Psychiatry & Psychotherapy Podcast - Sick Enough: Dr. Jennifer Gaudiani On Eating Disorders

Episode Date: November 3, 2023

In today's episode of the podcast, we talk with Dr. Jennifer Gaudiani (Dr. G), internationally renowned author of the book, Sick Enough: A Guide to the Medical Complications of Eating Disorders, and founder of the Gaudiani Clinic in Denver, Colorado. We deconstruct common myths and misconceptions about eating disorders, exercise, metabolic processes and why the term "sick enough" is such an apt title for a text and discussion on this group of complex and life-threatening mental health conditions. By listening to this episode, you can earn 1.5 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Welcome back to the podcast. I am joined today with a internal medicine eating disorder specialist, Jennifer Gaudiani, and she worked eight years in Colorado at one of the leaders of acute center for eating disorders at Denver Health. That was like an inpatient eating disorder stabilization center. And then she has worked seven years. at her own clinic, Gaudiani Clinic, since 2016. And so she has written a book called Sick Enough, which is a guide to the medical complications of eating disorder. And she was introduced to me by another person on this podcast, Sally Vanderweil.

She is a in-practice therapist in Perth, Australia. And she is, you know, it's always good to know, from someone who treats a lot of people, who the experts are, sometimes in fields that I am not like, you know, I'm not seeing eating disorder patients every day. And so it's really helpful to know from people, okay, this is a true expert. So it's great to have her recommend Jennifer, who wants to go by Dr. G. And Dr. G also has a podcast and has been on other podcasts. And so if this is something that speaks to you that you want to learn more about, I'm sure this can be just an intro. So, okay, I want to just jump into it.

Dr. G., what topics in eating disorders do you think are the most poorly understood by other physicians and therapists? It's a really long list, and I, too, continue to learn on a daily basis. You know, I think one of the most important ones is the idea that someone with an eating disorder lives in an emaciated body. That's pretty much the stereotype, that you've got. a young, white, wealthy, underweight woman who is the stereotypical person with an eating disorder, but the reality is that a truly tiny fraction of the total population of individuals with eating disorders are actually visibly emaciated. The vast majority of individuals with eating disorders, you would walk by in the street without looking twice. They either have

body weights that would be considered so-called normal or be in larger bodies. So when medical providers are engaging with a patient, they might have a bias to think this person is fine or healthy or lamentably needs to be advised to lose weight, which is never something I recommend. And in fact, that does quite a lot of harm. So I would say that's one of the most important stereotypes to debunk from the get-go. Okay. And how did you come upon this realization? Well, I've been in the field for 15 years now, so I've done a lot of work in it.

And it's not only my direct clinical observation, but the studies all fully back this up. The incidence of anorexia nervosa is 0.1% of the population of so-called atypical anorexia nervosa, a term I dislike because the individuals have all of the same psychological manifestations and suffering as those with anorexia and all of the same dieting, restricting, eating disorder behaviors, they just don't happen to be emaciated. Those probably represent more like 3% of the population, and those of binge eating disorder are equal across genders where there's a slight skew to female patients in the first two. And that's going to be four-ish percent, where bulimia nervosa comes in maybe around two-ish percent. So just by the numbers, anorexia nervosa represents a very

small number. And I think actually the relative incidences still over-represent emaciated anorexia nervosa, because historically, even though there's still not nearly enough funding and research money in this, it has historically gone more towards anorexia nervosa. So I still think that that population, while absolutely deserving and wonderful and vital, is overrepresented in our numbers. Okay, so when you were working at the acute center

for eating disorders, I understand this is kind of like a specialty inpatient setting for people with eating disorders. Did you have criteria for how you would admit people? or was it insurance-based? Like, this is what insurance will pay for? That's a great question. Yeah.

So when I was medical director at Acute, which is the nation's top medical stabilization hospital for critically ill adults with anorexia nervosa, we would typically accept patients who couldn't be cared for at any other level of United States eating disorder care. There are super programs around the U.S. that have very high acuity inpatient,

and residential settings, but the patients we took at acute were too medically compromised, both by weight and by organ system, to be able to receive care there safely. So when we were at acute, they needed to have round the clock cardiac monitoring, a multidisciplinary approach, a one-on-one approach, et cetera. Okay, Scott, because I'm seeing like there's a contrast between that sort of, like, you have to be sick enough to get in here, right? And your book, which is sick enough, like you don't have to, to necessarily look too sick to receive the needed treatment. So can you talk about that

sort of dichotomy there? I love that question. Yeah, it's actually one of the reasons that I left acute. You know, I love those patients. I love that team. That work is what brought me into this field and I am eternally grateful. But the reality is that even the patients who would admit to acute almost to a person within 24 hours of admission would tell me, Dr. G, I'm so embarrassed. is to be here. I know I'm not sick enough to receive this care. And that was the first time I ever heard that construct, which seemed mind-blowing to me, because of course these individuals, and I'm never going to use BMI numbers or weight numbers because I don't want to trigger anybody, these individuals were catastrophically medically complicated and couldn't actually get care

even in a standard hospital in the United States, much less in a specialized eating disorder program. And so I learned that that was really part of the distortion of the mental illness. This isn't just about not eating enough. This is about something far more complex. And almost to a person, the mental illness brings this sense of shame. I haven't gone far enough. I haven't suffered enough. It's embarrassing for me to ask for help because someone's going to tell me, why are you here? You look fine. And so it turned out that because acute only did take care of a very, very specific population and did a beautiful job with them, when I went outpatient, I wanted to see everyone. I wanted to be the outpatient internist with eating disorder specialty, who basically was

the primary care doctor for people with eating disorders. So our clinic, our four doctors, see patients from all over the United States, all ages, genders, body shapes, and sizes, all acuities and crinicities. And when I say all acuities, I always want to acknowledge that we want patients to be in the proper level of care for their degree of illness. But we do manage people at all levels of medical compromise. And so as I started my inpatient work, and I kept hearing this statement, and I'm not sick enough. I realized this has to be acknowledged. And ultimately, I wanted to write a book so that I could influence and support more people than I'll ever get to see one to one.

Or that I'll ever get to connect through podcasts. And so I wrote a book that shared as much of my medical knowledge and just my passion for these patients, the heart that goes into caring for them, as broadly as I possibly could. And the title, as you so rightly said, tries to show, and I think anyone with an eating disorder or anyone who's had a loved one with one is like, oh, yeah, sick enough. I know what she's talking about. Tries to show that anyone with any eating disorder is sick enough to seek help and get better. There's not a lab test. There's not a body weight.

There's not a degree of restriction. There's not a frequency of behaviors or something that's. shows up on an x-ray that means now you're allowed to get help. Just having an eating disorder is enough. But it is helpful as an internist to use objective measures of body suffering, both measurable and unmeasurable, to help reinforce with patients why it's right to challenge that edict in their head that says you have to do things like this or else. And I sometimes liken this, too, if somebody He says to a person, hey, you've got a mole on your back that I'm a little concerned about. That person never says, what mole?

I don't have a mole. You have a mole. Your mole's bigger than my mole. I'm fine. Why are you even bothering me about this? You know, that is evidently not clear thinking. But that is precisely what happens with our beloved patients. Somebody says, I'm concerned about you.

You know, I'm worried it. It looks like your relationship with food isn't so great right now. And I wonder if you might get help. I don't need help. I'm fine. What are you talking about? I'm good. Why are you even getting in my face about this? I bet you have problems too. And, and, you know, look, our patients are absolutely wonderful and lovely. That sounds a bit combative. But the reality is that's the voice playing out in their head all day long. Yeah. I just had a patient yesterday that said, I like being very, very slender. And it is not my goal for that to change. this person with a history of eating disorder. And I wonder sometimes how much it plays a part, you know. And so how do I, what questions would you say I should ask to see if the eating disorder is

playing a part of the bigger picture of what I'm dealing with or if it's like they have a healthier relationship with food post treatment? Yeah, yeah, absolutely. So there are a couple thoughts that I have. one is that we have to acknowledge that denial of disease severity is a hallmark of eating disorders and that shame and what we call egosentonicity is a part of it as well somebody with cancer isn't connected with the idea of maintaining their cancer because it's part of their identity and it's helped them in some way deal with the chaos of the world

perhaps their own background, the cancer is something they want to get rid of. That's not true with most people with eating disorders. And it's easy to frame the eating disorder as an abuser or as a bad guy. It's certain we can acknowledge where the eating disorder doesn't serve our patients. But the reality is, is that a lot of the time, the eating disorder started out for reasons that were protective. protective in our fat-phobic, thin, worshipping society, protective for an emotional state that wasn't prepared to deal with conflict at home, interpersonally, at school, in sport, at work. It was protective because eating less or binging or binging and purging are all numbing behaviors that help somebody cool off their brain and protect.

their sweet soul. So eating disorders start out trying to be protective and the reason that eating disorders are so compelling is because of the strength of thin privilege. So with that at the baseline, we have to acknowledge that there may be a lot of instinct to defend an eating disorder when someone's going to their therapist and may not have admitted to themselves, much less to a treatment professional, hey, I have a problem. You know, I in many ways have the benefit of when people come to me, there is an eating disorder. They know it. And they're seeking help for the medical stuff that's gotten in the way. When somebody is sitting across from you, and again, you can't look at someone and know if they have an eating disorder, perhaps except for the very, very extremes of weight,

perhaps, it can be tricky. And so you ask them open-ended questions to try to get a sense. And I'll often try to just disarm patience by saying, I don't need to put a label on you here. I'm interested in the way that your relationship with nourishing yourself has led to changes in how your body works and maybe has led to an impediment in you doing the things in life that matter to you. You're being able to live your goals and values. So tell me about your relationship with food. Tell me what you ate in the last 24 hours. How does it feel when you eat differently from normal or when there's a spontaneous eating opportunity that crops up?

What do you think about after you eat? How do you feel in your body? How do you feel in your heart after you nourish? What happens if you change your exercise plan suddenly? What happens if somebody asks to eat with you that you didn't expect or you're suddenly in a family setting where you've been typically eating alone? do you exercise for the purpose of changing your body or so-called burning calories or do you exercise to stay vital and well in the world? Asking a bunch of open-ended questions like this without judgment, give somebody the opportunity if they can be honest to share what's going on.

And even at the end of some of my initial consultations, I do have patients who are like, I don't have anorexia. I'm just a very controlled athlete and my dad forced me to be here. And so I'll say, look, I'm not, I'm not looking to label you. But what I can tell you by looking at your vital signs and listening to our conversation today is that your hands are chilly and you're wearing more layers than I am in the office right now. and you've told me that you've been quite constipated for the last three months, that you have fatigue and low energy and you're having a hard time sleeping and that your sex hormones aren't working so hot. You know, for women that can mean abnormal periods, for men that can mean abnormal sexual function. And so even though your labs are all normal, what I see here is a malnourished person.

Now, what the motivation behind that is, I'm not trying to doctor explain you that. We can come to that later on if you choose to work with me, but you are a malnourished person, regardless of what your body weight is. People can be malnourished in every possible body size. And so what I'll say is, you have told me that you're asking your body to do things while consistently underfueling its needs and I'm seeing medical stuff. So we don't have to say you're a zebra, but if you happen to be a horse that striped black and white and likes to eat grass on the savannas of Africa, if you get sick, I would like a zebra doctor to take care of you. And so what I'll say is regardless of motivation, if this isn't anorexia, then you're going to have relatively little problem

increasing your intake, resting your body more, and allowing your body weight to do what it needs to do to get you healthy. Because what you told me you want to do is finish grad school, be able to engage in your sport, not have stress fractures, and be less rigid and more social in your engagements with the world. So the reality is that your medical status and your big goals and values are both going to be benefited by nourishing consistently and exercising appropriately but not excessively. So great, if you don't have anorexia, we're going to go on a journey together and this is going to go pretty smoothly. But if it doesn't, if you find yourself bumping up against barriers, I'm going to be here for you because I've done this a few times. and if this turns out to be more complex than even you knew,

your therapist, your dietician, and I will all support you on what happens next. Beautiful, beautiful. Okay, I really appreciate that. So you're looking at, so, okay, so I'm trying to get my mind around, like, how you define someone who's malnourished. And so their hands are chilly, they're wearing layers, they're constipated, maybe, they're low energy, hard time sleeping, poor sex harm. hormones, abnormal periods, or maybe not as sexually, there's some other sexual sort of side effects there for men. And what kind of labs are you looking at and what are the normal abnormal labs

if there are? I know a lot of the time you're saying they're not abnormal. But what do you check and what is abnormal? Yeah. So let's just sort of spin back in time for a second and use a construct that I find super helpful to describe what happens to people when they undernourish. Because it is universal across body shape and size. There's this part of our brain that I'm not going to get neuroanatomical here. I call the cave person brain. And the cave person brain is the part of our human brain that evolved to identify undernourishment and to protect our bodies from harm from it. That's the only reason the three of us sitting here today exist on the planet is because our long, long, long ago ancestors involved a capacity to survive malnutrition. Because we evolved as a species

vastly more in a time of want than plenty. So this part of our brain is just as finely tuned as the part of our brain that asks us to take the next breath or that keeps our heart beating. I mean, this is innate to human biology. And so what the K-person brain does is it scans us each day for how the balance is of what we're asking our bodies to do and how we're putting nutrition into our bodies. So within days, much less the weeks, months, and years that our patients actually experience with an imbalance, the cave person brain goes, honey, I'll take care of you. I will protect you because you are magnificent to me and that is my job. And while each person's manifestation of medical complications will be unique, the general list of things that can happen is pretty well known.

So our cave person brain wants to slow our metabolism, meaning the rate at which we burn energy on a daily basis, stay alive. And the ways that it does this are genius. One of the ways is to make us chillier because it's not how many calories we burn at the gym on one of those silly machines. The vast majority of what we eat goes towards maintaining our body temperature at an appropriate mammalian level. So the first thing we're going to do to try to reduce our calorie burn is to get chilly. And so our core body temperature may not fall, but our instinct towards putting on layers and seeking out warm mugs of tea for our hands increases, which is why many people who are under eating feel cold. And then furthermore, their actual vascular profusion of their extremities

decreases. The actual blood vessels shrink down and don't permit as much nice hot blood to go to our hands and feet because it's so easy to lose heat out of our hands and feet, much like if you have a spare room and it's not being used and you want to save energy in the winter and you shut off the heat vent in that room and close the door so that you're not wasting energy. These are spare rooms as far as our extremities are concerned for our K-person brain. Then it also doesn't want to spend a lot of energy on digestion because working through food and wriggling our intestines uses a lot of energy. So we get gastroporesis or slowed stomach emptying. Our small intestine and our large intestine slow as well. all of these causing symptoms of bloating, nausea, and excessive fullness after we eat, as well as

bloating and constipation in general. Then also we want to decrease the energy of our heart being. So our heart slows down when we're starved. There are exceptions always, but these are generalities because it doesn't want to waste an extra calorie on a normal beat of the heart. And all of the things, that I've described are exactly what happens to bears when they hibernate. They develop a high, vagal tone, and they slow everything down. Their respirations, their temperature, their digestion, their heartbeat, and they pass through the winter without food. That's exactly what's going on in humans when they undernourish. They go into metabolic hibernation. And there's tons of other medical things that can occur, including eventually shutting off sex hormones. One of my friends and

colleagues who is a man who's recovered from an eating disorder describes that as he's talked with other guys, athletes and dancers, he says that when they come out of season, if they've had an eating disorder, they finally become more interested in their girlfriend than in a pizza. There's a really market shift in just how our basic functions work. So essentially, all of the cave person brain is shutting down our body to spare calories. And all the things that I just described don't come with lab abnormalities. You just talk about them. They are symptoms that people experience, much like migraines are real, but you can't take a blood test or get a cat scan to say this person is having a migraine. But they are very, very clearly real and there's medicines to treat them. However,

there can be lab abnormalities. And so, for instance, in somebody who purges, that is, vomits or uses latsitives or uses diuretics to lose weight, very low potassium levels can stop the heart. And intermediate potassium levels can make you feel achy, underperform in your athletics, etc. It's also possible to have fluctuations of your sodium level because of different levels of dehydration or of the way your body manages water related to the amount of food you're eating. You can have phosphorus changes when you begin to re-nourish as your body tries to slurp up that important electrolyte into the cells to build energy. And then, of course, depending on the individual, organ failure can occur, but it's so important to note that you can have an unbelievably severe, even life-threatening eating disorder with normal labs. But you can get liver failure, you can get bone marrow failure.

You can get really seriously abnormal labs from a variety of causes as well, but we're never going to diagnose an eating disorder based on that. And even the ones that doctors use as a nutrition lab, for instance, the serum albumin, which is a protein in our blood that we're taught in medical school goes low in malnutrition. It's almost always preserved, even in those with the most severe versions of malnutrition. because actually in adults without an eating disorder, what makes the serum albumin go down is the cancer, the infectious disease, or the rheumatologic disease that has caused them not to have an appetite and to lose weight.

It's those inflammatory processes that reduce the albumin because it reduces the liver's capacity to create it. So I can't tell you how many times I've had communication or a patient has said they were told in an ER, Well, you can't be that malnourished because your albumin's normal. Nope. Wrong. It's just the medical complications of starvation are just not broadly understood. So when I see a patient in my office of any possible body size, when I assess malnutrition, I'm listening to what they eat.

I'm listening to how they move their body. And I'm looking at their narrative experiences in their lived body to understand how malnourished they are and how it's showing up in them. Really awful. Really awful. Yeah. It's like nothing like a good history, right? Are you seeing things on the physical as well, which are kind of tell-tale signs?

Yeah, definitely. So one of the things that our clinic prides itself on, and again, we continue to get things wrong and we listen to patients and we try to make them more right. But we really pride ourselves on a trauma-informed approach. And I think anytime we're discussing a physical exam, it's worth starting there. Many of our patients have experienced trauma. And I think the world is coming to understand better that it's not just extraordinary exposures to horror that 100 out of 100 people would agree would leave a dreadful scar psychologically.

It's that depending on how people's brains encounter the world, things can end up traumatizing to them in ways that wouldn't to somebody else, depending on their genetic background, for instance, and their life experiences and perhaps even they're rearing. So very, very often, my patients have a history of medical trauma. They have a history of a medical provider devaluing and invalidating their experiences. In fact, the medical provider ends up sounding a lot like the eating disorder. You look fine to me. I don't think you that sick. I think it's okay. Your weight's fine. In fact, you need to lose weight. Your labs are fine.

Your EKG is fine. So so many of these patients just coming into a medical clinic are vibrating with unease. Even when they know that when they're coming into Gaudiani Clinic, they're coming into a place that embraces and loves and has expertise and people just like them. And in addition, people may have a history of trauma in their bodies that lead to a great deal of disheaval. with somebody laying hands on them. So when we examine a patient at the clinic, for the first time we say, here's the stitch.

We are such nerds about consent and body autonomy here that every time I approach your body, I'm going to ask permission to do so. Because you know how it normally goes. A doctor asks you a few questions, and it's like, yeah, I'm going to examine you. They move right in. They stick their stethoscope on you.

They put their hands on you. And I mean, those of us who don't have a trauma history, you're like, yep, that's just a doctorate appointment. But it's so nice for these patients. to know that anything you're going to do, you're going to say it in advance and you're going to ask their permission. May I listen to your lungs? Yes or no? May I listen to your heart? May I shift your gown so that I can palpate your abdomen? I mean, it sounds a little bit repetitive, but for our patients, they really appreciate it. So that said, with that exposition, when I'm doing

an exam for somebody who has an eating disorder, here's what I'm going to sort of look for, head to toe. sometimes malnutrition comes with the reformation of what's called lanugo hair on the face. These are fine, very pale strands of hair that have actually reformed on people's faces. They last had lenugo hair in their mother's womb. This is gone after infancy. But because the cave person brain is trying to spare energy and is trying to keep the person warm without burning energy, It literally reforms a very slight pelt to hold in heat on their head. If somebody has a purging history, their parodotid glands, which are in front of their ears and kind of wrap around their jaw line, can be quite puffy and inflamed.

And so with permission, I'll palpate that and see what I can experience. I'll generally look, I'll examine their thyroid as a matter of normal course. I may look in their mouth to see how dental erosion has gone. Many people who purge have unspeakably costly dental work for years to come afterwards that can be very, very complicated. I will look at their skin because people with eating disorders may, I want to make sure anyone listening to this isn't like, oh, Dr. G said, if I don't have skin problems, I don't have an eating disorder that's serious, may have fragile skin.

that means you know when i when my dog jumps up on me and her claws and she has a velociraptor claws uh scratch my arm you know it might be red for a second but i have healthy 47 year old skin so it's fine but when a patient of mine has that they may end up with deep bruising or gouges in their skin because it's become more fragile because it's not nourished and the skin is the largest organ of our body. So if that makes the skin that traumatized, the gut is no less traumatizable. No wonder they have the symptoms that they've got. I'll also look at the temperature of their arm. I'll say, may I lay my hands on you and try to figure out where it is on your arm that things get cold? And I'll encourage them to do the same. Warm, warm, warm. Oh, look, right about here mid-forearm,

you go from warm to cold. How about that? that. And, you know, some of my patients will be like, Dr. G. I have a long family history of Rino's disease. That's why my hands are cold. I'll be like, okay, cool. I mean, you know you better than I know you. Also, some of it may get better as you get better crushed, because this is one of the things your cave person brain is doing. I will look for evidence of edema or retention of water in any part of their body. We'll do a good lung exam, heart exam, and tummy exam. And I would say that those are the main things that I look for on a regular basis. And of course, there's going to be specifics for each patient.

But I'll be clear, the majority of the data I get from the patient is from their spoken word. It's from what they experience in their body, not what I find on its name. Okay. So what are the things that would make you think this person needs a higher level of care than once a week therapy and your management. Yeah. That is a great and super complicated question, it turns out.

There are a bunch of different ways to answer it. So the most algorithmic way to answer it is that the American Psychiatric Society has a table that lays out who belongs in a different level of care, period. And there's plenty of programs around the country who really go by that table. and they say, look, if your BMI is below this, or if you've lost this much weight, or if X, Y, and Z, you belong in day treatment called PhP. You belong in residential treatment. That's one. That's a guide. Another guide is to go by what the patient says they need. So when a patient says to me, Dr. G, this is the time of year that's my trauma anniversary and my parents are getting a divorce right now. and I'm just losing it, I need more support, I can't do this.

Then I will tell you, I will make sure to document things in a way that make it absolutely evident that this person needs a higher level of care and more support. No questions asked. If that's what they think they need, that's what I think they need to. And I'll make sure that it happens to the extent possible. Insurance can be very challenging. Okay, okay, slow down there. What are you documenting?

Oh, I mean, I'm documenting their symptoms, behavior frequency, their thoughts, their ability to cope, their ability to manage day to day with meeting their nutritional needs, their reactivity to stressors, not being like, let me take a nice walk, let me have a call with a friend, but rather diving into self-harm or into binging and purging, et cetera. And where I can document objective findings, I'm going to make sure that I share those two. That is not a super common finding because there's a lot of treatment, higher level of care resistance amongst my patients. Again, the I'm not sick enough piece is pretty powerful. But if somebody asks, or, you know, for that matter, if I've got a teenager and their parents are like, every day is if I can't do this anymore, you know,

I cannot arm wrestle my 17 year old to please eat the, you know, 3,500 calories a day that are required to get them to gain weight slowly. Everyone's exhausted. Everyone's freaking out. Okay, great, we need a higher level of care. The next category I might use is where I am convinced they would benefit from a higher level of care, but they're really resistant. And that is a pretty common situation we find ourselves in where a patient's behaviors have escalated, where their weight may or may not be getting unstable, but when it comes to anorexia nervosa, the weight is falling, where maybe we're starting to have escalated. where their weight may or may not be getting unstable, but when it comes to anorexia nervosa, the weight is falling,

where maybe we're starting to have more lab abnormalities, maybe not. But it's clear that the patient is developing medical risk. I want to be clear. Medical risk is not the only reason to go to a higher level of care because if someone has a flare of their schizophrenia or their bipolar too, they're not at medical risk, but they have psychiatric condition that needs a higher level of care.

However, I'm an internist. And so when I'm assessing patients, I am looking for medical risk. And that might be in the form of what the EKG is looking like, the electrocardiogram, where their pulse is getting much, much lower and slower, or where I'm finding evidence of cardiac strain on the EKG. I might look at their blood sugar. We haven't mentioned that yet, but the cause of death in restrictive eating disorders is low blood sugar. everyone says oh it's the heart it's the heart well of course at the end of life everyone's heart

stops but the reason the heart stops in anorexia is because it runs out of fuel the blood sugar goes too low because they're not eating enough they don't have any stores of glycogen in their liver or muscles and they no longer have enough body tissue to tear apart and synthesize glucose so the cause of death and anorexia is low blood sugar. When I start seeing low blood sugars, it is a massive red flag to say, look, you know, now we're really playing chicken with mother nature because you're trying to say, I can do it, I'll be fine. And I'm trying to say, any one of these nights that your blood sugar falls, you could have a stroke, you could have a seizure, your heart could stop. So I use again to the best of my power, objective evidence of body suffering to encourage a higher level of

care, but not only am I going against the eating disorder, innate resistance, I'm also going against treatment trauma. Most of my patients, not all, have been to higher levels of care, sometimes upwards of 20 times. And they say, Dr. G, I don't want to go back. I know what I'm going to get there. And it takes my autonomy. It makes me feel like I'm a bad person. It makes me feel punitive. My shame reaction is so high. My natural tendency to compare myself with others is unbearable because I walk in there and everyone looks thinner than I do and I just feel so ashamed. It's particularly true in my patients and larger bodies who go into settings that are full of people who are in fact emaciated and who are saying I'm so fat, I'm so fat. And for my patients who are fat,

they're like, this is hell. I apparently am embodying the form that is, your worst nightmare. Thanks a lot. Wow, this is not therapeutic for me. So, I mean, treatment is so life-saving for patients and I have great programs around the country that I will like to fit patients to. But I have to be honest that wherever I can help their outpatient therapist and dietitian, keep them in their lives. Where they have the things that remind them why they're working so hard. Their art, their sport, their school, their work, their family, their dog. It gives me more power to help them be brave enough to make change. But there's no doubt that at any given time, I always have a number of patients in higher

level of care treatment around the U.S. Beautiful. And Sally, I want you to jump in if there's a question you're dying to ask. Well, okay. Sure. I suppose maybe a comment as well just on the I talk with some patients that even, I know fainting is one of something that, and I'm not quite sure exactly what causes fainting, but I know that some patients are very easy to faint, but others go through all the symptoms, but never actually get to the fainting point. But I know that for those patients, they also feel that extra, I suppose, that extra level

of feeling fraudulent when they have those symptoms, but they don't look like the typical, yeah, like you said, I suppose, a stereotype of in anorexia, I mean, I suppose, yeah, I had a few discussions this week, actually about patients who would faint if they could, but they have bodies that protect them. And I wondered, yeah, how do you work with patients on that? that's such a great point. And isn't it so striking that at any turn, our patients will find a reason to decide they are inadequate, that they're not worthy, that they're not enough to be taken care of. It just fills my heart with so much compassion and love. With regards to fainting, there are a couple of different reasons why that can happen. One is that in addition to slowing the heart rate, the cave person brain lowers the blood pressure in starvation.

And so when somebody goes from sitting or lying down to standing up, suddenly gravity is pulling all of our blood towards our feet. And if you already have low blood pressure, your brain is suddenly going to be less filled with blood. And Mother Nature is extremely clever in these situations. She says the brain must get blood. So if nothing else, I'm going to get the person flat on the ground so that their heart is even with their brain. And that's why we faint. Basically, it's to get more blood to our brain. I love that. That's a great, that's a great explanation.

So it's really, really clever. So when patients stand up and their vision starts to go in, they feel a little nauseated or they see those sparkles or their vision gets dark, they feel a little bit breathless, maybe a little sweaty. Those are all the symptoms that Mother Nature is like, hey, go lie down, put your feet up. Get some more blood into the heart, please, because I need some more blood in my brain. And if people don't listen to that, and we know that oftentimes with our patients, there's a great disconnect. connect sort of their brain in a bottle. They don't want to have any knowledge of what's happening in their body because they want to just ignore it because don't you know, they're fine. So they'll often ignore that symptom and they can faint in that situation. Also, even when the

blood pressure is all right, you can faint just from being empty. You're an empty tank. Of course you're going to faint. You know, our cars faint when they run out of gas. They stop working. And people faint too when they run out of gas. So that's another reason that people can just go down. There are also associated reasons that share venn diagrams at times with those who have eating disorders like postural orthostatic cardiac cardiac cardiac cardiac syndrome pots. Don't need to go into it here, but it's worth mentioning. Also a very, very, very slow heart rate or a very fast heart rate can make someone faint. All of these can happen in our patients. But they're so critical. I mean, a patient can tell me, Dr. T. I can't sleep. I feel like

crap. I'm so anxious. I can't pay attention in my schoolwork when I've always been a fabulous student. I have to read the same page five times. I've got no concentration. But I'm fine, right? It's like I really shouldn't have come in today. I'm okay. And you're like, oh, my love, no, let's enumerate all of the things that are going on that show you're not fine, that show you must make change. Beautiful. That's really good. That's really helpful. You know, as you're talking, I can see so much compassion in your face. And I hope for those listening, they could go back and watch the YouTube as well, because it seems like there's been a couple times where I can literally feel your frustration at the way things are with medical providers and the things that they tell

people with eating disorders, with the suffering that people with eating disorders go through. And I'm curious, can you talk a little bit more about what are some of the common mistakes, other medical providers have said to people with eating disorders or how, I guess, how unempathic, like, what are some common empathy gaps maybe as well? Yeah, for sure. I want to say first that medical providers mean well. And I'm going to say that first because I'm going to say some not so nice things about medical providers when it comes to people with eating disorders.

but I am a Western trained physician with all of the goods and the bads that that includes. And for those who are listening, who are medical providers, it is very evident that everyone wants to do right by people. The system is deeply broken in so many ways in this country. And the eight minutes that are a lot of a primary care doctor to see a patient, when I, in my private pay clinic, get to see patients for two hours initially, and then half an hour or an hour in every follow-up, and they can follow up as often as they need to, sometimes every two weeks,

you know, it's a very different setting. I am in an absolutely optimal setting to practice optimal medicine, and that comes with its own downsides in terms of access. But there are unfortunately legion mistakes, and one of the other systems elements that goes into this involves our training. So from the very get-go in medical training, and I think it's starting to improve, there are two major problems. One is that I got zero hours of training on eating disorders throughout my medical school and my residency.

Zero. So there was literally no knowledge base at all. Second, and doctors can get uneasy, which can sometimes result in belittling or minimizing of patient symptoms, when we feel uneasy that we're not sure what we're doing, we can tend to say, it's probably fine, you know, so that we take ourselves off the hook for responsibility. The other thing that's even worse than no training at all is that we are absolutely bathed in fat phobia throughout our training. Everything, according to Western medicine, comes down to the quote-unquote root evil of fatness.

So even we, you know, nice, friendly, compassionate doctors and, you know, I can't do a preb cycle equation to save my life. I was a poetry major in college. You know, my, my skill is not breaking down the science. It is communicating as best I can with my beloved patients. Even when super nice ones are going to be sharing crappy, fatphobic information. And I have done a so much harm as I look back on my history and think about things I said to patients, I just cover my eyes and dismay. I'm like, oh, my heavens. And so I had to unlearn a ton of that and replace it with better knowledge. But the way that that manifests clinically is that somebody who is completely healthy and, you know, by the way, health is a complicated subject. Health does not mean worthiness. And yet our country has this weird tendency to be like, well, if you're not doing things that make you healthy, you're sort of morally questionable. Why wouldn't you do everything to make you healthy? And yet we're not looking at people with cancer as morally inferior,

actually in the history of medicine that used to be a dynamic. But of course we would never do that. But we look at someone who's fat who has diabetes. And there is great judgment about that. The sum total of this is that a healthy person who's in a fatter body goes into their doctor for their primary care appointment, and they just get nonstop lectures about losing weight, about counting their calories, about getting on the scale more often, about actively focusing on reducing their weight. They're basically being given the recipe for an eating disorder in the name of health. So this is super problematic and I can't even express to what extent the system ripples out. But here's an example. Many patients are denied necessary surgeries because of their body weight. They're told you need to lose weight before we'll give you this surgery.

So let's say it's a knee surgery. Somebody now can't get around because they've got such bad arthritis. And the surgeon says, you know, I'm not going to give you this surgery until you lose 20 pounds. Well, probably, if this is a person in a larger body, they have had diet cycles and posed on them since they were a kid. And dieting does nothing but ratchet up weight. Biologically speaking, cave person brain. When our ancestors were exposed to starvation, when they finally did get even essential food, they would make sure their body weight got a little higher to protect them from the next time they were in a famine. So diets do nothing but make people heavier. And the surgeon

is telling this person who has a knee that doesn't work, go lose weight. Well, the person may already have been living restrictively because it's very, very difficult in this country to be living in a fat body and not be constantly bombarded with the message that you're inadequate in your body. And so they basically put the person in a place of total lose-lose. If the person has to be a person happens to have the genetics to diet and lose 20 pounds, they will be entering that surgery seriously malnourished. Mnourished tissues don't heal, and they don't do well intraoperatively. And if they can't biologically or psychologically or psychologically are wise enough not to try,

then they're denied the knee that would give them the mobility that regardless of body size will actually make them healthier because they can be out and active. more in their bodies. Yet, routinely, surgeons and anesthesiologists are content to green-like surgery for people for bariatric surgery, which is vastly more risky. We're not talking about an orthopedic knee. We're talking about an open abdomen six-hour, unbelievably intense intestinal surgery and they do that without having people lose weight because if I'm being frank the moral positives as the surgeon views them of causing weight loss outweigh the risks that is not a very interesting study has shown a number of years ago actually that it was the thinnest people

in a study of over 100,000 patients who actually had higher mortality rates coming out of surgery, even than some with so-called overweight. I don't use those words because they pathogize weight. Using fat is just a descriptor. And yet what was so striking in that study, unlike other studies where they show that, look, there are some more risks with anesthesia if you have obstructive sleep apnea related to weight. no one in that study said, you know, then people should gain some weight to improve their mortality risk. Because the medical institution could never dream of actually recommending something like that.

They always have to conclude this sort of morally proper, you must lose weight in order to be well. So the way that this plays out in clinics are constant. My patients with eating disorders who are in larger bodies are prescribed self-same behaviors they're trying to escape. My patients who have returned from an eating disorder program where they finally gain the weight they desperately needed are told by a nurse at the very beginning of a first session back with their primary care doctor, wow, you gained a lot of weight, didn't you? My patients who are in so-called movements on bodies, who are. You almost like, just want to yell.

You want to yell. It's the worst. You know, it's like three months of progress. Three months, three months, right? So all the points in between, it's really the. theme of a fat phobia and thin focus and the lack of knowledge of eating disorders. And even when doctors know about eating disorders, there's a reason that my clinic is one of the few in the country who does this.

Doctors don't want to do this work. They consider the patients to be too complicated, too difficult, too resistant. And I get it. Not everybody should do this work. But I do wish that there are more of a recognition of how fabulous and wonderful. the patients are. Yeah, I'm curious. Okay, well, I want to highlight something that I've heard you say before that there's three important things. I can identify my need, except it exists, I can meet my need. Can you talk about why that's important for someone, specifically someone who struggles

with their relationship with food? I love that. Yep, that's one of my faves. I am not a mental health professional. I am an internist, but I have certainly had to absorb and learn. I mean, it's really important that I stay in my sandbox. No, I think you have enough empathy and I think you've done somewhat EFT training, right? And you've been in the field long enough. I would consider you mental health professional. That's very kind. regardless, I have not had formal training. And so in the course of learning from my amazing psychologist colleagues and from my patients and from the dietitians who work with them, I have come to understand a series of framework ideas that helped me see the big picture of what one of my patients might be going through,

because it would be easy for me to get lost with the individual trees of a low heart rate and not pull back and see the whole forest. We've got to keep our eyes on the forest. what I have seen and I'm quite sure that I'm not creating this. It's just that I've observed it in my patience and continue to look for it is that one of the fundamental tasks of growing up and we all arrive at this different stages in our life is to be able to say, I know what I need right now. Two, I'm not going to resist that or judge that. I'm going to accept that having a need is appropriate and this is the need that I have. And three, I now know how to meet that need. So that might be at the end of a day when I come home. I've been tired. I've been working all day. I've got my fabulous teenagers who are going to be coming home soon from their ultimate practice. And my husband will be home soon too. I'm able to say, I need to sit and grab a snack and put my feet up and watch Netflix for half an hour before everybody gets home. that's step one. This is what I need. Even though in the back of my mind, I'm thinking I've got

notes to write, I have work to do, I've got that bill to pay, but right now this is what I need. And then the second thing I do is accept that that's the fact. I don't beat myself up. You shouldn't do this. You shouldn't do this. You should be doing the other stuff because I don't need extra pressure in that moment. I need to relax and breathe. So I accept it. And then I sit down and I get my snack and I put my feet up and I watch my Netflix. So when I do that, I am much less likely to turn to behaviors like overuse of alcohol or self-harm or eating disorder behaviors to deal with that pressure of whatever I've been going through during the day. And I love it most when teenagers can engage in this process because it is part of their relationship with their self.

In this modern era of parenting and don't get me started, parents have so very much overtaken teenagers' decision-making and have marionetted them. It's a broad generalization, but we do see this. They have controlled them to such an extent that teenagers don't know even that they should ask themselves the question, what do I need right now? Much less go through those three stages, even if they've managed stage one and stage two, just as they sit down to sort of chill out with a friend, their parent is like, have you done your math homework? And that cycle gets interrupted. So really, as my patients recover, it's helpful for me to be like, yo, I walk the talk. I walk the talk here. I eat all the things. I recognize.

I have all the points of privilege, including health privilege. I've never had an eating disorder. So it's going to be easier for me than you. But I got to tell you that when I went home last night, knowing I was going to have dinner shortly, I made the most delicious mug of cocoa because my COO and my clinic makes this magic concoction of cocoa. And I grabbed a pretzel roll. And I just sat there and watched a show.

And I knew that I was having dinner and a half an hour. And that didn't bother me one bit because I knew I'd eat an enjoyable, complete dinner, that's what I needed in that moment. And so when I tell my patients those stories, or when I show them my whole milk decaf latte that I love and I say, you know, when I'm at home and I drink my coffee, I help to put a little extra cream in it because I just like that mouth feel of the dairy fat. Mmm. So good. You know, this starts to give them a sort of like, like a sense of this exists. And so the process of helping them identify their need, validate it and have the courage to need it without judgment is a super important part

recovery. Beautiful. I wonder how common it is to go from like anorexia to orthorexia. Orthorexia being like an overfixation on a particular diet. I remember one patient when I was covering eating disorder partial at my institution had found this like raw diet. and she would only eat raw, non-GMO, organic, food, no seed oils, kale, so kale salads, that type of thing with like avocado.

I mean, some of it was like, like, you know, if it was like maybe 50% of the diet would be like, hey, that's great, you know, but it was like only, right? Only that. Yeah, so I can see for those of you who are listening to this, there are looks of pain Dr. Cheese's face. Go ahead. Yeah, orthorexia is really, really interesting. You can see it going into an eating disorder,

and you can see it coming out of an eating disorder, both. The key about orthorexia is the arbitrariness of the rules. The idea that I'm going to make a certain number of rules, you know, organic, non-GMO, no animal products, know this, know that, they're completely, completely arbitrary, except within a broadly, sort of a broad ethos that we're vaguely aware of that, like, yeah, when you can buy organic, that's probably better for the earth than if you can't, but many people can't afford it. Or non-GMO, yeah, maybe, because, you know, maybe there's reasons for that. But when it becomes a fixation, when it becomes a rule that is inscribed in steel, and when, the psychological sequela of breaking it start to break the person, you know, oh my gosh, I had this food and it's one of the foods I wasn't supposed to.

Then we realized there's a big problem. And there's been plenty of stories now of original influencers who peddled these kinds of diets as the way to, you know, prevent cancer and reduce inflammation. who later come out and were like, hey, I'm really sorry. I actually lost three quarters of my hair and my nails all fell out. And I got really, really sick on that. Sorry. Sorry, that was not the right thing to be telling you guys to do.

I wasn't healthy. I was sick. The likelihood that the kind of highly circumscribed diets and don't even get me started on the idea of intermittent fasting, because I mean, baloney, baloney, baloney. the idea that those are going to lead to wellness is zero. Okay, someone in the audience is thinking, okay, finish your point and then we'll come back to intermittent fasting. Okay, yep, it's super fair. The reality is that health, broadly speaking, and there are people with very specific medical conditions or metabolic conditions or allergies that do need to follow circumscribed diets and they have my compassion and support.

But the real pathway to the greatest health you can experience with relation to food and body is to eat consistently and adequately through the day, foods that bring you joy and that are basically well balanced and to move in order to stay vibrant and strong so that you can do in the world what you wish to, to get enough sleep and to be kind to your mental health. That's basically it. That's it. It's not about like five things you can do to improve your gut health today. Like, no. And there are so many things in our world that conspire against people being able to follow those basic guidelines. Among them, systemic poverty, food deserts, a history of growing up in one of those settings that primes your cave person brain towards extreme eating because it's always trying to

to make up for food and security of your youth. Any of the isms, discrimination across any topic radically impacts someone's food intake. For instance, a study showed that for Latina women in this study who are exposed either to body size or racial discrimination, they had a 1,000 percent increase in binge eating compared to people who hadn't experienced that discrimination. So the upshot, because we're going to get back to orthorexia and then eventually to intermittent fasting, is that society has long wished to imply that following food rules

means moral superiority. And there's a brilliant book called Fearing the Black Body by Sabrina Strings, who's an extraordinary PhD, who has written about the racial origins of fat phobia and how the Europeans, as far back as 1500s, wanted to distinguish between a moral superiority of a white body and that of a black body, which was shaped somewhat differently.

I mean, there are so many interesting roots that we're not even aware of when we casually say to a friend like, oh, yeah, I'm going to go gluten free this month. You know, you are actually speaking from a history of lots and lots of oppression and, you know, really serious problems with people. So orthorexia makes no sense in terms of health, but it has become the religion of the populace as they have lost their relationship either with former religion or with spirituality

and a sense of sort of morals. Now having a sense of superiority and knowing you're doing, the right thing has to do with how you're eating, not the acts you're doing in the world, not how you're treating other people. So I think humans flock towards those kinds of experiences, and right now it's about food. The upshot is that people can start out with orthorexia, and if that happens to make them lose weight, they can slide down a hole into anorexia nervosa, where it's not about the purity of the food, it's about the size of the body. Or as people emerge from anorexia, they might be willing to eat more, they might start to tolerate gaining

weight, but they only feel that certain foods are safe foods and the rules are highly, highly detailed. And I mean, have nothing to do with health. You know, a patient who eats a hundred splendas in a concoction in order to have the sweet that her body craves so much, won't eat a pizza So because it's unhealthy, please. You know what I mean, please. So that is the way that orthorexia can kind of interact with eating disorders. And by the way, restriction of any kind messes up our brains, regardless of the goal behind it, orthorexia, eating disorder, diet, fast, whatever. I'll just briefly say there was an amazing study in the 1940s in this country called the Minnesota Starbation Experiment, where Ansel,

He's a dietitian took conscientious objectors who wanted to serve their country, but not on the battlefront. And he said, I want to know what's happening to our prisoners of war as they get starved. And this was the first real experiment that watched this. So he took this group of young men, and he started by giving them plenty of food. I think in the study, it was around 3,500 calories a day. Nice, good, hearty portions they ate normally to make sure that their nutrition was all at the same level. And then he starved them down to about 1,500 calories a day. And I'm sorry to say that 1,500 calories a day now for many people is considered like their cheat day.

I mean, it's so appalling the degree to which people are encouraged to restrict their calories. But he restricted them to that. He had them do manual labor to reflect work camps. And he made detailed observations about their physiology. And then to his surprise, started needing to make detailed observations about their psychology as they lost weight. And what he was so struck by, in addition to writing down all the physiologic stuff that we've been talking about with a cave person brain, he found that these guys, when they would be allowed into town, would press their faces against the glass of the diner and think, those gluttons, look at how disgusting they are with their food. That's, that's just horrible how much they're eating. You know, they got really judgmental about other people's eating. And when they started to be refed, I get chills every year. time I say it, they would cut their food into little tiny pieces. They would squirrel some of it away in a napkin in their pocket. They would only want to eat food of one type. They basically showed

up like people with anorexia. But these weren't people who had anorexia. These were just people who had gotten starved. So when our human mammal brain gets starved, we get weird about food. And very often those same guys would end up feeling bingy for a lot of years later because that's what our cave person brain said to do. It says make up for the time you didn't have food. So in the final analysis, if people are like, should I try a purely vegan diet, you know, vegetarian, okay, you know, there's some ethical environmental issues there. Don't. Do not roll that. do not play roulette with your own wellness because human brains want consistent, adequate,

relatively balanced food throughout the day. I love that study. I'm glad you brought that up. I was going to ask you about that by the end of this. And I think that it also shows, the one thing that it shows me is that you take a normal group of people and you starve them for a long time and they act like people that we say like, oh, you have a disorder. It's like, maybe, maybe not. Maybe you have what anyone would have if they restricted themselves for a long period of time, you know? So there's a normalization

that I really appreciate about that. And then also, like, I was on a wrestling team in high school and we all cut weight. Oh, honey. Oh, you saw some stuff. No, I- You probably did some stuff. I dropped like 20 pounds going from football to wrestling. But I had a friend who was like, he struggled to lose weight. And he would get obsessive, just like you said, about like, all I want to eat is peanut butter. That's all he would eat, right? And yeah, I'm thinking, man, I have a unique relationship with food, too. I've been vegan for a while. I thought it was like the best thing ever. And then I realized I was biasing my own self, how I read the articles. I was, um, food was comfort growing up. Food was like, you know, you know, if you don't have a safe place to process emotion,

if you don't have a bunch of secure attachments it's like how do you comfort yourself food is a great a great way to comfort yourself right and so and then oh and then i also want to ask you sorry i'm like jump at topics here g lp1 what's your feeling yeah let me go back to intermittent fasting okay because he wanted to like bookmark that briefly yeah let's do that is there a specific question you had about that or do you want me to just rant uh it I just was looking for a rant. It's all the rave, you know. I've tried it.

It was miserable to me. You know, I'm like right now, I had like a conversion when I started strength training consistently to this idea of, no, eat a lot. You know, eating is healthy. You're not exercising for aesthetics. You're exercising for strength. It's like you don't need to starve yourself. You know, so I have, I've had like this multi-year conversion in that way, which I feel is healthy, helpful to my like psychological well-being with my relationship with food.

But I think that there's tons of people who get obsessive about like, oh, I need to do intermittent fasting. And so, yeah, go for it. Let's do two topics in this. Let's actually talk about intermittent fasting. Then let's talk about exercise. Then let's talk about the GOP-1 agonist. Got it.

Is that nothing its cousins? Is that okay? Yeah. Let's go. Awesome. Okay. Okay. So intermittent fasting. It is a diet and sheep's clothing. I mean, it is, there is nothing specifically rigorous or anything else. You know, you're going to get a bunch of slightly gaunt-looking runners with, you know, reasonable amounts of financial security in a room. and they're all going to convince each other that if you just don't eat from X hour to X hour, everything is better. But the reality is that that's just going to trigger your cave person brain

to slow down your metabolism during the time you're not eating and then to have a weird relationship with food when you're allowed to. It's going to make people feel better for the first month or so, maybe because you feel morally superior. You feel elated. You're doing the right thing. All of us feel good when we're doing the right thing. Like, yeah, I'm getting stuff done. But the truth is there is no science behind that. And I have seen people try to present science after science, but as an eating disorder doctor, I know how our biology is wired. There are certainly some people who are going to have the kind of brain who can comfortably just go along about their day and not eat during certain hours and then eat reasonably during the hours they do and they'll make up

their needs and they'll be like, this is fine. What are you talking about? Fully for them. the rest of us are going to be wired to get weird about food and our bodies are likely to be wired to gain more weight because our key person brain is going to say uh-oh you're in a famine at least half the day uh that's that's my feeling about intermittent fasting eat food throughout the day good quantities of it make it satisfying broadly broadly balanced that's it um exercise i think should be talked about. When we talk about eating disorders, exercise got a really bad rap for a long time in eating disorders. And unfortunately, when providers told patients don't exercise, you'll burn calories, they were literally reinforcing the reason the eating disorder wanted to do exercise in the

first place, which was to burn calories. That is not what exercise does. So let's make sure that we really dive for a second into the physiology of exercise and nutrition and calories. Because I hope that your listeners will take away from this, a sort of freedom from what they had been thinking exercise does and actually feel inspired by what exercise truly is wonderful for. Fascinating study on a nomadic modern people in North Africa. A couple of years ago, scientists said, let's show those lazy American couch potatoes how many calories are burned by one of these tribes. that by definition of just their everyday life, walk miles and miles a day. So we're going to do a detailed metabolic study on these folks,

and we're going to show that when you are virtuous enough to walk miles and miles a day, hashtag drop your Apple Watch, stop counting steps, we're going to show everybody how much better their lives can be. To their befuddlement, this modern nomadic tribe walking miles and miles, a day was burning exactly the same number of calories as their quote-unquote compares in couch potatoes. And the scientists were like, what? Here's the situation. Laws of thermodynamics, of course, mean that when we move our body in the world, it burns energy. Of course it does. But if we're not fueling that extra movement, you know, fueling the movement that we do, our underlying metabolism,

will just slow down and go slowly because we're not eating enough. So let's say that somebody, quote unquote, burns 500 calories in an exercise a day. Modern medicine has told them, yep, that's a burn. That's a net burn on the day. You've gotten rid of 500 calories that day. Good job. Wrong. If you didn't eat an extra 500 calories, your metabolism will go 500 slower because,

because your body is trying to keep you in homeostasis. So probably if that modern nomadic tribe had had access to 4,000 calories a day, that's what they would have burned. Their metabolisms would have come up. They would have used some of it for the walking and the rest of it for a nice fast metabolism and that and they would have burned more. But because they don't have access to that kind of food, they're essentially sort of on a restricted diet.

Their underlying metabolisms go slower. So when we exercise, we're not net burning anything. Exercise is not for weight loss. All of the studies show that when you just focus on exercise, people don't lose weight. But here's what has does happen. They have reduced risk for downstream cardiometabolic problems. And we know increasingly that the obsession with cardio exercise, was misplaced. Sure, if you are a person who loves doing cardio, wonderful, enjoy it,

do things that feel great in your body. But we also know for those who absolutely abhorre cardio or who don't have access to it because maybe they have different abilities and they can't actually, you know, go for a run or a walk or whatever, strength training is just as good as cardio at reducing diabetes, heart attacks, strokes, hypertension, et cetera, just as good. And we're not talking about massive quantities of it either. We're talking about sort of consistent essential amounts. So when people are like, oh, I don't want to go to the gym today, just doing some sort of resistant workout, 20 minutes is going to be amazing for their health. We know that as people get older, their muscle mass starts to decline. And so actually actively

doing strength training, not just taking a walk around the block with their friend, is going to meaningfully improve not just their ability to avoid a fall or their robustness when they're doing their lives, playing golf, playing with the grandkids, but also will probably extend their lives. So when it comes to people with eating disorders, of course, we want to avoid exercise if they're not psychologically or physically stable for it. You know, if they're not essentially nourishing themselves, if they can't resist but do excessive, harmful exercise, if they cannot resist measuring and becoming obsessed with how fast or much they did something, take a break.

Take a break. But earlier than we used to think, bringing back lovely movement to re-engage your identity is something besides a human with an eating disorder is so valuable. It is magnificent. And I have people improve their body image. They reconnect with their athletic. identity and help themselves heal from, say, their anorexic identity in the process,

has to be done under careful observation. It has to be fueled. It has to be rested. But it's wonderful. Exercise is great. And I'm happy to take questions or thoughts about that. And then we can do GLP-1 Agnes if you want. Oh, no, I love it. I love it. We talk a lot about strength training for your brain. The muscles are a neuroendocrine organ. You know, they stimulate all sorts of good things in the brain. And I think that it also is a helpful mind shift. I think the one sort of to create a strong man argument for strength training, here's what I hear from female patients who have more of the propensity to want a low body weight. It's like I'm so fearful that I'm going to look like super strong and unattractive. So I don't want to do strength training. What do you say?

I mean, oh, there's so much to unpack there, right? The idea that being strong is unattractive, especially in a woman, really has its roots and stuff. We want to challenge. We want to break down. Everyone is going to respond to strength training differently. Everyone's bodies genetically are going to look a certain way. And when they strength train, they're going to look the same way or a little bit different. But nothing you do with your things.

food is going to change that. Now, at the very extremes in the bodybuilding world, etc., the amount of disordered eating that goes on is 100%. And I've been really grateful for some of the male actors recently, Zach Ephron, Channing Tatum, who have come out and publicly said that it is deeply unhealthy for them to participate in these movies where they have to be naked or partly naked. Channing Tatum wrote that he worked for three months with a dedicated trainer and a dedicated nutritionist to get the appearance of the body that he has in the various um um oh something mike movies dancing whatever uh like stripper movies um so he was able to film the relatively naked scenes and then literally the same night that he had his first normal meal his body looked

totally different totally totally but all we see is him in that movie looking like the cover of a men's health magazine, almost without question, no one who looks like that is engaging in things that are healthy, is hydrated, nourished, rested, et cetera. So that's really, really important to say. And living our lives takes a certain amount of acceptance and compassion. How we look is how we look. Now, that doesn't sell products. So that's not what people do. here. What sells products is if you do this, you can look different. But the reality is, is that our bodies are genetically programmed to have a certain amount of muscle and a certain amount of fat and a certain shape and our age plays in, our health history, our trauma history,

the history of what we have access to in terms of, you know, money. All of these things play into how our bodies look. And I'm sitting here with thin privilege talking about this. And I'm now acutely aware of what that gets me and what it doesn't get me in society. but you know people should do strength training because it will keep them well and vital and vibrant and if they do strength training and they truly cannot bear how their body looks time to talk with therapist you know um or they can alter it somewhat but like yeah let's try to move away from these assumptions of of what bodies are acceptable and what aren't yeah no i i really really appreciate that. And I think most people don't realize, you know, like to be in a film or

commercial where they're, you know, they have their shirt off and such. It's like they are using diuretics. They're using testosterone. They're sometimes using human growth hormone. They are using, you know, they're water restricting the day of the shoot. They are salt restricting. So it's like they ate a pizza and it's like it's all gone. The abs are gone. And so there's this culture and this sort of, you know, imprinting into our minds of this is what is attractive. And it's just completely worsened by filters now, video filters, Photoshop, you know, so much kind of changes our perspective on what is attractive, what is normal. Yeah, I'm super recommend that especially your male listeners, but really anybody, read Matt McGorry,

MCG-O-R-R-Y's article, My Journey Toward Radical Body Positivity. It's on Medium.com. And he's a Hollywood actor who talks about his journey, looking the part and getting roles and being, you know, everybody's thirst trap. And he was so unhealthy and unwell. And when he got well, his body did look different.

But in no way that was any way bad, it was his healthy body. and he was just profoundly criticized for it. So it's a beautiful article. He really writes beautifully and he knows. That's good. Modern concepts. GLP1, give me like three sentences.

I know we're wrapping up soon. Very complex. They're great diabetes medicine. Before they were the fashion for weight loss, I had a couple of my patients on them for their diabetes, and they were wonderful for diabetes, and the patients didn't lose any weight and they were happy on them. They didn't have GI side effects.

It's been my decision not to use GLP1 agonists for patients for weight loss in this clinic because we are avidly not only a weight inclusive clinic but a fat positive clinic. However, I'm speaking from a place of thin privilege and I understand that there are people out there who are deeply, deeply criticized by harmful. by society in their fat bodies. And I want to be really cautious that I don't shame them if they think about that class of medicine because I'm speaking from a place of thin privilege. I don't have to deal with the shit they have to deal with. It's my position not to prescribe them except perhaps in cases where despite advocacy, a patient of mine and a fat body

cannot get access to a necessary surgery. And after a very intense discussion of risks and benefits, if the patient might decide to try that and see if it happens to work for them without undue side effects, I would consider it in that instance. But I feel very sad about the rampant misuse of this medicine when people already are in perfectly reasonably sized bodies. They're exposing themselves to a medicine

and they make them feel extremely sick is not going to result in any kind of permanent weight change and very likely if they go off of it will result in the same thing that everybody does when they go through diet cycles, which is ending up at a higher weight than they were before. Yeah, wonderful. Sally, any dying questions that you want to jump in there

as we kind of wrap it up? Just perhaps two. One question, maybe one statement. So maybe just two statements about exercise and one about patients in larger bodies. So just with exercise, I find I don't, because I know nothing about the strength training and gym staff or anything to do with that. I often just encourage the most unstructured exercise possible in nature. So whatever is potentially opposite to the rules and regulations around the eating disorder,

then if it's surfing, if it's surfing, if it's bushwalking, if it's, yeah, so as unpredictable as possible. But it doesn't work for everyone, but I just, and then the other thing I just wanted to say, I suppose it came up today with a client and I have permission to just speak on this, but like you talk about thin privilege, so I've never known what it's like to be in a larger body and to struggle to leave the house for those societal reasons. there's other reasons but not for those. And I think just when you have this is actually a question, Dr. G,

when you have a patient where, you know, it's so ingrained that they feel that their body is, the body they're in is perhaps punishment or justice for whatever they've done to themselves so that they deserve it or that the shame and the guilt of the disgust is so great that they can't access the feelings that you're desperate. want them to be able to. And it's so much easier for patients who are in smaller bodies to access those feelings and feel more, what's the word, more validated. So I suppose that's, I think that's the hardest part of this work.

Just, yeah, I don't know if that's a question or just a statement about just really feeling for them, but also not knowing what that feels like and knowing that. perhaps for me and you, we're coming from a place where we've never. Yeah, those are such beautiful comments. One, totally agree with you on unstructured, joyful, especially that connects you with nature. Wonderful. Yes, fantastic.

And at some point, if someone wishes to do some strength work, lovely, there's plenty of little apps and videos that can give you a guided 10, 15, 20 minute sort of ability to learn how to strengthen your body. doesn't have to happen in a gym. I never go to a gym. Two, I couldn't agree more with you. And I think what we can do as providers is not make assumptions, but ask, what is it like for you to be in your body? What have your experiences been? Everyone's experience is unique. I can know themes, but part of my showing respect and joy and enthusiasm in the patient, in encounter is to ask with curiosity and great, great interest, which I feel. So to have a space to tell

their story, to be believed, to be held, validated, and shown compassion. And then to know that each time they walk in your door or show up on your screen, they feel like an unbelievably precious, magnificent part of your day, I think gives them a space in which they might be able to see themselves as that as well. But it can be a process of many, many years. Wonderful. Just, yeah, thank you so much for both of you coming on. This has been really meaningful. I've learned a lot. And I'm sure my listeners will really appreciate this and probably want you to come back on and do another deeper dive into some of these things.

So if they want to connect with you, I will put your website link. What other ways are there to connect with you? Are you on social media? What's your podcast called? Yep, we're on social media at Goudiani Clinic. I know that's far to spell. It's G-A-U-D-I-N-I clinic. We try to put out really positive, thoughtful content that is safe and engaging and peaceful for people.

Sick enough is my book. It's available on Amazon as well as other places. And yeah, www.gianiclinic com is our website. I no longer take new patients myself because I am so enthusiastic about caring for the ones I've got as well as doing teaching like this. I try to do a lot, a lot of teaching where I can to spread the information that I know. But I have three extraordinary partners who do, and I supervise all of them and they're amazing. Awesome. Yeah, that's kind of what it's become for me too. It's like you get too busy and then you have to like slow it down. Otherwise it takes over your life. So I appreciate that. And then Sally, thank you so much for coming on as well. Really appreciate it. Pleasure. Yeah. It's wonderful. Yeah. So, okay, one more question. Any conflicts of interest from either of you? Great. No.

Sally, any conflicts of interest? No. Okay. No. We will be leaving it there for today. Thank you so much for coming on. Thank you both so much. Thank you so much.