Episode 168: This week I chat with sports and eating disorder specialist dietitian, Renee McGregor. We cover RED-S, Hypothalamic Amenorrhea, and orthorexia. We also dive into Renee's history with an eating disorder, which she hasn't discussed publicly before now.
Renee McGregor is a leading Sports and Eating disorder specialist dietitian with 20 years experience working in clinical and performance nutrition, with Olympic (London, 2012), Paralympic (Rio, 2016) and Commonwealth (Queensland, 2018) teams.
She works with individuals, athletes of all levels and ages, coaches and sports science teams to provide nutritional strategies to enhance sport performance, manage eating disorders and overtraining.
She is presently working with a number of national governing bodies, including Scottish Gymnastics, Scottish Ballet, and The GB 24 hour Running squad.
She is regularly asked to work directly with National Governing Bodies and institutes, high performing and professional athletes that have developed a dysfunctional relationship with food that is impacting their performance, health and career.
She is the best-selling author of Training Food, Fast Fuel books and Orthorexia, When Healthy Eating Goes Bad.
She is the co- founder of  #TRAINBRAVE a campaign raising the awareness of eating disorders in sport and dance; providing resources and practical strategies to reduce the prevalence.Â
In 2019 she collaborated with Dr. Nicky Keay and they have together opened the first Sports Endocrine nutrition clinic in the UK, looking at hormonal profiles in order to optimize health, training and sports performance.
She is on the REDS advisory board for BASES (The British Association of Sport and Exercise Science) and sits on the International Task Force for Orthorexia.Â
She is on the advisory board for The Be Well Collective, a charitable initiative that aims to bring nutritional education and mental health coaching to the world of fashion models; the women and men that represent society’s aesthetic paradigm yet off camera often face the greatest body consciousness, self-esteem, and stress-related issues.
Renee has been invited to speak at several high profile events including The European Eating Disorder Society Annual Conference as the UK expert in Orthorexia, Cheltenham Literature Festival, Cheltenham Science Festival, The Stylist Show and Google.
She writes for many national publications and is often asked to comment in the national press. She regularly contributes to radio and TV, including News night, BBC 5 Live and Radio 4.
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Chris Sandel: Welcome to Episode 168 of Real Health Radio. You can find the links talked about as part of this episode at the show notes, which is www.seven-health.com/168.
Welcome to Real Health Radio: Health advice that’s more than just about how you look. Here’s your host, Chris Sandel.
Hey, everybody. Thanks for joining me for another episode of Real Health Radio. This week’s show is another guest interview, and my guest is Renee McGregor.
Renee is a leading sports and eating disorder specialist/dietitian with 20 years’ experience in working in clinical and performance nutrition with the Olympics (London 2012), with the Paralympics (Rio 2016) and with Commonwealth Games (Queensland 2018) teams. She works with individuals, athletes of all levels and ages, coaches, and sports science teams to provide nutritional strategies to enhance sports performance, manage eating disorders and overtraining.
She is presently working with a number of national governing bodies, including Scottish Gymnastics, Scottish Ballet, and the GB 24-Hour Running Squad. She is regularly asked to work directly with national governing bodies and institutions, high performing and professional athletes that have developed a dysfunctional relationship with food that is impacting their performance, health, and career. She is the bestselling author of Training Food, Fast Fuel, and Orthorexia: When Healthy Eating Goes Bad.
She is the co-founder of #TRAINBRAVE, a campaign raising the awareness of eating disorders in sport and dance and providing resources and practical strategies to reduce the prevalence. In 2019, she collaborated with Dr. Nicky Keay, and they have together opened the first sports endocrine nutrition clinic in the UK, looking at hormonal profiles in order to optimize health, training, and sports performance.
She’s on the REDS advisory board for the British Association of Sport and Exercise Science and sits on the International Task Force for Orthorexia. She is on the advisory board for the Be Well Collective, a charitable initiative that aims to bring nutritional education and mental health coaching to the world of fashion models, the women and men that represent society’s aesthetic paradigm, yet off-camera often face the greatest body consciousness, self-esteem, and stress-related issues.
She writes for many national publications and is often asked to comment in the national press, so regularly contributing to radio and TV, including Newsnight, BBC, 5 Live, and Radio 4.
I’d been aware of Renee for a number of years. I think it was because of her book Orthorexia, which came out 2 years ago or so. That was how I first saw her name. I know she was doing a lot of speaking engagements around that time. Then more recently, as I’ve been doing more reading and researching around relative energy deficiency in sport, or RED-S, I saw her name coming up a lot. So I reached out and invited her on the podcast.
During this conversation, Renee is very open in the interview about her own past eating issues, and it’s something by her own admission she’s never done before, so it was great for her to feel comfortable opening up about this and talking about her own home life growing up and the struggles with that, and then developing an eating disorder early on and what her recovery looked like.
We cover RED-S and HA and orthorexia, all areas that Renee works a lot with in clinical practice. I had wanted to cover ideas around Health at Every Size and weight stigma and the connection between weight and health, as I feel this is an area where Renee and I differ in our opinions, but this part of the conversation didn’t make the final cut. It’s definitely something I’d love to have further discussion with her about, so hopefully, at some point we’ll be able to do a Part 2 where we can cover this.
So that is it for the intro. Let’s get on with the show. This is my conversation with Renee McGregor.
Hey, Renee. Welcome to the podcast. Thanks for taking the time to chat with me today.
Renee McGregor: Hey, Chris. Thanks for having me.
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Chris Sandel: There’s a lot that I want to cover with you today. You’re someone who does lots of different things and has lots of knowledge around different areas. I know you work with athletes and also more recreational exercise enthusiasts who are dealing with relative energy deficiency in sport, or RED-S. So I want to go through that. I want to talk around hypothalamic amenorrhea, or HA, because this is another area you work in. Also, you’ve written a book on orthorexia and deal with eating disorders more generally, so there’s another piece to go through. It’s a lot, and I imagine and I hope we go down different tangents and explore other ideas, but that’s a bit of an overview.
I guess to start with, do you want to give the listeners a bit of background on yourself, like who you are, what you do, what training you’ve had, that sort of thing?
Renee McGregor: Sure. I’m Renee McGregor. I guess my official title is Sports and Eating Disorder Dietitian. I started as a clinical dietitian, so I did a biochemistry degree first, and then from there I went on and did dietetics.
I spent 6 or 7 years working my way up through the NHS. With a dietetic qualification, it’s very much like a junior doctor. When you get your Basic Grade Dietitian, as it used to be called – I think it’s Band 5 now – you do pretty much everything. You cover every ward and look after all sorts of different patients, and you do that for about a year and a half. Then you move into more of a rotation, so you go up a grade. I’m trying to remember. I did renal, gastroenterology, pediatrics, and cardiac during that time.
You do that for another year and a half, and then you can specialize into more specific areas, just to get a feel for where you want to go. I did pediatrics. It was mainly pediatrics and different areas of pediatrics, so cystic fibrosis and liver, eating disorders, allergy – you name it, you basically get a really good grounding in that particular specialty.
So that was the first 6 or 7 years of my career. I worked in the NHS, like a 9-to-5 job. It was towards the end of that – I was working in a district general hospital at this point. I’d worked in two major teaching hospitals in London, and then I moved to a district general just because I moved as a person.
In this district general, although I was a pediatric dietitian, pretty much every single case I had was eating disorders. And I’d had quite a lot of eating disorders experience working in the larger teaching hospitals because again, they were quite well-known for having eating disorder units. So it’s been something that I have worked with pretty much since Day 1 of my qualifications.
It’s interesting because at that stage, even though I would get good results and I would get them to engage and I could get them to move on, I just became a little bit disillusioned generally with my work. I’m one of these people that had gone straight from A levels to uni to then another degree, straight to a job, and I wasn’t really sure if this was the direction I wanted to be in. I was feeling a little bit tired of working with people who were sick. It felt hard work at the time.
So I took a bit of time out. I decided to leave the NHS, and I started a post-graduate in applied sports nutrition, which was a year long. It was really intense, but basically doing that was brilliant because it consolidated everything that I already knew about sports nutrition, but it also gave me further in-depth into the biochemistry, the endocrinology, the physiology. I was then able to go into a more sports-specific role.
My first job was actually working with the rhythmic gymnastics squad going into London 2012. Again, the main reason I was chosen over other people was this cross between my clinical background, so I could really get to grips with any health implications, as well as my sporting knowledge.
I guess from there on in, pretty much most of my roles have developed in that way. We got some great results out of 2012. I then started working with the Paralympic teams, I started working with the Great Britain Wheelchair Fencing Team and the Great Britain Wheelchair Basketball Team. Again, because they were disability sports, there was that real crossover between clinical understanding and sport, and how you get the two to merge and work together.
That took me into 2016, and then post-Rio, I was going through some very difficult stuff personally at the time. The two cycles going into the Games had left me feeling quite exhausted and burnt out. I knew that it wasn’t the direction – although I’d really enjoyed the roles and I’d really enjoyed working with the athletes – they were great athletes, all of them, and I gained lots of experience, and we’d got medals in all the sports – it just didn’t really fit with my core values, I guess. I was struggling with aligning with who I was as a person.
I’ve always been someone who’s very, very compassionate, and obviously probably more clinical-minded, and I really care about people’s health and their longevity. That’s not something that is always thought about in very high-performance sport.
During this time, I was seeing more and more athletes within the different sports I was working with, and then from other sports because people sent them to me, who had difficulties with eating and over-training. Again, it’s one of those things, it’s that crossover between the clinical knowledge, the experience I’d had within the NHS and working in some really quite difficult situations with eating disorders, and then bringing the understanding of the athlete mindset and how that all fits together.
So post-Rio, I left working with very, very – I say that; I still work in high performance sport, but I stopped working with the Paralympic and Olympic teams that I had been, and I decided to do more consultancy work. That’s kind of where I am now. Obviously I have a clinic. I have my own clinic, my own practice where I work with athletes that have difficulties with food and training, but I also do, once a week, a joint clinic with an endocrinologist where we look specifically at RED-S and hypothalamic amenorrhea. Then on top of that, I still work with some national organizations. I work with Scottish Gymnastics, I work with Scottish Ballet, I work with the Great Britain 24-Hour Running Team, and I work with a number of individual endurance athletes.
So I’m still very much in sport, but I guess it’s the more complex area of sport where the balance has gone off, and it’s about helping them to become more robust and resilient so they can go back into their sport and perform better, if that makes sense.
Chris Sandel: Yeah, it does. There’s a lot there that I definitely want to go back through, and I think it’ll come up as we go through stuff on RED-S and HA, and then also in terms of orthorexia.
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But if we go back even further, so you as a kid, what was food like in your household?
Renee McGregor: I grew up – my parents are Indian, so food was always abundant because in an Indian family, it’s all about feeding and feeding and feeding.
But that said, I had quite a difficult upbringing in that my parents had to work several jobs in order to provide, and they were very insistent that my sister and I got a private education because where we were living, the comprehensives and the primary schools weren’t that great. And we were the only Asian family in the entire area. I mean, we were getting bullied anyway, but there was even more chance. Both my sister and I ended up doing quite well and getting scholarships to both our primary and our secondary schools, but there’s still costs and stuff.
So it was difficult because my parents weren’t around that much. They weren’t really present, both physically and emotionally. It was quite an interesting time. When I look back on it now, I think my relationship with food probably wasn’t the healthiest. I had a very difficult relationship in myself in the sense that obviously I belonged to this very strict Sikh, Asian family, and at the same time I really wanted to belong to my peer group.
Particularly as I was going through my teenage years, this became more and more difficult. I did often reject the food my mum would make for us – which now I just can’t believe because it’s so delicious. But at the time, I did, and I wanted pizzas and I wanted pies. I wanted very traditional English food that my parents had no idea how to create or cook for me. So food, yeah, it was an interesting relationship.
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My relationship with myself was very, very poor. I’ve never really spoken about this on a podcast. [laughs] I’m not going to lie. I suppose nobody’s really asked me about my background.
I had a very, very difficult childhood with, like I said, lots of bullying. There is a huge amount of expectation within Asian families for academia, to do well. And I was very, very sporty. I was a very sporty child. I was very good at dance, I was very good at swimming, I was good at hockey and netball. But that wasn’t really accepted. It was very much about getting the grades and doing well academically. There’s a kind of joke within the family that if you’re not a doctor or a dentist or an accountant, you’re not really successful.
So I suppose I had a very negative narrative in the sense that I never really believed I was good enough. I always felt like I was slightly disappointing to my family because I never got the top grades. I was always someone who had to work really hard. And I didn’t want to be a doctor or a dentist or an accountant, or any of the chosen careers. I had at that stage no idea what I wanted to do at all. I knew I was pretty good at science, but I was also very, very good at writing and being creative.
In an ideal world, my job would’ve been something like journalism, but I knew that was frowned upon, so I ended up doing A levels in science, and that’s how I ended up doing biochemistry. But now, because of the work I do, I can see that I carried this very negative narrative through to my adulthood, and it has definitely impacted my view of myself and my view of my body. I haven’t always treated it well.
But I’ve also worked really, really hard on myself, particularly in the last, I’d say, 8 years. I’ve worked very hard at understanding what’s going on for me and creating my awareness, and then learning to challenge those intrusive thoughts and not always – now I’m no longer being defined by what I look like or what I achieve or what my weight is or any of those things.
So my relationship with food is fantastic now, but as a kid, it almost mimicked what was going on for me. It was quite fraught, it was quite tense, and I suppose that is the environment I grew up in – like a lot of families. I’ve got two teenage daughters and it’s not plain sailing. But it’s interesting to be asked that question, because I’ve never really thought about it properly, to an audience, I guess.
Chris Sandel: Sure. You said you wanted to be matching up with your peers and be more “British.” Did that mean dieting and wanting to get into that side of things? Was that something your friends were into?
Renee McGregor: I never felt like I belonged. I am a very petite, small Asian person, and I’ve always been petite. I’ve always been small. When I say that, I was overweight as a very young child, but by the time I got to 10-11, I was what you’d call petite and small.
But because of the negative narrative I felt, I never believed I was good enough and I felt very uncomfortable in my body. Very, very uncomfortable. I would look at my peers and they were tall and slim and had long legs, and I longed to look like them. I was never going to, but that’s what I wanted. I guess I didn’t feel like I was part of that group.
School was tough for me. I really struggled. I only had a couple of very, very close friends, and otherwise – what can I say? It was an all-girls private school. It was bitchy. It was nasty. Everybody was out for their own, and it was very competitive.
So I did fall victim to eating issues, and I did become very, very poorly at the age of 13, 14, 15. Very, very unwell. I guess that probably explains why I ended up working in this field. I never thought I would, I’ll be honest. I never thought I would because it was such a difficult experience having an eating disorder and being so unwell. The journey that followed was one that took a long, long time to ever be completely free.
If I do tell people that I had an eating disorder, they look at me and they’re really surprised because obviously I don’t have any issues with food anymore. I don’t have any issues with body image. I’m a very balanced person. Obviously, when people say “Can you get better?”, I always say, yes, you can, because I know I did.
I was very ill. My weight dropped down to 28 kilos, so I was very, very unwell. It’s amazing I survived, I guess. Like most people that I work with, I lost my periods and had 8 years or so of no menstruation and did have issues with bone health – which thankfully, again, through good nutrition, getting my periods back over the last 20 years now, my bone health has managed to improve and not get any worse.
I’m very, very aware of what it feels like to be one of my clients. I completely get it. I try and distance myself from having – when I say distance, I don’t feel like it’s relevant to tell my clients that I’ve had an eating disorder because that was something that has obviously shaped me to be a better practitioner, but it’s definitely my practitioner skills and my professionalism and my ability to understand what’s going on for them that makes me better at my job.
So yeah, it’s quite weird. Like I said, this is probably the first time I’ve ever opened up about my past history. I’ve never spoken about it publicly, ever, so it will be interesting to see what the response is.
Chris Sandel: Sure. This is something I should’ve said in the beginning: at any point, if you say something that you want removed from the podcast, either instantly and we can do it over again, or at a later point after we get off this call and you’re like “oh, I wish I hadn’t said that” or “I don’t want that to go out,” we can do that. So don’t feel like you have to get everything right first time round and that it’s going to be some kind of “gotcha” interview. It’s great. I’m really thankful that you’re being this honest in talking about it, but I also don’t want you to say something that you later regret.
Renee McGregor: You know, I have thought about this, because I do so many podcasts, and nobody’s actually openly asked me the questions you’ve asked me. I’m very honest, so the fact that you’ve asked me the question, I would always answer honestly.
It’s something I’ve been thinking about because it does concern me the number of nutritionists coming onto the field who are working in eating disorders who have had their own experience of an eating disorder. You might say “that’s really hypocritical; you just told us you did.” But we’re talking 20 years. By the time I got to my dietetic degree, I had to be free of my eating issues because they checked. They did an interview with us to ensure that our relationship with food was healthy in order for us to be accepted on the course.
So I worry now because I do know the number of nutritionists who have only recently had their own issues, and then it’s almost like “I’m fixed, so now I’m going to work with people and help them” – and I’m not convinced that all of them are completely recovered.
I have spoken to my psychiatry and psychology peers and friends, who I do a lot of work with. We’ve had this conversation, “What would you say is the average time someone should be recovered before they start working in this field?” And the majority of them say minimum of 5 years where you’re completely balanced and able to not have any concerns about food and body image before you really start working in it.
I think, unfortunately, as we both know, it’s a condition that can coerce people in. It’s very manipulative, it’s very deceptive. So if you’re somebody that is still not fully recovered, it could, one, trigger things for you, and two, encourage you to feel the empathy, almost, of the eating disorder and work alongside it so that you break your non-negotiables. I have key non-negotiables with the people I work with, like “I’m sorry, but no, that is not happening. You will eat these three things. If nothing else, these are the things you will have,” type thing.
I think if you are not emotionally recovered enough or you don’t have the awareness of why you developed an eating disorder in the first place – I’m very aware of what mine was about. Mine was very much a negative narrative. It was about the abuse I received through bullying and conflict at home and that identity of who I was. There was so much there, and I’m very conscious of that. Even now, when I have those days where I feel inadequate or I feel like I’m not good enough, I’m able to challenge that now because I’m so conscious of what it’s about. Obviously everybody’s issues are different, but if you’ve not dealt with those issues, then you’re not in a position to help somebody else.
So in some ways it’s important that I have this conversation, because I think, yes, I’m admitting I had eating problems, but I’m 43 now, and mine happened when I was 13. I would say I probably wasn’t fully well until I was maybe 20. But even then, even over the last 20 years, it’s been a constant evolving process. When I do talks and people say, “How long does recovery take?”, it’s like, it’s constant. You’re always evolving from it. But I think it’s important to be at a certain stage before you start working in it.
Chris Sandel: Yeah, I would agree. I think it’s hard to say it’s got to be 5 years, but I do think that there is definitely some messiness around it.
The other part that also comes to me is when you’ve been in that place, food has been such a focal point, and when you’re recovering, for some people there’s this feeling of “this is the work that I want to do and I want to help people,” and actually the longer someone gets out of that, the more they’re like “actually, I don’t want to do this with my life; I want to do something that is not related to food whatsoever” or “I notice that being in a position where I’m potentially having to take on a lot of other people’s problems can be very triggering for me.”
Especially because a lot of people who develop eating disorders are very empathic. They can potentially have problems with boundaries in terms of taking on other people’s stuff. So that field just might not be the best thing for them, and they can get to that place if they have a long enough gap between eating disorder finishing and then making a career choice. But if it’s right in the midst of it, yeah, someone can end up then starting something that later on down the road, they’re like, “I don’t know if this is actually my calling or what I want to be doing.”
Renee McGregor: I also think it can be dangerous for the other person. I have had a number of clients that have come to me where they’ve not been fully understood because the individual that they were working with previously is not well enough or recovered enough in their own place to be able to actually be very balanced and objective about food. So I think from my point of view, I worry more about the client. I think that’s something that people really need to be mindful of.
And I’m very conscious that I’ve recently had a number of students who have been studying specifically to work in the area of eating disorders, and they are still fully immersed in an eating disorder, hence they’re working with me. Those sorts of things really concern me. I suppose the reason they concern me is because, probably like you, I end up picking up the pieces.
It’s a stage that’s not necessary. When you’re recovering from an eating disorder, it is a long, hard, slow process, full stop. If you have to add another stage where you’ve ended up working with somebody that potentially has set you back, I have issues with that personally.
Chris Sandel: Definitely. I think – and we can talk about this more when we go through orthorexia, but there’s become a normalization of disordered eating and disordered habits around exercise, etc., where that just becomes normalized. So when they’re having a conversation with their coach or their practitioner or whoever they’re working with, if they are also of that disordered mindset, then things that should be flagged up as “this is a problem” or “let’s do some more exploring around this” don’t get flagged up at all or get congratulated, as if you’re doing a really good job.
Renee McGregor: A hundred percent. Exactly.
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Chris Sandel: There’s two things I wanted to ask you. One is about your recovery, but the other one was about you said “I don’t open up about this to my clients.” I’m just wondering what your reasoning for doing this is. If I look at the work of someone like Carolyn Costin, she’s very much of the mindset that if you’ve had an eating disorder and you’re working with people, try to get that front and center as a way to say “I have recovered” and to show that recovery is possible. So from her thought process, it’s like “I think this is a really good thing to be telling clients.” I just want to know how you think about that.
Renee McGregor: It wasn’t a conscious decision. It’s not something that I initially was like “I’m not going to tell people.” It just wasn’t something that I felt was always relevant. What I’ve done in the past is in some cases, in extreme cases where people just aren’t moving forward, maybe because they feel like no one understands them, then on those occasions, I have said, “Actually, I do get it because I’ve been there.” Then they’re quite surprised because, as I said, they don’t see that in me.
So it’s not like it was a conscious decision that I haven’t told people. I suppose initially I didn’t because when you get jobs in the NHS, although you have to disclose that you’ve had a past issue when you go through occupational health forms and things, it wasn’t something that I particularly wanted to bring up again and again and again. I always declared it, but I didn’t necessarily need to discuss it, I felt.
And I suppose, maybe like lots of people – and this was a discussion I was having the other day with a few people – there was a part of me that probably was like, that is something I’ve had to deal with. It was a very personal experience for me, and I’m not ready to share that with the world just yet. I think maybe now that it is many years on, maybe 30 years on, maybe I am prepared to share it.
But I guess I don’t want people to – I’m very aware that sometimes having had an eating disorder, you come across as a victim, and I’ve never wanted to be a victim. I’ve never wanted people to think – I don’t know. I suppose I’m not really answering the question very well, but it’s been a personal decision not to share it. Not because I was ashamed. I’ve never been ashamed of it. I’ve always known that my experiences and my own journey have meant that I have been in a better position to support and help people.
But I’m also very conscious that my journey is my journey, and everybody has to go on their own journey. I guess it’s the whole n = 1. That really irritates me. It’s being very conscious that I’m not going “Hi guys, this is what I did, this is what you should do.” I definitely, definitely don’t want that because that’s not what I’m about at all.
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Chris Sandel: Okay, yeah. I get that side of it.
Talk a little more about your recovery. Did you have time as inpatient, as outpatient? What did it look like? The other part as well that comes up for me is you talked about coming from this Asian background and that having a real impact on how you were brought up and your parents’ beliefs, etc. How does an eating disorder fit into that as well?
Renee McGregor: Like I said, we’re talking 30 years ago, when eating disorders weren’t that well-known, full stop, anyway. Then you have this Asian family that really did not understand it in the slightest, at all. It was difficult. It was very difficult.
I was never an inpatient. I was sent to the Maudsley as an outpatient, and I was one of the first people that did the Maudsley method. Did it work for me?
Chris Sandel: Do you want to just take a step back – can you just explain what the Maudsley method is for people who don’t know what that is?
Renee McGregor: The Maudsley method was very much the control of food went over to parents. They gave me what I ate and I had to eat it, and that was very much it, basically. It was not family therapy.
It really is an interesting one, because I don’t often – I suppose to a certain degree, you know when you blank out a whole time of your life? That year of going back and forth to Maudsley and having therapy sessions and being forced to eat grilled cheese sandwiches and goodness knows what else I was fearful of on a daily basis, and arguments about whether I was going to drink the milk or not drink the milk – the usual things you would see in a family household now, even.
But did it work for me? I was young, if you think about it from that point of view. I was 14-½, 15, around that age, and I was still very much the dutiful daughter. I didn’t really understand what was going on for me, and it was never really explained to me properly what was going on for me.
Chris Sandel: Meaning no one said: “you have an eating disorder”?
Renee McGregor: No, they did. They explained that, but they didn’t explain what it was. The way I explain it to people, nobody ever explained that to me. I never understood that it was about not wanting to feel and it was my coping mechanism, and it was my way of containing these negative emotions that I felt about myself. Nobody ever explained that to me at all. It was very much “you are underweight, you need to eat.” It was very food-focused, it was very weight-focused, and I’d never really got any support with regards to accepting my new body image or accepting my new weight or any tools on how to cope with my anxieties at all, full stop.
So from my point of view, it was literally a weight restoration process to get me to a weight where I could function again, and then I was discharged. I was restored to a target weight. I maintained that target weight for I think about 4 weeks, and then they were like, “right, you’re free to go,” and we were left to then do our own thing.
I remember leaving feeling completely lost, like “What do I do now? I still don’t really know. Do I carry on eating how I was? But I don’t want to put any more weight on. Or do I drop” – all these questions and no answers. I didn’t work with a dietitian. It was very much just the psychologists and psychiatrists just providing information to my parents – and my parents are clueless when it comes to nutrition, bless them. So it was a lot of chocolates and puddings and lots of sweet things that they would understand, I guess.
I left there and, if I’m honest, I probably fell back down again fairly quickly. However, the one thing that I had learnt from my experience was I didn’t want to go back back. I didn’t want to go back to the point where I was so incredibly unwell that everything hurt, everything was cold, and I was numb. I didn’t want to do that. So I guess I dropped about a stone, and I was functional. I was definitely a functional anorexic for probably all through my GCSEs and A levels, until I got to uni.
It was when I got to uni that I suddenly realized that I couldn’t join in. I couldn’t have toasties at 2 a.m. I couldn’t drink beer. I suddenly felt like, oh my God, what am I doing? It was actually at uni I went in search of help. I’d got to a point where I was actually very, very, very depressed, and the depression was all around food and not being able to be relaxed and not being able to enjoy life – often the place where people come to see me. I was desperate, to the point I had had suicidal thoughts at this point. I was like, I can’t keep living like this. I’m 18 years old, and this has taken up already my whole teenage life. This is unacceptable.
So I went and got some support with the university student services for 3 years. That for me was probably pivotal, because it started to help me understand about me and my relationships and my personality and why I struggled so much with letting go. I suppose understanding it – I am a very analytical and scientific, logical person. I needed to understand why I had these behaviors before I could change them.
That probably was the main support I had, and then after uni, it was very much just a case of constantly stepping out of my comfort zone and realizing the world didn’t end. Just kept on doing that and kept on doing that. I suppose my body got to a point where it was comfortable, the weight just stayed where it wanted to stay, I started to trust it more.
I suppose to be 100% honest with you, the time I completely became very aware of how much I could trust my body was when I first fell pregnant the first time. I was 26, and I was petrified, as you can probably imagine. [laughs]
Chris Sandel: [laughs] I’ve done this at 36 and I understand what you mean.
Renee McGregor: Yeah, and I was a bit like, oh my goodness, okay. Watching my body change, knowing that I was nourishing another human being, and then after the birth, being able to feed this baby and keep her alive, and just watching again how my body automatically went back to where it wanted to, without me putting any pressure on it, without me having to starve it – within a few weeks, I wouldn’t say I was back to normal, but I was back into my clothes. I suppose that was the real turning point for me, was actually, my body knows what it wants to do, and I’m just going to start listening to it.
Through that period of time, I’ve just become more and more in tune with it. I’m very much an internal cues type of person. I will listen to my body. I always say that to people when they come in and say, “I want to learn how to eat intuitively. I need to learn” – it’s like, we are all built to do that, but it doesn’t happen until you’re hormonally and biochemically regulated. Once you are at that place where the body knows what’s going on, then you can tune in to those feedback loops. It will tell you.
But it’s also getting to a point where you appreciate – as I said right at the beginning, a lot of mine was about not accepting myself and not being comfortable with the body I had and wanting to be something different. People do struggle with the fact that maybe the place their body wants to be is not mentally, in their head, where they want it to be.
I had my first daughter at 27, and I had my second daughter when I was 28, and it was a busy time. [laughs] It was busy and I had small children to look after, and it sort of doesn’t matter anymore. It wasn’t a priority. My physique wasn’t a priority. I suppose you learn to realize that you are more than just a physical form. So for me, my relationship with myself is the best it’s ever been, and a lot of that is about the fact that I’m very aware that I’m loved for being who I am.
As I said to you, in 2016 I went through a very tough time and my marriage broke down, and I’ve been a single mum now for 3 years and it’s incredibly tough. But my relationship with myself is the best it’s ever been because I’m very conscious of the people that I have in my life and the work I do, and even the respect from my peers is not about what I look like; it’s about who I am and what I offer and how I am as a person. That is enough. That constant narrative that tells me I’m not enough – actually, I am enough. That’s where I’m at now. But this has spanned, like I said, 30 years. So it is a long journey.
00:44:10
Chris Sandel: Yeah, definitely. In terms of – you mentioned about seeing someone when you were at university – have you had false starts with seeing people where you saw someone and it didn’t really work, and then you saw someone else?
Renee McGregor: The only formal treatment I have had was the Maudsley for a year, which was the weight restoration, and then I went to work with this counselor at uni, at Nottingham. Then after that, the only other input I’ve ever had has actually been post-divorce, and that was not really related to food; it was other things.
So no, I’ve been fairly fortunate that a lot of the work – maybe because it’s my interest area as well, I’ve done a lot of reading for myself. I’ve worked stuff out for myself and I’ve challenged myself. A lot of the work I’ve done has been just me, but obviously with that real starting point at university that helped me to understand more about behaviors and relationships and connections and why these things happen.
Chris Sandel: Thank you so much for being so open and honest about your story. It’s great to be able to hear this side about you and know that this has helped to inform the work that you do today. I think it’ll come back up as we go through some of the things that I mentioned at the top.
00:45:30
Do you want to spend a bit of time talking about RED-S?
Renee McGregor: Sure, let’s talk about something a bit more comfortable for me. [laughs]
Chris Sandel: I recently did a podcast all on RED-S, so I’m going to put a link to that in the show notes – and we did go through it in quite a bit of detail, but people aren’t going to have listened to every one of my podcasts. So what is relative energy deficiency in sport, or RED-S?
Renee McGregor: Basically it’s a mismatch. It’s the mismatch of energy taken in for the work you do. It’s an interesting one because I think people automatically assume that you need to lose weight, or you need to be very thin, and you don’t with RED-S. A lot of the times, it is simply that the body is prioritizing movement, so it starts to shut down those other demands by the body because there’s just not enough energy in the system.
When we do exercise, it’s a very energy-demanding process. We also have bodies that need an awful lot of energy, so sometimes what can happen is you can increase your training load and you don’t increase your intake alongside, or you consciously make a decision to not eat as much, but you keep your training load high.
RED-S can develop in anyone. A lot of people think it’s specific to elite athletes. It can be anybody, and actually I’m seeing it more and more and more recreationally, because to a certain degree, we have this constant message in the media about moving more, eating less, moving more, eating less. Everybody’s picking up on it, and yet it’s not actually relevant to every single person. A lot of us are already very physically active. For me, I’ve always been sporty. I’m a very sporty, active person, and I can’t do any more. If I move more, then I’m probably going to do myself more harm than good. Again, it’s about that awareness and understanding of what’s relevant to you.
The interesting thing about RED-S is that there are two types. There’s the conscious and the unconscious, or what we call voluntary and involuntary. Involuntary RED-S is simply a mismatch. People just don’t appreciate how much energy they need for the exercise they are doing. This is often people I see who maybe are juggling their work and their family life, but they’re also trying to fit a triathlon in, so they’re doing lots of different disciplines. Or it can be athletes where they commute to their training sessions and they don’t really think about the commute as part of it. It’s more just the training session they focus on.
These people are really easy to work with because they usually present in clinic, perhaps because their performance has fallen a little bit or perhaps because they’ve got an injury or they’re getting sick or they’re not seeing the results they would expect to based on the training they’re doing. So you can have a look at their nutritional intake, you can look at their training, and you can go, “You’re just not quite having enough.” Particularly things like carbohydrate availability is really important.
With these individuals, it’s easy enough. You can provide them with the advice and guidance they need, they go off, they put it into practice, and lo and behold, within a few months they’re great and it’s all good.
Chris Sandel: Sorry, just to stop – how often do you see that? As a percentage of the people you see, what would fall into that more involuntary end of the spectrum?
Renee McGregor: It’s not big, to be fair. It’s probably about 10% of the people I see.
00:49:20
Voluntary RED-S, if I’m honest, is pretty much an eating disorder in sport. It’s a conscious decision to either over-train and under-fuel or both. The reasons behind that can be anything from the mentality of the athlete, the culture within the sport, the coping mechanism of coping with managing expectations and they can’t manage their expectations – it’s a whole mishmash of reasons. This I see probably 90% of the time in my clinic, where people have consciously made a decision.
And it might just be simple, like I had a climber in clinic a couple of weeks ago and she was really interesting. She knew what she was doing. She ate potentially quite well, but it just wasn’t quite enough for the work she did. But what was really interesting from my point of view was on her days off, as she called it, she basically cut carbs out because in her head, “I’m not doing any training, so I don’t need any carbohydrates.” But on her days off, she was still running and doing gym work. It was just that she was having a day off from climbing.
So it’s this disequilibrium of understanding of what’s going on. It’s usually a conscious decision to reduce energy intake and increase energy output.
Chris Sandel: I would say for the clients that I see, often it does start out under the health bracket of “I had this doctor’s appointment and they said that maybe I could potentially be having diabetes, so I need to change this thing” or “I might have PCOS” or “I read this article and they were talking about the dangers of grains” or whatever. Coming from this place where, yes, it’s a lot of misinformation, but it starts out fairly innocuous and then it just goes from there and there and there until someone gets to a point where to walk themselves back from that now becomes this monumental task.
Renee McGregor: Yeah, and I think that is most people. It starts from a place of – whether you want to call it trying to improve themselves or a health scare or something. But often, particularly in the sports world, the people that tend to be very, very physically active anyway, they tend to be of a certain type of personality where they’re very driven and focused and compulsive-obsessive types. That initial step of “I’ll just do this” doesn’t feel like enough, and then they do more and then they do more, and as you know, it can then become a very difficult place for them to be in.
Chris Sandel: Yeah, because each step of the way then becomes the new normal. Having this amount of calories is now the new normal, or doing this amount of exercise is the new normal. It’s very easy for that to ratchet up in terms of exercise or down in terms of food, but to go in the opposite direction feels very challenging.
Renee McGregor: Yeah.
00:52:50
Chris Sandel: RED-S has come in as a model to replace the female athlete triad, which was limited in terms of A) just focusing on bone health and reproduction, and B) then completely excluding men. How much of the population that you’re working with are men that you’re seeing in practice?
Renee McGregor: I think we probably see about 40/60 split, male to female. I’ve got quite a lot of male athletes at the moment that I’m working with. It changes continually, but yeah, at the moment I’m working with a number of male athletes. I think it’s becoming something that male athletes are now realizing that is an issue.
Like you said, with females we had a complete, immediate sign. Menstruation became erratic or it stopped, and that’s a sign that there’s not enough energy in the system. With males, it’s a bit more difficult to pick up, but we do know that the same process occurs. The metabolic rate slows down, it affects your pituitary gland, it blocks your production of testosterone, which then also affects all the other systems within the body. So we’re very aware that it’s the same.
When Dr. Keay and I do our endocrine-specific clinic, we do blood tests and we look at specific biomarkers of what’s going on, and we can identify RED-S as a means of – it’s diagnosis by exclusion, as we say. There are key things that we have been seeing, key trends that we know this is definitely the body under stress. It’s in energy deficiency.
Chris Sandel: I think it’s good A) that you’re including men and B) to get out of just the bones and reproduction, because while you say it’s a good immediate feedback, I don’t think that’s the case all the time. There’s been lots of women that I’ve worked with who’ve been training and undereating but are still able to maintain their periods, or they go for a DEXA scan and it looks fine, but they’ve got all of these other things that are now going wrong.
I can’t remember if it was the website or a BMJ article where they have RED-S as the center circle and then all of the other systems that are involved. I think having that much broader way of looking at it means that more people aren’t missed over because, for whatever reason, they have this inherently strong reproductive system that doesn’t shut down even when they’re really training themselves too much.
Renee McGregor: Yeah, exactly. That’s why I always think it’s so important to get a holistic view of what’s going on. I get a lot of clients that come in with digestive problems, and we know that that’s a big indicator of delayed gastric emptying because, again, the energy system, there’s not enough energy for the food to transfer and be transferred efficiently through the gut. We also see a depressed immune system.
So you’re right; I don’t immediately assume that because someone has periods, that they’re fine. I would look at the bigger picture and definitely look at what they’re eating and what they’re training.
The composition of the diet is also very critical. Again, one of the key findings is it’s not just about energy availability and that energy through the day. We’ve had a lot of athletes who actually, energy intake, if you look at, it matches what they’re doing. But it’s the carbohydrate availability specifically around their training and the intensity of training that seems to be the limiting factor. It’s more complex than just calories in, calories out, which is what a lot of people assume.
Chris Sandel: Yeah, I think the amount of macronutrients are important, and even the timings. You can get the amount of calories that you need, but you have long periods of the day where there’s not enough coming in. I made reference to this last time on the podcast where there’s research from Sweden looking at that, and how that can be a problem as well.
Renee McGregor: Exactly, and that’s what we’re constantly looking at. We’ve had some very high profile athletes come to our clinic recently, and when you look at their intake, they know what they’re doing, but it’s the specific timing and the specific choice of what they make at key prior-to- and post-training sessions that’s the critical factor.
00:57:20
Chris Sandel: Is this getting more attention? Maybe it’s just because I’m part of certain groups, but I’m seeing, especially in the sports world – and especially also around men, it being talked about in terms of – I saw an article about cycling and someone talking about how common this is in the peloton. Another one around ice hockey and rowing and swimming. Sometimes it was RED-S focused, and sometimes it was drifting much more into this person ended up with an eating disorder and they had to take themselves out of that sport or be taken out of that sport. So I just wanted to get a sense from you; is this becoming much more widely talked about?
Renee McGregor: I think so. Like you, this is very much my niche, it’s very much my field, and I’m being asked to talk on this a lot. I’m off to a conference next week in Ireland and speaking there about RED-S and the implications, and then I’m also talking at the British Association of Sports Medicine and Sport Science on the same topic. Later this year I’m talking at the Royal College of Psychiatry as well.
So it’s definitely something that is my area of specialty and people are associating me with it, and it’s definitely something that I’m hoping I have increased awareness through my Instagram and also by co-founding #TRAINBRAVE, the campaign that’s raising awareness about RED-S and eating disorders in sport specifically.
It’s definitely becoming more apparent that it’s an issue, and I think more and more athletes are starting to understand that their requirements are much higher than what they initially thought. I think perhaps because of having worked in the industry, the whole focus on performance, I think, can be very dysfunctional and destructive. Again, if you are specifically fixating on sports performance and the nutritional implications of that, it’s very easy as a practitioner to get caught up in manipulating the diet to the point where it is detrimental to this athlete’s health.
That’s where I am now trying to make more impact, and hence doing quite a lot of these conferences to try and educate practitioners that actually, if you want performance gains, if you want the lean muscle mass compositions that you’re looking for, you actually need regulating hormones. Without estrogen, without testosterone, you can’t produce growth hormone. If you don’t get growth hormone, you’re not going to get lean muscle mass and training adaptations. It’s completely futile getting athletes to do things like intermittent fasting or low carb, high fat, or even to a certain degree periodizing carbohydrates, because you will not get the goals you’re looking for.
That’s what’s been really interesting for me, because when I studied sports nutrition, it was very balanced. It was very much about you need a high number of carbohydrates per kilogram body weight. It was very scientific and made sense. Then you start working in it, and you get pulled in all these different directions. There’s been lots of novel ideas that come through by some sports nutritionist, and some of it’s their own ideas, some of it’s things they’ve created or they’ve read about.
But in my view – and that’s one of the reasons, like I said, I left in the first place. The athlete’s health to me is so much more important. When I work with athletes now, I always say to them, “I only work with athletes that want to be sustainable athletes.” I’m not in it for just the next competition or even the next year. We’re looking at the next 5-10 years. For me, you’re not going to get the instant gratification, the instant results you’re looking for, but you will get results. But it’s a long-term game.
Chris Sandel: Definitely. You mentioned about performance there, and it can be impacted when people do the wrong things. I would say that also takes a while to catch up with people. Sometimes when actually what someone is doing is incredibly detrimental to their health and is going to catch up with them in the long term, in the short term kind of works for them.
This can be just so maddening, because they think “I’ve found the perfect solution, I’m really onto something here,” when really they’re pushing their body in the wrong place. The person who’s coming to mind more than any other is Amelia Boone, who won so many things in obstacle racing until she got injury, injury, and now has gone into eating disorder treatment.
Renee McGregor: Sorry to interrupt, but that’s exactly it. The problem is it is a slow process, because the body is so resilient. It’s not something that is instantly picked up. We had, again, a very high profile athlete in our clinic a few weeks ago and she said to me, “But none of the girls have periods. It’s normal.” And yet it’s not. It shouldn’t be normal. But again, there’s this mentality that it’s okay to – it’s almost like if you do have a period, you’re not really training hard enough, which I think is so old school and backwards. But there is this culture that we’re trying to change, definitely.
01:03:15
Chris Sandel: With that, are you doing things differently if you’re working with an athlete where being an athlete is their full-time job versus someone who is just a regular person who does exercise on the side, but it’s not their whole life?
Renee McGregor: No, I think I still would work with very much the same principles, because fundamentally, even if it’s not their whole life, it probably still means quite a lot to them. Hence they’re in that mess, they’re in that position where they’re pushing – the thing I’m always trying to teach is that often the people that end up in the difficult situations are, like I said – and I put my hand up to this as well – those very perfectionistic and driven individuals that are constantly cracking the whip and don’t always know how to manage that inner critic of theirs. They’re very self-critical.
It’s helping them to understand that you have to learn to manage your personality type rather than having to manage your workload, if that makes sense. It’s your personality type that’s making you feel like you’re not doing enough. It’s not that you’re not doing enough; it’s who you are as a person. Often they feel the weight of this world. They have this huge expectation that they’ve got to do everything right, and they want to control things that are out of their control. It’s about helping them to navigate life a little bit better, whether they’re an elite athlete or whether they’re a recreational athlete.
01:04:40
Chris Sandel: Definitely. I want to go through some of the more practical side of things in terms of how you would think about the eating or how you think about exercise or ceasing exercise, but I want to just touch on HA first. I think RED-S and HA are going to really come under the same bracket in terms of how you deal with clients, although you can correct me if I’m wrong there. Do you want to define what hypothalamic amenorrhea is, just so if anyone hasn’t heard that term before, they know what it is?
Renee McGregor: Sure. Hypothalamic amenorrhea is a diagnosis by exclusion. It’s the result of basically the body being under stress and affecting the hypothalamus. The hypothalamus is like the boss, as Nicky would describe it. It’s the main control organ of all the hormones within the body. And that means all the hormones – not just the ones we’re talking about today for reproductive, but every single hormone.
When the hypothalamus is under stress and can’t work efficiently because there’s not enough energy in the system, it will affect everything, including the thyroid, your digestive system, your cardiovascular system, and your reproductive system.
In a female, if the body is under stress – this can be also mental stress, but obviously we’re talking mainly about physical and mental stress – but as in there’s not enough energy going into the body, then the body will pick up that there’s not enough energy in the body and it will basically prevent the hypothalamus from producing the hormones that you need in order to have a period. You basically become amenorrheic.
The definition of amenorrhea in this country is actually 6 months of no period, but in the States, it’s 3 months. Nicky and I generally get very twitchy if someone hasn’t had a period for 3 months.
That’s what it is. In terms of how we diagnose it, we always get bloods, so we’re looking at the controlled hormones, we’re looking at follicle-stimulating hormone, luteinizing hormone. We always look at prolactin, because that can be affected by various things as well, so we need to check that that’s okay. Then we’ll obviously look at estrogen and testosterone.
This is really important. This and the full clinical picture, the full history, is the really important thing. The reason I’m saying that is we’ve had a number of clients recently who have come to us who have been misdiagnosed with polycystic ovary syndrome or early menopause. That’s because the individual practitioner, whoever, the doctor involved, has just looked at the bloods and not looked at the bigger picture, hasn’t looked at everything else that’s been said to them – and also often looked at the bloods wrong as well, but then given the individual an ultrasound and seen these little follicles. Well, those would always be there, because if the woman has previously had periods and is waiting to have periods but the switch has been switched off – which is what’s happening – that’s going to be there.
So it’s really important to look at the whole picture. This is why it’s so great working with Dr. Keay, because she’s an endocrinologist, so she very much looks at the hormones and what’s going on, and I very much look at the energy balance, like what is this person doing? How much exercise is she doing? What’s the intensity going on? And then what’s the food going in? How much carbs, protein, recovery? Is there a rest state? We’ll look at the whole big thing. Then we’ll also obviously look at their relationship with food and training, the anxiety levels and what that is. So it’s usually a full-on assessment.
01:08:50
When it comes to the treatment of hypothalamic amenorrhea, it sort of depends on what’s going on, but we very much try not to stop people from doing exercise because we know that it’s something that is important to them. But we would guide them with regards to volume, intensity, and we maybe even would potentially suggest something different.
For example, we had a young lady in clinic a few months ago; she was a very keen runner, but when we looked at her whole history, her bone density was hugely affected. It was one of the worst Z-scores I’ve ever seen. Your Z-score is your age-matched score for your bone density. It was the worst I think Nicky and I had ever seen. She’d already had two stress fractures. So her clinical presentation was very much this is somebody whose body is not doing particularly well. She was also underweight. They’re not always underweight, but she was underweight.
In this case, we did have to tell her she had to stop running because she was at a huge risk of more stress fractures and more damage to her body, basically. But what we did encourage her to do – we’re very fortunate that in our clinic we have this setup – we have a strength trainer who we work with. He’s a strength and conditioning coach, and he’s been learning from us about RED-S and he’s been doing his own background reading. So what we do is refer in to him, and he starts off with body weight, functional movement type exercises so they feel like they’re doing something. Then as they restore and as their bloods go back to normal and as things get better, he starts adding more weight and more challenging movements.
But there’s two reasons for this. One is because it obviously means that they’re still doing something and they feel like they’re doing something, but also, it is so, so important for bone health and also just so important in terms of generally your strength and your stability, to do any sort of sport. So we really actively encourage it.
It’s unusual for me to stop someone from training unless I’m really, really quite concerned. I had a runner present to me last week and he is incredibly unwell. Initially I was like, “I haven’t got your bloods yet, so let’s just wait.” Then when his bloods came through, it was very aware that his body is shutting down big time. So in his case, again, I had to say no training.
So it’s very individual. But what we do know from studies is that it does tend to be related very much to the intensity of exercise. A lot of people who do very high-intensity training, and particularly if they do it fasted, that is a no-no. That is definitely not going to help hypothalamic amenorrhea. Also, like I said earlier, the carbohydrate availability around training. Again, depending on the situation, we might say “you can carry on doing the volume, but we want you to bring your intensity right down to an exertion of 6 out of 10 and you need to make sure you eat before you train and recover after training.”
We did say it’s all very individual, but you get the general idea. It’s very specific to the person and their clinical presentation.
01:12:25
Chris Sandel: Sure. I’m going to say that I do things differently. When someone comes to see me, it’s their decision what they want to do, but I’m typically one that will push for someone to have time off exercise.
The reason that I do that A) it just means there is more energy coming in for that person to be able to heal and repair, and B) – and I think this is a big part of it as well – I want people to discover other coping skills outside of exercise. For a lot of people, that is their only way of being able to cope with life, or one of their big ways of being able to cope with life. That’s not necessarily a bad thing, but I think by them having some time off of that, it means that they have to branch out and find some other skills and other ways of dealing with it.
In terms of your comment around the importance of exercise for bone health, I get that, but my thoughts are also that it’s not going to be forever, and from a bone health perspective, I would much prefer the person be getting their period back quicker so that they’ve got the estrogen and they’ve got the progesterone, they’ve got those hormones that are going to be supportive as part of that.
So my leaning typically is to get people to not be exercising because I find that that’s better from a bigger picture of where I want to get that person.
Renee McGregor: I can see your point. A lot of the people we work with are professional athletes, so it’s very difficult for them to have complete rest and time off from their sport, so we have to come up with strategies that work for them. But we definitely do talk about using different coping mechanisms. That’s pretty much my role in the partnership, is helping them to understand what’s going on for them and that this is a coping mechanism – you might think it’s about training, but it’s not – and then providing them with new strategies to help them deal with that.
So we definitely set lots of challenges, but like I said, from my point of view, unless somebody is specifically very, very clinically, medically unwell, I don’t stop training. We’ll change it, but we don’t stop it.
01:15:00
Chris Sandel: What about on the food front? How do you think about that side of things?
Renee McGregor: Again, it really is very different and it will depend on where the person is. Some people come in and they’re really willing to change and they’ll do anything because they’ve really struggled, they’ve had a bad time, and they just want to feel better. Again, depending on what it is, what their presentation is, it may be that we have to do some mechanical eating, so we provide them with a mechanical eating pattern that helps them to regulate their body –
Chris Sandel: Sorry, can you just explain what mechanical eating is, if people haven’t heard that term before?
Renee McGregor: Mechanical eating is very much trying to basically provide them with regular food. I usually work on a three meal, three snack process. It’s providing them with snacks and foods that are complete and nutrient-dense.
But it’s more about getting them into good patterns so their body starts to appreciate the threat of starvation has disappeared. This is one of the key reasons why you get hypothalamic amenorrhea as well, because if the body has big periods of time where it’s not receiving food, it does go into shutdown mode, and again, this affects the appetite and weight hormones, ghrelin and leptin. We want those to regulate and we want those to go back to normal.
One of the ways in which you do that is to ensure that somebody is being provided with nutrition regularly throughout the day. How long that takes – how long is a piece of string? Some people it’s 12 weeks, some people it’s 6 months, some people it’s a year. It very much depends on how long they’ve been struggling for.
For other people, if their relationship with food is incredibly poor, then obviously you can’t just go in guns blazing and go, “Here’s a plan, off you go,” because that’s not going to work. I then will work very much along the lines of working out where they are with food and then providing them with maybe one or two goals to achieve that week, and then building on that every week so that then becomes more and more normalized and accepted.
I don’t have a prescriptive process of what I do because it really does depend on who’s in front of me and what the issues are. But one of the things I will say is it’s not – when I say it’s not always based on healthy eating guidelines, what I mean by that is I definitely include all the food groups that they might not want to accept. So I will be encouraging them to have sugar and I will be encouraging them to have dairy and I will be encouraging them to have carbs. It’s not like suddenly they’re going to eat platefuls of salads and fruits and things like that all the time. It’s about helping them challenge that.
I guess that’s where I’m much more challenging in that I want them to be able to get to a point where if they want to go out for a pizza and stuff, it’s not a problem. It’s not something they have to think about, and it’s not something that they have any negativity around or anxiety around.
Chris Sandel: That’s definitely the way that I approach it. I think there is often a real overlap with, if not orthorexia, at least a real fear around certain foods and that they have to eat “healthy.” So it is getting people to eat foods that they would potentially think of as unhealthy.
When you were about to say that, it almost felt like there was a bit of reluctance or maybe a tension of “oh, should I be saying this if I’m a dietitian?” Is there any of that kind of worry for you?
Renee McGregor: No. Like I said, my own personal relationship with food is very relaxed. I openly admit I drink beer and I eat chocolate and I have dessert, and I don’t have an issue with it. I know that I’m balanced because I know what a balanced approach to eating is.
I guess the reluctance came probably from the fact that I do know of a number of nutritionists working in this field who do prescribe very – what I would call “wholesome” nutrition plans, and that’s where I get worried. Again, what I come back to is that cohesion of being coerced into keeping it neat and tidy. The thing is, anorexia and eating disorder recovery is not neat and tidy. It’s chaotic and messy, just like life is.
I think that’s why what I always try to explain to them is that you’re trying to have a tick box, you’re trying to keep everything neat and tidy because that’s what feels safe. That’s how you’re trying to live your life. You don’t want uncertainty. You’re too scared of taking risks and opportunities, and yet life is full of risks and opportunities, and life is uncertain, and until you can learn to navigate that and accept that sometimes it doesn’t work out and sometimes you do fall flat on your face, but that doesn’t mean that you’re perceived in a negative manner, you’re not going to be able to move forwards.
I try and emulate that with food. I want them to feel messy and uncomfortable because I need them to know that they can and that they survive, and nothing awful happens, and actually that can then become normalized. I think there are too many nutritionists that don’t do that.
Chris Sandel: Totally. I completely agree. I also think it’s hard to get in the amount of calories that these people often need, not just like “what do I need for today?” but “what do I need because I’ve been doing this for the last 10 years and there’s this huge debt I’m dealing with?” If you’re trying to do that with just “whole foods,” it’s really difficult. From an energy availability standpoint, having more processed foods – I know as much as they’re demonized – are a really good thing for people.
Renee McGregor: A hundred percent. It’s getting away from the good and the bad and the healthy. It’s understanding that healthy is an attitude, which means that on our birthdays and Christmases and over holidays, we may eat differently to what we would eat normally, but that doesn’t mean that we suddenly become unhealthy or we suddenly become bad people. It’s about understanding that food is just one part of who we all are. Yes, we can make good decisions based on our health, but actually, for these individuals, good decisions based on their health means meeting their energy requirements. And if that means they have to eat puddings and desserts and drink juices, then so be it, because that’s how we get the calories in.
That’s the thing – you mentioned it – their requirements are high. These individuals that have been very low weight for a very long time and been restricting for a very long time, they have this massive fear where their anxious mind is telling them that if they eat even slightly out of place, suddenly they’re going to become obese overnight. That doesn’t even make sense when you say it out loud. But their requirements are huge, and I often have to have people on 3,000-4,000 calories a day in order to get them to restore back to a normal weight.
When the body has been really, really restricted, the metabolism has been really slowed down. When the metabolism kicks back in, it’s almost like the metabolism of a 12-year-old boy. It’s really high. So you need a lot of energy to maintain that, but then also to start doing all the repair and restoration work that needs to occur within the body.
01:23:10
Chris Sandel: Let’s switch then to orthorexia. You mentioned that there. What is the definition of orthorexia, or how would you define orthorexia?
Renee McGregor: Orthorexia is defined very much as the obsession with eating purely or eating correctly. A lot of the issues come from the #cleaneating that was about several years ago, about eating clean and eating unprocessed and all these kinds of things. As wellness trends have developed, it’s become easier and easier and easier to escape, use these wellness trends as a disguise. But the reality is they’re still overly restricting their food. They have food rules that they live by, and if they deviate from these food rules, it creates a huge amount of anxiety.
Chris Sandel: With orthorexia, when I read through your book, a lot of the focus on orthorexia and how it differs from anorexia is that it’s not focused on or afraid of weight gain; it’s much more about cleanliness and purity and that sort of thing.
Have you ever come across someone who has orthorexia who wasn’t afraid of gaining weight? Because I know from my own experience with clients, I’ve yet to see that happen. Even when they initially say it’s about health, it doesn’t take that much digging before actually it is really about aesthetics and appearance and that being a big part. And even when they can admit “having these foods come in would be healthier for me” or “me putting on weight would be healthier for me,” they can then still struggle with doing that from an aesthetic standpoint.
I know why things get separated out in terms of this is what orthorexia is and this is what anorexia is, and there’s obviously a Venn diagram with those things overlapping. But from your experience, have you seen anyone with orthorexia who wasn’t afraid of weight gain?
Renee McGregor: Yes, I have. I think it’s a very fine line. Many anorexics who have been severely underweight and then restore weight will move into more orthorexic tendency, because it’s still a means of control and it’s still a way of maintaining that weight, absolutely, but it’s not about going backwards. It’s not about that rapid decline to almost numb and not being significant. If you think about anorexia, sometimes people want to get to such a small place because they just don’t feel significant enough, and that’s what they’re trying to express. So I think there’s a big difference there.
But equally, I have seen people who started off with orthorexic tendencies, and the restrictive behaviors have become so extreme that their weight has dropped, and once their weight has dropped 10-15%, it affects how their brain functions, so then that becomes something that becomes more compulsive and obsessive, and then they continue to lose weight.
So you’re right, there’s a very fine line, but one of the things that we have definitely agreed on within the taskforce is that orthorexia has a much, much higher crossover with compulsive-obsessive disorder than it does with eating with anorexic traits. I think it is a very obsessive way of thinking and an obsessive behavior around food that tends to be how we would more likely diagnose orthorexia, if that makes sense.
01:27:00
Chris Sandel: Have there been some further advancements in diagnostic criteria? Is it the ORTO-15? Is that what was going on before, and is that where we’re still at with orthorexia?
Renee McGregor: I think some practitioners use ORTO-15. We’ve established that it’s not reliable enough, so I don’t personally use it from that point of view. But yes, we are getting much closer.
One of the things that’s difficult about the taskforce is that we are all practitioners who work full-time in clinical practice around the globe, so trying to get together – and it usually happens once a year – is actually quite difficult because we don’t always – we were in Europe last year, we were in Rome, but then people from the States couldn’t make it over because it was too far for them to come. And this year I think it was in the States, so I didn’t go over. So it’s always quite difficult for us to come together and come up with what we’ve learnt and what we’re learning through our work and through studies that have been done, and then obviously doing those studies on top of our daily work.
So it’s been quite difficult, but yes, we recently had a conference call where we are very much getting very close now to understanding what it is. We had a conference call and we have had some – it’s a fairly new questionnaire that’s gone round for us all to comment on, and that’s where we’re at at the moment. Everybody has commented, and now that’s being looked at, and hopefully very soon – fingers crossed – we will have something a little bit more concrete to offer everybody.
01:28:50
Chris Sandel: You made reference to clean eating being a thing from a couple of years ago. Has that died out, or is dying out? I’m not seeing it talked about like it was a couple of years ago, or if it is, it’s more articles about how it was so problematic as opposed to the positive stuff that used to be coming out. Has everyone just moved on to keto and intermittent fasting? Or is clean eating still a thing?
Renee McGregor: No, I think you’re right. I had a conversation with somebody on Instagram yesterday about that very thing. She said the whole clean eating thing seems to have disappeared because it’s not even a hashtag – I think people do sometimes use it, but yeah, it does feel like we’ve moved on to the next thing, which does seem to be intermittent fasting. We have veganism as well, don’t forget.
I think unfortunately, there’s always going to be something because everybody’s always in search of that golden nugget, that one piece of information or that one behavior that’s going to instantly make their life so much better because that’s what we’re being promised.
That’s where a lot of this comes from. When you don’t feel good about who you are, when you struggle with your sense of self, you are constantly looking for external cues to help you feel better, when the reality is it’s about starting to become comfortable with being you and understanding who you are as an individual and learning to be kinder to yourself, really. And learning different coping mechanisms for anxiety and stress and uncomfortable feelings rather than constantly beating yourself up about it.
So yeah, I think probably you’re right. Clean eating does seem to be a thing of the past. It’s occasionally mentioned in some bodybuilding circles. You do hear people saying, “I’m going to eat clean.” It’s like, what do you mean by that? But yeah, I think the next trends are now well and truly being established as we speak.
Chris Sandel: Definitely. With your book – you wrote it 2 years ago – is there anything that you would want to add to that if you could do a second edition in terms of what’s changed in research and what you now know, what’s changed because of your own time further in clinical practice and seeing more people in that area?
Renee McGregor: Yeah, my practice has definitely moved on because practice does move on. Every year that we practice, we learn and we reflect and we change.
I think generally, Orthorexia the book is still very educational and provides people with the basic understanding of what’s going on. I get messages daily from people saying “your book really helped me to understand what was going on for me,” because it wasn’t anorexia and it wasn’t bulimia, but it was definitely some sort of dysfunctional relationship with food. There wasn’t a name for it, I think. Again, because it’s not a diagnosable condition, I think people get lost when they go into their GPs sometimes.
But would I change anything? I always think I can improve my books, all of them. You go back and you read them and you think, I should’ve said that and I should’ve said that, and we should’ve included this. But fundamentally I’m still really happy with Orthorexia. I still feel like it’s a very well-written and educational book that provides people with a good understanding.
Maybe the only thing I would change is giving a bit more insight into the psychological aspect of it a bit more, just because I have more handle on that myself now. But apart from that, no, I don’t think I would change anything else.
Chris Sandel: Part of the reason I’m asking you that is I’m going through a process of doing second editions for a lot of my podcasts. I’ve been doing this now for 4 years, and I’ve done a handful of them at the moment, and I’ve got others to go through. There’s not huge wholesale changes, but there are definitely things where I’m like, yeah, I’ve changed my mind on that, or I don’t do that anymore, or I was wrong about this thing. So I was just giving you an opportunity in case there was anything glaring.
Renee McGregor: No, I think at the moment, 2 years down the line, I’m still happy with it. So it’s all good.
Chris Sandel: Okay, cool. This has been a wonderful conversation. Is there anything we didn’t go through that you hoped we could chat about?
Renee McGregor: No, not at all. I think you’ve taken me in all sorts of different directions. It’s been quite interesting for me. I think it’s nice because I have done a lot of podcasts, and I think I get asked the same sorts of questions. Hopefully, people who like listening to me will hear a different side of me and will find that really useful as well. So no, it’s been good.
Chris Sandel: Perfect. For people who aren’t familiar with you and they do want to find out more, where should you be pointing them, whether that be website or social media or anything else?
Renee McGregor: My website is https://reneemcgregor.com, which is nice and easy. And my Instagram is @r_mcgregor.
Chris Sandel: Perfect. I will put them in the show notes. Thank you so much for coming on the show. This is great.
Renee McGregor: No worries. Thank you for having me.
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