could be this other collection of things that you also notice.

Livia Sara: Yes. I feel like this is an entire conversation in and of itself. Don’t worry, it doesn’t feel like you’re trying to drive this home and convince me. I think it’s, again, so nuanced that we can’t even have a productive conversation about this without basically unpacking every single principle in depth. I think they have done a wonderful, remarkable, revolutionary job in this anti-diet space, and I actually have heard them acknowledge that some of the principles are not written in a way that is necessarily neurodiversity-affirming.

Just the fact that they’re able to be humble about that goes to show that they’re amazing people that don’t claim to have it figured all out, because no-one does. I think that’s really, really important. Again, any books we write, any programmes we put out, we’re never saying “This is the answer and the solution to all your problems.” The solution to any problem is never external. It’s an internal shift that happens.

Chris Sandel: Definitely. Anyone could critique something I’ve said, like “What about this thing?”, or something you’ve said. There are always going to be nuances, there are always going to be edge cases. And I really want to have this conversation about interoceptive awareness because I do think this is something that, as you talked about earlier, where people kept labelling this as “This is just your eating disorder” and you’re like, “No, actually, this isn’t just my eating disorder. This is something that predates my eating disorder and this is something that’s going to be there well after my eating disorder is gone. This is who I am genetically, this is who I am from a physiological standpoint.” I think that’s a really important thing for people to understand.

It then means that treatment can look different because of that. You talked about all of the other added things on top of that in terms of the sensory stuff, being in a loud environment, being in lots of lights, if the room is too hot or too cold – all of these extra inputs where for someone, they just don’t notice that, and for someone else, that is a huge thing that overburdens the system.

Livia Sara: That’s so funny that you said they don’t even notice that, because the amount of times that that has happened on vacation with my family – I’ve said, “Oh my gosh, do you guys see that?”, and the amount of times I’m met with, “Oh my gosh, I didn’t even notice that.” [laughs] It’s just hilarious. That’s the joke in my family, like, “Livia sees everything. You can’t keep a secret from her because she knows everything.”

But I think, again, it’s that hypervigilance. It’s just being so on hyperalert all the time that of course you’re going to notice everything. If you were in the wild, you’re going to notice everything too because everything could be a potential killer and could bite your foot off, I don’t know. [laughs]

01:39:21

Adding food variety in recovery

Chris Sandel: The final thing I want to talk about – and we’ve probably touched on it a little bit, but it’s the variety piece. I think you’ve talked about the fact that prior to your eating disorder, yeah, you ate a fairly limited number of things and you liked them to be just so. I think, again, so often we can talk about “This is coming from the eating disorder and this is why you’re afraid of these different things.” I’d love to hear your experience and how you dealt with this in recovery, and how you work on this in terms of your clients.

Livia Sara: I think first of all, coming back to that autonomy piece, it’s like, how much variety do you want? Because I think a lot of times, the conversation is like “You need to have more variety.” No question about it. But sometimes, or most of the time, people come to me and say, “I feel really stuck and I have this really limited range of foods, and I genuinely want to eat more and tolerate more; I just don’t know how>”

Then we can go somewhere, because they’ve already decided and chosen for themselves, “I want more variety.” So then it’s a question of, what feels feasible? What’s a specific food that you would want to eat? How can we build off of what you’re currently eating to get to that food?

Silly example, but say someone’s really afraid of bread, but they’re fine with eating two strands of spaghetti. Both products are made with flour, so then we can say, how can we increase flour amounts? I’m just making something up. But like, okay, two strands of spaghetti – can we get you to an actual serving of spaghetti? When you’re constantly eating spaghetti, maybe now you can try eating bread and remembering that it’s not actually a different thing. They’re both flour in different forms.

That almost very simplistic but logical way of thinking about variety is so helpful for autistic people, because that was me. I had this huge fear of bread, but I would eat brown rice, and I would eat other carbs. I think for me, when I first increased my carb amounts, and then I was like, “Okay, I’m fine eating more carbs; I’m just going to switch the source”, that made it a lot easier for me. And I think it can be helpful to have someone who is willing to be patient with you in that process and not like, “You have to eat an entire sandwich right here, right now, otherwise I’m kicking you out of the treatment centre because you’re not committed to recovery.” That’s just not fair.

Chris Sandel: I agree. If I’m thinking about variety, I’m also thinking about, what’s the most important thing for this person? If someone’s undereating, the most important thing is them getting in more food.

Livia Sara: Exactly.

Chris Sandel: At that point, we don’t need to be changing variety. We may need to change variety if the food you’re eating is taking up so much volume that you’re unable to get more energy in. Then yeah, we need to change some things and we need to bring some food in. But that’s not variety for variety’s sake. That is variety for “We’re trying to get more energy in.”

I think what can often happen is that when we try and increase variety, at the best, food levels or energy level stays the same, and at its worst, it starts to drop down. So if you’ve already got someone who is in a depleted state, who’s already not taking in enough food, adding in variety that then potentially means that they are getting in less food – that’s not a great thing to be happening.

So when I’m looking at this, looking at what is the stage someone’s at? What’s the most important thing for the stage they’re at? And then when we’re at a stage where you’re getting in good amounts of energy, or “Wait, you’re not getting in good amounts of energy and we need to make a shift in terms of the food you’re getting in to allow that to happen” – this is when we can start to talk a little bit about variety. But then, as you talked about, coming back to, what did you use to do before your eating disorder?

I know this isn’t always a helpful question because there can be times where people were masking, or there can be other things that get in the way of this. But as a starting point, it can be worth having a conversation around it. And if someone, for all of their life, has had this very limited range of food, it doesn’t mean that that’s how it’s going to be forever. But we can at least not be labelling it as “This is just an eating disorder behaviour.” The eating disorder can definitely make it worse, but we can’t just lump it into that category.

Livia Sara: Exactly, and I think it’s really important that you brought up that it’s different and that someone goes through different phases in their life. I definitely do not eat like I did when I was a kid. If I’m going to be eating sugary cereal all morning, I just know that’s not setting me up for a helpful day because I understand protein and vegetables and fruits and fats. I understand all that now. Like you said, it can be a great starting point because it’s like, “I’m overwhelmed. I don’t know what to have for dinner.” Then I will literally make macaroni and cheese because that’s what I loved as a kid.

And what you also brought up with just increasing the calories, the nutrients someone’s getting in, if that’s the most important thing, let’s hook the variety conversation. Because for me, when I was having a meal plan and it was like, “You need to increase on the meal plan; what item can we add?”, I’d be like, “I don’t want to add anything!” But if it would’ve been, “You’re already eating peanut butter. Can we double the amount here?” – that’s less overwhelming than adding a completely new sensory input.

Chris Sandel: Yeah. I always have those as the options, like, “We can look at what we’re already doing and you can increase the portion size. You can add something in addition to what you’re doing. There’s a snack missing between your breakfast and your lunch, so we could bring this in, something in there. What do you think would be the easiest way for you to be making this change to bring more energy in?” So giving someone, again, that autonomy to make that call. If they want to double the portion, they double the portion. If they want to add this dessert thing or this other thing in, great. Let’s go down that route.

Because the real goal is, how do I get more energy in? How we get to that point doesn’t really matter in the whole scheme of things.

Livia Sara: I love that you asked, “How do you want to do it?” because that’s exactly what it is. Every time I’ve asked my clients that, they have all these elaborate plans for what they’re going to add and when they’re going to do it. So I’ve learned it’s not that they don’t know what to do; it’s that they need permission to actually do it.

Chris Sandel: Yeah. The thing I would add to that piece – and again, this is where I’m like, I want to be honest with you – if someone is giving me an elaborate plan where I’m like, “You are making this way more complicated than it needs to be”, I will also say, “I think you’re making this more difficult than it needs to be. I think you’re changing something small with every single meal and you’re creating so many opportunities where this is going to be a challenge. I think what would be easier is making a change at one of your meals, or two of them, where it’s something simpler, where you bring one thing in or you make one thing bigger. Is there anything in that realm that makes sense? We can do it your way, and I want to just say these are my concerns with that. Tell me your thoughts.”

Livia Sara: Yes. What I meant with the word ‘elaborate’ was – I have this one client who basically said, “This week I’m going to add this, and next week I’m going to add that, and the week after” – she basically had and whole 6-month mapped out plan for her increases, and I was like, okay, let’s just start with the first one today and we’ll reevaluate a week from now. But that’s what I mean. She knew that she had to eat more, and she knew exactly what she wanted to eat more of, but she just was afraid to do it by herself.

But I completely agree with you. If someone’s wanting to make a change to every single meal and snack and all these different things, we know from experience that when we try and change things, that doesn’t work if you try and change everything. Because if you change everything, you might as well change nothing. That’s not true, but you get what I’m saying.

Chris Sandel: I do. Liv, this has been an awesome conversation. I love chatting with you. I think you’re doing such great work in this area, and I think there needs to be more attention about the fact that there is this overlap between eating disorders and autism. Where can people go to find out more about you and your work?

Livia Sara: My website is pretty much where you can find everything: livlabelfree.com. I have my books there, I have a course there, my coaching is there, blog, podcast, I have a free audio training that people can listen to. You can find it all on my website. I know you mentioned my Instagram a few times, which is just @LivLabelFree on Instagram. So drop a comment, say hi. I usually share podcasts teasers there, as well as just informational posts. So that’s where you can find me.

Chris Sandel: Perfect. I will put all those links in the show notes, and thanks so much for coming on the show. I really enjoyed chatting with you.

Livia Sara: Thank you for having me, and I can’t wait to have you on my podcast soon.

Chris Sandel: Sure. I will get that sorted out and we can have that conversation then.

So that was my conversation with Liv Sara. She’s doing great work in the recovery world, and I highly suggest checking out her Instagram or her great content and other suggestions.

As I mentioned at the top, I’m currently taking on new clients. If you’re interested, please send an email with the subject line of ‘Coaching’ to info@seven-health.com.

That is it for this week’s episode. I will catch you again next week. Until then, take care of yourself, and I will see you soon.

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