Join me and Dr. Jennifer L. Gaudiani as we discuss Why you don’t have to be underweight for your fertility to be compromised.

Jennifer L. Gaudiani, MD, CEDS-C, FAED, is the Founder and Medical Director of the Gaudiani Clinic. Board certified in internal medicine, she completed her undergraduate degree at Harvard, medical school at Boston University School of Medicine, and her internal medicine residency and chief residency at Yale. Dr. Gaudiani served as the medical director at ACUTE Center for Eating Disorders prior to founding the Gaudiani Clinic, which is a Denver-based outpatient medical clinic that offers telemedicine throughout the US and is dedicated to caring for people with eating disorders, disordered eating and malnutrition. Dr. Gaudiani’s first book, Sick Enough: A Guide to the Medical Complications of Eating Disorders is available on Amazon. 

In this Episode

• The gap in doctors identifying and diagnosing eating disorders 
• Defining Relative Energy Deficit in Sport (RED-S)
• Identifying the body systems impacting by under eating 
• How to distinguish between healthy behaviors and ED behaviors
• Why women in their 40s are at a higher risk for developing an eating disorder
• Is full recovery from an eating disorder even possible?
• Why some women lose their period and others do not
• The shocking statistics of EDs among patients seeking fertility assistance 

Transcript:

Dr. Jennifer Gaudiani  00:00

And it doesn’t have to be an eating disorder. One of the things I’ve been so grateful for is that about a year ago, the International Olympic Committee came out with a new set of criteria for what I’m sure your listeners are familiar with…which is Relative Energy Deficiency of Sport or RED-S.

And what we know is that just like any other human, athletes with low energy availability will have all of the medical things I just talked about. And they’ll not heal their bodies after a workout, and they’ll be more prone to injuries. The injuries will last longer. So all of these things can be subsumed under RED-S. If somebody just doesn’t kind of feel like they connect with the idea of, I have an eating disorder. Great. Let’s keep it neutral. I don’t care what we call this. Let’s call it RED-S. It’s not getting in enough food.

Lindsey Lusson  00:51

Welcome to the Period Recovery and Fertility Podcast. Here, we discuss the challenging, rewarding and life changing process of recovering your period and finding freedom with food and exercise. Whether you’re hoping to regain your cycle to get your health back on track or you’re ready to become a mama, this podcast is for you. While the recovery process isn’t always rainbows and butterflies, it’s my hope to bring you both information and inspiration during your own recovery journey. I’m your host, registered dietitian and fellow HA woman, Lindsey Lusson. 

Lindsey Lusson  01:22

Jennifer L. Gaudiani, MD, CEDS-C, FAED, is the Founder and Medical Director of the Gaudiani Clinic. Board certified in internal medicine, she completed her undergraduate degree at Harvard, medical school at Boston University School of Medicine. Her internal medicine residency and chief residency at Yale. Dr. Gaudiani served as the medical director at ACUTE Center for Eating Disorders prior to founding the Gaudiani Clinic, which is a Denver-based outpatient medical clinic that offers telemedicine throughout the US and is dedicated to caring for people with eating disorders, disordered eating and malnutrition. Dr. Gaudiani’s first book, Sick Enough: A Guide to the Medical Complications of Eating Disorders is available on Amazon. 

Lindsey Lusson  02:00

Welcome everyone back to the Period Recovery and Fertility Podcast. I have an amazing guest today. I have been so psyched for this interview. Welcome to the podcast. Dr G.

Dr. Jennifer Gaudiani  02:10

Thank you so much. I’m so psyched to be here. 

Lindsey Lusson  02:13

Well, your book has been so helpful for me in my practice. And on a personal level, when I read your book, I think last summer, I was almost transformed back to my high school self and thinking about when I was actively struggling with an eating disorder. And God bless my mom, who would just look for so many places on how to get me help. But I was never fitting the mold of being clinically underweight.  We would go to so many doctors, and they would be like, Oh my gosh. Like, you are so healthy. Keep doing what you’re doing. You’re incredible. My mom was just so defeated for years and years and years and years. So reading your book, I was like, This is what I needed 20 years ago.

Dr. Jennifer Gaudiani  02:58

My heart just aches for you and for her. You know the parents out there who want to do so right by their children, and know that they are the best advocates their kids have at any age. And yet when they’re getting the wrong information from the sources who are supposed to be giving them the right information, that can be so gaslighting. It can be so frustrating. It can be so undermining. 

Dr. Jennifer Gaudiani  03:25

Especially depending on where their loved one is in the eating disorder journey, because those commentaries on You’re fine, you’re great, nothing’s wrong, everything’s normal.  It just like pulls the wrong Jenga block out of the whole stack, and all of the blocks fall down. The parents and the team can be like, Oh my gosh, we worked so hard to establish an understanding that things aren’t okay, and then this authority figure just destroyed it all.

Lindsey Lusson  03:56

And like, I would love going to the doctor’s office. Because I was like, Oh, I can’t wait for everyone to tell me how healthy I am, and it’s just, it’s just wild. And so for those who are unfamiliar with your work, I feel like we’ve kind of like teased this already, but why did you write your book Sick Enough? What is it about? What is the thought process behind it? And then we’ll get into some more specifics about what you’ve learned in the work you do. 

Dr. Jennifer Gaudiani  04:19

So as an internal medicine physician who specializes in eating disorders, my focus for the last 16+ years has been helping people understand the measurable and the unmeasurable things that happen in their body when they are doing disordered eating and eating disorder behaviors… At every body shape and size. And the benefit of what I get to do in this field is that where an eating disorder rain can very much think I’m fine. I’m not sick enough… for everyone to be fussing over me or for me to even change my behaviors. Talking about what’s happening in a body is really objective.

Dr. Jennifer Gaudiani  05:06

It can actually break through that denial of what’s going on. And help people be like, Oh, okay, well, yes, I see that this mentality and these behaviors are not necessarily congruent with my values. But furthermore, there are some things happening in my body. And we don’t get any training on this. Zero hours of training on the medical complications of eating disorders throughout my medical school and residency. And so, because this is not well known, and because doctors or medical providers in general are so steeped in diet culture where they automatically see a more thin, privileged body and mistake it for health. 

Dr. Jennifer Gaudiani  05:57

I really wanted to write the book primarily so that I could help clinicians, patients and family members who might never be able to see one on one in my practice. For whatever reason. So that they could have a resource that was scientifically sound and psychologically up to date. In order to try to get that benefit, that like motivational boost towards being brave enough to make change. 

Dr. Jennifer Gaudiani  06:22

So so many of my patients had told me, I’m not sick enough. Dr G, I’m not sick enough for X, Y or Z. And so the name sick enough seemed perfect. Because the idea is, if you have an eating disorder, or disordered eating, by definition, you are sick enough to get help. I don’t care what your weight is, I don’t care if your labs are perfect. I don’t care if your vital signs are perfect. Having an eating disorder is not good for you, and you are sick enough to seek change. And so that’s why wrote it.

Lindsey Lusson  06:55

Absolutely! that’s so beautiful. Well, a lot of the women listening to this podcast, and a lot of the clients that I work with fit the gray area of not fitting the DSM five for an eating disorder. Yet they are thinking about food all the time. They’re compulsively over exercising. They’ve lost their periods. They’re struggling with infertility. And so can you kind of help us understand… Obviously, like loss of a period is a pretty big red flag that like something’s going on. But what else is going on in the body when somebody’s in this constant, low energy? I think you described it in the book as, like a hibernation state, or the body’s kind of turned off. What other body systems are impacted and what might be some things that listeners very likely might have going on, but have kind of maybe just like, tuned out?

Dr. Jennifer Gaudiani  07:46

Yeah, it’s amazing how we can tune out data that we don’t really want to pay attention to. So let’s think about this from a big perspective. Sort of the 30,000 foot view. And then let’s kind of focus in. Because it can be really easy for a brain to be like, Oh well, I’ve looked at the official criteria for needing disorder, and I don’t have one, so I’m fine. So I’m not sick enough to need to make change. In fact, I’m being praised for what a healthy person I am. And not only does that phrase feel good. But it feels very confusing as to why I would ever do anything differently if all of the authority figures seem to be telling me that I’m doing the right thing. 

Dr. Jennifer Gaudiani  08:28

So, big picture, we evolved as a species to survive starvation. And therefore our brains, I tend to call this the cave person brain so that we don’t get too neuro anatomical. Our cave person brain is as exquisitely designed to recognize what we might call low energy availability, or LEA. Meaning just not enough nourishment. That could be not enough calories, it could mean not enough carbs. It’s just not getting what we need, and it changes how our body works, and it changes how our minds think about food. It is as inevitable as being underwater and needing to come up for the next breath.It is deeply written through our DNA. 

Dr. Jennifer Gaudiani  09:20

So what that means is that when, for whatever reason, we are in a low energy intake state, each person is going to be different. But broadly speaking, our bodies are going to try to slow our metabolisms. Meaning how much energy we use each day to get through the day in order to save our lives. And this is totally below any kind of conscious level that we can have any control over. And so bodies, for instance, might, in the course of slowing down our caloric burn get a little chillier. We might be the kind of person who in the room always has the extra sweater on. We might have colder hands and feet and sort of, I’m always so chilly. But should pay attention to what that actually might mean. 

Dr. Jennifer Gaudiani  10:11

That doesn’t mean everyone who’s chilly isn’t eating enough. But it’s something that we pay attention to. Also our energy can start to flag.  A lot of people, especially women, are programmed to push ourselves beyond the cues that we need rest. And so many women can find themselves just feeling exhausted. They’ve talked to their doctor, and their iron levels are okay and the thyroid is okay, and their sort of vitamin levels are okay. And they’re like, Well, why am I so exhausted? I’m working out really hard. I’m “eating really healthy”. And the answer is, your body is trying to make you do less by having less energy to spare, burning more.

Dr. Jennifer Gaudiani  10:56

Our digestion slows. So people might find that when they do eat a normal sized meal, they feel unduly full. And they’re like, no, wait a second, they just had a half a sandwich and an apple. That is not a lot of food, but I feel like I just ate Thanksgiving dinner. I am like, stuck. I’m painfully full. That is a sign of slowed digestion. So is bloating or constipation, where you’re just like, things feel sluggish in my tummy. Then we also see changes, like hair can get a little more dry and brittle and kind of start to fall out. Our skin can be a little more dry. We can take a longer time healing. Can have a greater tendency to bruise or to sort of mark our skin with, you know, the dog jumping up on us or something. 

Dr. Jennifer Gaudiani  11:40

And our sleep can get worse. So when a mammal is not fed enough, it’s not going to be as comfortable sleeping because it knows it’s kind of vulnerable. So sleep stuff can be the part of this. Then all of the psychological pieces too.Finding yourself thinking about food all day. I mean, that is literally what our ancestors, 1000s of years ago, were programmed to do in order to find food when they weren’t getting enough. Really being interested in having that cooking show on in the background all the time, and yet you’re not nourishing with what you need. 

Dr. Jennifer Gaudiani  12:19

And I think the feeling emotionally of reactivity around food. I’ve just something I didn’t plan to Oh, what am I going to do about that? Or when am I going to next eat? And how am I going to make sure that people around me don’t notice that I’m having a little less than they are. Like the more energy we’re putting into how do I feel after I eat, and what am I going to eat next? The more we have a sign that things aren’t great. And it doesn’t have to be an eating disorder. 

Dr. Jennifer Gaudiani  12:50

One of the things I’ve been so grateful for is that about a year ago, the International Olympic Committee came out with a new set of criteria for what I’m sure your listeners are familiar with, which is Relative Energy Deficiency of sport or RED-S. And what we know is that just like any other human, athletes with low energy availability, will have all of the medical things I just talked about. 

Dr. Jennifer Gaudiani  13:17

They’ll not heal their bodies after a workout, and there’ll be more prone to injuries, and the injuries will last longer. So all of these things can be subsumed under RED-S. If somebody just doesn’t kind of feel like they they’ve connect with the idea of, I have an eating disorder, great, let’s keep it neutral. I don’t care what we call this, let’s call it RED-S. You’re not getting in enough food. 

Lindsey Lusson  13:41

And that’s what I tell a lot of the women that I work with. Because they don’t identify with the idea of having an eating disorder. In the last 20 years from what I’ve observed, I think we have come such a long way in actually talking about eating disorders. Talking about actively struggling, talking about being recovered after struggling with one for a decade. But I think even with the progress we’ve made, there’s still this stigma of, oh, an eating disorder, of like that is serious. You belong in a hospital. You belong in a treatment facility. And that’s not always the case for people, even people who are very, very sick.

Dr. Jennifer Gaudiani  14:23

Yeah, I totally agree with that. And while the name matters for insurance reimbursement, he’ll often tell my patients, I don’t care what we call this. And if you have a particular resistance to a particular name, let me listen to your instincts about your body, and we can always come back to it later. What I’m observing is these medical things. Again, some of which are measurable and some of which are narrative. Let’s focus on the fact that those are not congruent with what you want for your body and for your goals in life. And let’s change your relationship with food and movement to resolve those. We can go back to the the name of it later. 

Lindsey Lusson  15:03

Yeah, I do think it helps to not try to put somebody into a box, especially when they don’t self identify with that. One of the questions I got from one of my Instagram followers this week when I told them that I would be interviewing you and about your book and how fabulous I think it is, was, how do you distinguish between a health minded, health promoting behavior and disordered eating, or eating disorder behavior? Because I think a lot of people get stuck here, and a lot of people justify their habits with food and exercise. And then they’re kind of just stuck in this constant loop of, I want to be healthy, but I want to recover, but I want to be healthy, or I want to do it the healthy way?

Dr. Jennifer Gaudiani  15:43

It’s such a good question. And I want to say first that I do not in any way, view this whole topic as being a series of like, individualistic choices. People are deeply influenced by the authority figures in their life. Who may include their own parents and how they were parented around bodies and food, their peer set, perhaps their teammates as they were athletes through their lives and continue to be. Physicians, for sure. And then, authority figures on social media that talk about things like anti inflammatory diets and never eat these five foods. 

Dr. Jennifer Gaudiani  16:29

And so these are humans who are just trying to be good citizens of their bodies. I think again, if you if you sort of jump right in and say, Oh, that’s an eating disorder, even though we continue to have to unpack stigma around that, a lot of people think, Oh, you just believe that I’m making choices for myself for some perhaps esthetic outcome. And reality is, is that whether someone has an eating disorder or whether they have RED-S they are responding to a series of incredibly complex cues and pieces of feedback that they’ve gotten throughout their lives. 

Dr. Jennifer Gaudiani  17:03

So I love to start by approaching this with rich compassion and just ask for their background. Tell me how you came to believe some of these things. No judgment. Let me find out how did this unfold for you. And what were some of the really big turning points where you were like, and then my dad said this, and then my coach said this, and it has stuck with me ever since. So just understanding the background, rather than jumping in and being like, Hey, I’m an expert. Let me guess this for you. Your individual, unique journey. 

Dr. Jennifer Gaudiani  17:38

And then we want to think about what specific beliefs this person has. Let’s say, for instance, carbs aren’t good for you.  That’s a very specific belief that many folks have. We can then apply good science to that false statement. Because, especially when we’re talking about an athletic population, carbs are absolutely vital.  I’m very fortunate to care for a number of elite athletes. And it is 100% true that when they are not only getting in enough calories but also enough carbs, they are performing better, recovering better, and competing better. 

Dr. Jennifer Gaudiani  18:18

I’m just doing a big lit review to start writing the second edition of Sick Enough. And it’s very exciting and satisfying for me to see the newest literature on elite athletes and on recreational athletes show how vital it is for muscles, bone, mindrecovery and also or bacterial health in the gut to nourish with enough carbs. So when people are like, I don’t even knowhow to start. I don’t even know sort of what I named myself. Am I just being healthy or not? One of the ways that I like to distinguish this is especially for athletes… but we can extrapolate it to other values as well… Is are your behaviors driven by fear, or are they driven by an objective desire to improve? 

Dr. Jennifer Gaudiani  19:14

So when you’re an athlete who does not have disordered eating, then you will do whatever it takes to get better.Including rinsed more and eat more and increase intake of things you didn’t think you needed. If you are from more of an ED or DE perspective, you’re driven by fear. And you say, I can’t make this change because something bad might happen. That’s when we’re sort of like, okay, now I’m seeing one from the other. It can help distinguish. Because if it’s pretty clear that resting more and eating more are going to actually make you function better. But if you can’t get to that, then we’re talking a little bit more of a psychological…

Lindsey Lusson  20:01

Yeah, that is so, so helpful. The fear, I think, resonates with so many of the clients that I know that I’ve worked with. And another way I’ve heard it kind of described with the same idea, is, what is the level of distress that you experience when you are unable to do that exact seven mile loop? Or you are unable to have access to these clean, healthy, organic foods. If it’s something that you can feel a little bit caught off guard and then be like, You know what? This is, one meal, one day, etc. 

Lindsey Lusson  20:38

That’s very different than completely shutting down, having a panic attack, going out of your way to, drive across town to go to a different restaurant. Eating before you go do something, skipping out on social engagements to still get that seven mile run. And so I feel like one of the hardest places that I see a lot of people get stuck is maybe not answering those questions honestly and being in denial. Do you experience that a lot with your patients? 

Dr. Jennifer Gaudiani  21:06

Absolutely. Yeah. I think that’s such a great way of distinguishing as well. And again, coming to it with such gentleness, just like your approach is just being curious. Tell me more. A lot of the times, people’s behaviors have gotten so entrenched that they don’t even recognize that there’s an alternative. Because they would never do anything differently.And so to gently ask, what would it be like for you if suddenly your partner said, Let’s go out to dinner. If the weather were bad enough that you couldn’t complete the workout that you had planned. What is that like for you and your soul?What does it feel like in your body right now as you imagine that? 

Dr. Jennifer Gaudiani  21:46

And that really can help bring people’s attention to that. Some might say, Well, why does that even matter? Okay, so I’m disciplined. So I am the kind of person who does the same things over and over. And there’s a piece of that that I’m really, really interested in right now that does have some Venn diagram overlap with neuro diversity. When we talk about flexibility and variety and comfort, a lot of the time we are speaking from a neurotypical standpoint. Because I enjoy flexibility and variety and all of this stuff. I have a lot of health privilege. There are some who because of the way their brains work, they actually need things to be more rigid and more sane. 

Dr. Jennifer Gaudiani  22:30

That may be perfectly healthy for them. The question then, for those individuals is when you need to do things differently because you’re sick, for instance, and you shouldn’t go out for that run. You should take a nap. Do you do okay with that? And for those who you know sort of are neuro diverse and not psychologically caught up in a more eating disorder mentality, they’ll be like, Yeah. As long as somebody’s not asking me to just do something totally novel, of course I’m going to take a nap.

Dr. Jennifer Gaudiani  22:58

Others would be like, no, no, no, no, no. So I love keeping a complex topic complicated. It’s fun to simplify. But this is complicated. The more we can embrace the richness of the complexity, the more we open our arms to make sure more people are represented when we talk about these subjects. 

Dr. Jennifer Gaudiani  23:20

So the other piece is, to what degree does a lack of variety and a lack of ability to nourish yourself well and to work out thoughtfully and mindfully, and to have periodicity in your workout. So that sometimes you’re easing back on intensity and sometimes you’re increasing? How much is it affecting your life? How much does it stress you, how much it distress people who love you? 

Dr. Jennifer Gaudiani  23:44

Because everyone’s response to that is going to be different. And when you take the time to really listen to all aspects of it, you can help someone create a plan that is responsive to their needs. And they’re going to trust you more. Because they don’t feel like you’re just giving them a one size fits all solution in which everyone has the same experience in the final analysis. Because that’s a disrespects human uniqueness. 

Lindsey Lusson  24:14

Definitely. I work with a lot of newlyweds, a lot of people who are in their kind of first to third year of marriage. And that just comes with nature of me working with people for infertility. One thing that I think starts to come up and gives people a bit of a light bulb moment is going from living by yourself or living with like a female roommate. Then moving in with a partner, where you share meals together. Just how their habits and their rigidity with food and movement are highlighted in a way that they didn’t recognize when they were living on their own. 

Dr. Jennifer Gaudiani  24:54

That must be such a moment for them to kind of realize and open their eyes. Seen that with my patients as well as sort of like, I think, especially as people partner up a little bit later than in the past. And they’ve had a longer time. You really kind of get in their pathways. It can be shocking. And that’s really helpful feedback. Because then the question is, which is more important to you? Is it to do things exactly the way you’ve always done them, or is it to have a peaceful, joyful time with your partner. And to be learning how to do things a little bit differently. And to really engage this partnership in a way that reduces stress and improves a sense of joy?

Lindsey Lusson  25:35

I think it just adds to the list of reasons why recovery is worth it is because it’s not about you anymore. For my clients, specifically, you’re thinking about starting a family. So it’s not about you, it’s about your future child. And it’s about the relationship that you’re already in with your partner. So I do feel for some that recovery can get more urgent whenthey’re thinking about starting their families or as they’re drifting beyond their 20s and into their 30s. But I’ve also heard of a surge in eating disorders in women who are in their 40s. Kind of that perimenopausal into menopausal range. Do you see that in your practice as well?

Dr. Jennifer Gaudiani  26:19

Absolutely. Yeah, absolutely. We see patients. I think my personal range so far has been 10 to 74. And really folks all through that spectrum. What you point out with these different stages of life is so right. Because,  let’s say that someone had a particular level of eating disorder or just behaviors through high school. And they found that with hard work, they were able to regulate them enough to live decently in college. Maybe to do their sport, to stay uninjured. But then when they do find a partner or, their life circumstance changes, they recognize that the degree of recovery they got to isn’t quite meeting their life goals and values anymore.

Dr. Jennifer Gaudiani  27:04

And so it’s time to take it to the next step. As we approach people, not by being like, see, you haven’t even been fully recovered this whole time. Like, no, let’s instead say What a beautiful job you did. Overcoming everything you did to getto that stage you were in that worked for you. Amazing. Wow. Now you’re in this new stage. How are you feeling about it, and how are you responding to it? 

Dr. Jennifer Gaudiani  27:32

And sometimes novelty actually pushes people deeper into their old behaviors. Because that feels like something they can control. And it’s the opposite of what they actually want. So coming into it with that, just like warm, open curiosity, really listening carefully to what they want. My favorite thing to say when I meet new patients is, you’re the captain of your ship, and I will be the wind in your sails. So you tell us where we’re going, and I will help us get there.

Lindsey Lusson  28:02

I love that. I love that. It’s so important to meet people where they’re at. Because too, on a personal level, I feel my own eating disorder recovery did occur in phases. There was the getting really functional and then feeling out of control and slipping deeper into it. And then getting formal treatment, which got me, I always like to describe, almost to, like at 85 to 90%. Then when I realized that I still couldn’t get pregnant without a cycle, that was the last 10% that needed to be healed. 

Lindsey Lusson  28:38

But it took, oh my gosh, it took like, 15 years to do all of that. And I do think that sometimes people just hit a fatigue in their recovery. So sometimes people just kind of have to hang out for a little bit as long as they’re not self. Or getting back to a really, really, really unhealthy place where they need medical treatment.

Dr. Jennifer Gaudiani  28:59

I think that’s such a good point. Because when we as a field try to go by check box or algorithmic recovery, we can require a certain time frame of people that they don’t have the ability to give. Like you said, if they can get into a safe enough place, physically and psychologically, they should have every right to determine how long they stay there. Before and if they want to push to the next phase. And that’s a little bit of a controversial perspective, I think.

Dr. Jennifer Gaudiani  29:33

Because, especially, I think when we’re talking about parents of younger children with eating disorders, the party line is 100% recovery right away, all the way across the finish line get there. And of course, that is what we want. That is what we want. But once again, it actually disrespects the unique individual experiences and pasts of folks who might, for instance be able to get to a much safer place in their ED recovery. And then have to pause there while they do a big, long piece of trauma work. Or to pause there while they take a breath and catch up with their peers in terms of relationships and schooling and work.  

Dr. Jennifer Gaudiani  30:15

We have to have that sense of flexibility to recognize that recovery means a lot of different things, and the more we do keep it individual. Well, keeping track of medical and psychological danger, or sort of risks of long term harms. We actually do people so much greater a service. Because then their recovery feels like it is… the tiller is under their hands.They are the ones driving it. 

Dr. Jennifer Gaudiani  30:42

The more you give them a sense of agency and power, the less tempting it is to say the only thing I can control is what I eat. You’re like, oh, no, wait, that’s not true anymore, because my team is telling me we love you, we trust you, we’re so proud of you. If this is where you need to hold right now, okay, great. And then you get to move on next. When you want to.

Lindsey Lusson  31:03

You mentioned controversial topics in the eating disorder field. What do you think about the idea of full recovery? Is that a real thing, Is full recovery possible in your professional opinion? Is it a bit of a misnomer? Tell me a little bit more about what you think about that idea of full recovery.

Dr. Jennifer Gaudiani  31:24

I’m going to try to keep it complex as I’ve promised. I absolutely think that full recovery is possible. So can a person, andthis is off the cuff. Not something that I’ve kind of pre thought. Can a person manage the complexities of one’s life without turning inward and being harshly critical of one’s body? And choosing to under care for oneself or punish oneself through food or movement? People can absolutely get to the point where they can manage life’s challenges without being mean.

Dr. Jennifer Gaudiani  32:03

I just sort of use that as a an umbrella term. And it’s okay for people to sort of define recovery as they feel is right for their values and their background. That doesn’t mean that someone’s like, Aha. Dr G said that I can define what recovery is, and I think I’m recovered at this extremely underweight and blah, blah, blah, blah, blah. Like, no, no, that’s not what I’m saying. But what I am saying is, is that people get to compare the way they’re living with the way that they hope that they might live and function. 

Dr. Jennifer Gaudiani  32:37

And if they’re close enough, and they are not, doing things that harm them harm others, and they’re able to live their values. I’m okay with that. I don’t need to assert myself. Because if I assert myself, if I’m the one who says, Well, I’m the grand authority on exactly what recovery is.. People could very appropriately look at me and say, Dr, G, you have all the points of privilege. Bully for you to define recovery that way. Boy, that sounds really nice to me. That’s never been accessible to me. So why do you get to define it in those ways? I’m going to need to define it for myself. 

Dr. Jennifer Gaudiani  33:17

And I just love staying flexible. I love being an internist. Because I get the chance to really go deep on again, like, how is your body functioning, and how do you need it to function. And what are going to be the long term possible costs of this. While it’s so satisfying to be like, bright line, under it is bad and Over it is good. Or actually think that that reinforces the binary thinking of those with eating disorders. And by the clinicians staying more flexible and open and ready to hear different things, they actually model for their patients. That the patient could think about life too that way.

Lindsey Lusson  33:59

Yeah, yeah. And in your book, you do mention that idea. You talk about some physical signs that clinicians like to see as hints of someone getting to a place of recovery. And one of those is having a menstrual cycle, or having the menstrual cycle return. Why do you think some women can regain their cycle really, really easily? With maybe even not a lot of tweaks, maybe even still not maintaining a healthy weight for their individual body. And others struggle for years, or, like in my situation, decades. I know the answer to this question for me. But I’m just saying like in theory and what you’ve seen or like what you’ve observed in much more than a sample size of N equals one. 

Dr. Jennifer Gaudiani  34:45

It really comes down to non specific genetic sensitivity to environmental exposures. So the model that I love to use is that someone might learn of a person who, after five years have been drinking, dies of cirrhosis at the age of 30. and they’re like, Oh my gosh. that’s that’s so tragic. Then there might be somebody who’s 90, who’s been drinking heavily for years, and he like, toasts at his 90th birthday. And you’re like, What is this right thing with smoking. Same thing with exposure to any kind of environmental sort of toxic effect. 

Dr. Jennifer Gaudiani  35:24

Some people are going to be extraordinarily sensitive to it and have everything fall apart. And some people will be extraordinarily resilient to it. The truth is, is that, exactly as you’ve seen and experienced, some people never lose their periods. And some people lose it early and struggle like hell to regain it. The answer is just different genetic propensity to be sensitive to that. 

Dr. Jennifer Gaudiani  35:49

And it can be so confusing, because there’s so much comparison that that happens. Unfortunately, when it comes to Ed mentality, no one wins. The person who loses their period early and gets it back early. Or, sorry, who loses their period early and then gets it back late. Might be like, Well, I don’t even think that I’m as sick as so many other people I hear about. Why am I being singled out? Excuse me. And other people might say, Wow, I still have my period, and I know things aren’t going well. Apparently I’m not yet sick enough. 

Dr. Jennifer Gaudiani  36:25

So like, the ED mentality just always ends up being mean to the self over whatever the reality is. And we just have to focus on the individual person’s experience. 

Lindsey Lusson  36:38

Sometimes I’ll tell my clients who asked that question of Why did I lose my period whenever so and so is so much thinner than me? Or she’s training so much harder, or she doesn’t have any difficulty getting pregnant. She already has three kids. And sometimes, I’ll remind people that a missing period is sometimes a blessing in disguise. Because it’s kind of an undeniable evidence. 

Lindsey Lusson  37:00

Whereas the other person can justify, well, I never lost my period, and I’ve already completed my family. So I guess I’m fine. You have this opportunity to really work on healing the eating disorder. Which is going to bring your period back.Whereas this person could potentially live with a highly functional eating disorder for the rest of their lives. 

Lindsey Lusson  37:23

Where’s the gap in diagnosing eating disorders? Why you mentioned at the beginning of our interview that physicians do not get any training on diet? Is this correct diagnosing and treating eating disorders?

Dr. Jennifer Gaudiani  37:37

Yeah, almost done.

Lindsey Lusson  37:38

And yet I can’t diagnose as a registered dietitian. I understand that there’s a lot that goes into that. But of all the people who know the most about food and are probably spending the most time talking to patients about food, it’s interesting. And so how do we how do we fix this? Have you observed any changes in the medical field since you’ve published your book in 2018? Yeah, I think there

Dr. Jennifer Gaudiani  38:04

Yeah, I think there have been some really good developments. One of them has been a much greater recognition of RED-S Relative Energy, Deficiency in Sports. I think with coaches recognizing it more and more even since 2018 there’s less of a sort of, if I lost my period, I’m doing it right mentality. Was super prevalent, and,  even more recently. 

Dr. Jennifer Gaudiani  38:27

Now, I think people recognize, gosh, if I want to go the distance, as it were, and have bones that work and don’t fracture, and have ligaments and tendons that stay well… I actually think it’s a point of pride to care for myself well enough that I have my period. So there’s been a shift in sort of what the goal looks like, and a recognition of how vital Good nutrition is to that. 

Dr. Jennifer Gaudiani  38:49

I also think that there’s been, at least a couple of different bubbles of improvement in awareness of weight stigma and in the importance of recognition of the ills of diet culture. So probably back in 2018 when I published my book, I would say the eating disorder field as a whole probably had not yet embraced weight inclusive care. I think for the most part, everyone pretty much understands that that has to be a tenant of treatment. If not the central tenant. So that’s really improved.

Dr. Jennifer Gaudiani  39:23

And that means that finally, kind of the earliest circle of medical students are starting to embrace a fat positive or a weight inclusive care perspective. The earliest kind of sheen of of medical providers is starting to embrace it, And that’s really going to be the leading edge of where we go next. Because right now, the medical system is so deeply broken. And it’s broken for both patients and for providers. 

Dr. Jennifer Gaudiani  39:50

If you have minutes to see someone, you have to rely on split second visual cues even when they are completely wrong to try to make progress. To get everything done in eight minutes, that requires half an hour. That means that when you walk into the office and the overwhelmed nurse takes a quick look up and down and goes, you look great. She may have just silenced you from saying anything about what you intended to talk about that day. Which was, I’m not doing well. I feel really miserable, and I’m unwell and I’m not nourishing myself, and I need help. 

Dr. Jennifer Gaudiani  40:26

But that kind of comment is so powerful that it can completely silence someone. And then the doctor comes in and just makes certain assumptions based on your body. These harm everyone in every body size. It harms the thinner privileged people, because they are going to be missed in whatever they’re actually needing care on. And it, of course, harms the larger bodied people. Because they’re going to be judged to be having a different kind of trouble with food and exercise when none of that may be correct. 

Dr. Jennifer Gaudiani  40:57

So you know what we really need to do as a field of medical providers is stop assuming we know anything about someone’s health just by looking at them. Yes, perhaps on the very edges of the bell curve. We can probably assume that things aren’t going great, But for the very rest of every part of it, we actually have to ask patients, how are you doing? How are you caring for yourself? How is that showing up in your body? 

Dr. Jennifer Gaudiani  41:27

Because the medical system is so hyper focused on weight and weight loss as being virtuous. And the rest of society is focused on weight loss as being virtuous, that everyone ends up getting hurt.

Lindsey Lusson  41:42

I think it’s so hard you already talked about this, but anybody that is in a health related field, like a traditional medicine field. Dietitians, nurses, therapists, physicians, assistants. Our training is very, very deeply rooted in weight stigma and prevention of obesity and diseases that are associated based on, studies in being in a larger body. And so I think that anytime a healthcare professional is working with a patient, it’s a constant battle to fight against what is in the back of your head or your own internal biases. But I think just what you said is the answer. 

Lindsey Lusson  42:24

You can come in with those, but you still need to be curious and ask questions. And you need to treat the patient as an individual. Because the size of their body isn’t going to tell the whole story about what’s going on with them, physically, emotionally, socially, psychologically. Like there’s no way that you can know on both ends of the spectrum.

Lindsey Lusson  42:46

One of the other questions I got from followers is, what about long term damages from eating disorders? I know that we talk about, like digestive stuff. I know can do a total 180 through proper nourishment supplements when necessary. But like that nutrition just being a cornerstone. And fertility for the most part, I think, can also be reversed and healed. What are, though, some of the long term consequences of eating disorders that… Is there a point like that we reach that like the damage is done?

Dr. Jennifer Gaudiani  43:17

That is also going to vary by genetic makeup and sensitivity. It’s also going to vary based on duration, intensity of what the ED actually has looked like. On the whole, You’re right. Most medical complications of eating disorders can resolve. Our bodies are so miraculous. They are so resilient and extraordinary. They are not the enemy, they are absolutely the friend. We think, though, that many cases of low bone density will not fully normalize. Especially where adolescence is the time when people put down the majority of the strength of their skeleton and people of all genders.

Dr. Jennifer Gaudiani  43:58

And so if during adolescence you have a disruption in the axis of adequate nutrition, adequate types of nutrition and movement, as well as sex hormones. You may never actually mineralize your skeleton. And then around age 20, maybe as late as 25 in males, that door closes and you’re just dealing with what you’ve got. Then we’re talking about the bone you make and the bone you resorb. 

Dr. Jennifer Gaudiani  44:26

So that may be a permanent sequela. We’ve got great medicines now that can really help. I’m sure that we’ll talk about patch estrogen being so key for bone density, until someone’s recovery is in a place where their natural sex hormones come back. But early use of patch estrogen and really consistent use all the way through menopause, as long as there’s no obvious breast cancer family risk to watch for… And and really, I think the the gyns and the endos are now continuing patch estrogen just for Post menopausal estrogen safety until age 60, at least. 

Dr. Jennifer Gaudiani  45:04

So we really have things in our arsenal now medically that can improve outcomes. I think that a lot of dental damage can be irreplaceable. You can pay $30,000 and end up with a set of teeth that looks a certain way, But if you’ve had a long time of purging, you’re probably going to end up with an unbelievably high percentage of your money going towards dental work for the rest of your life. And so that is great motivation to be like, whoo, well, I’m not quite ready to ditch the eating disorder altogether. 

Dr. Jennifer Gaudiani  45:37

But maybe I can really reduce the purging or knock it out altogether. There are ways of thinking about this, but it can be hard. The ED in the moment can be so compelling that even that long term peace may not be motivational enough. And I don’t think, on the whole that we think that an experience, a history of an eating disorder, should permanently cause infertility. 

Dr. Jennifer Gaudiani  46:03

There are obviously humans who have never had an eating disorder and who are infertile. And so probably the ones who had an eating disorder history and who got fully recovered, who simply weren’t able to conceive. That was probably just in the cards for them, as it was, and it’s not due to the eating disorder. But I will just say doctors have been so guilty of saying something awful to young people with eating disorders. 

Dr. Jennifer Gaudiani  46:31

Which is in the doctor’s own distress intolerance, fatigue, overwhelm, lack of personal recharge their frustration with the suffering patient comes out. When they say to some sweet 12 to 18 year old girl, if you continue this, you will be able to have children. That is unacceptable.That is absolutely unprofessional and unacceptable. We can say, as of right now, your miraculous body is trying to save your life by shutting off sex hormones. 

Dr. Jennifer Gaudiani  46:56

And that’s so smart of it. Because we really do want to focus on keeping you alive. But we have a lot of motivations, your bone health, if you choose it, your future ability to have children that will help motivate moving you forward. But I recognize right now, 13 year old, having children is not exactly what you’re focused on. It’s a yucky, mean thing for a doctor to say, and yet it’s so common. 

Lindsey Lusson  47:30

Also, like, not true. Like, how do you know what is gonna happen to this 13 year old in 20 years? You know? Like, what type of foresight do you think that you have? But you’re right. I’m sure that it is a bit of like a scare tactic or the frustration coming out. 

Lindsey Lusson  47:48

You talked a little bit about the use of estrogen patches for someone who’s not cycling. And the way that I usually describe hormone replacement therapy to people, and again, we’re not typically supporting clients that are very sick and patient have tons of weight restoration to do. But like being a bridge in their recovery, until we get to a place where cycles can return. Or we’re at a stable place where we can really embrace the way that we need to nourish to get cycles to return. 

Lindsey Lusson  48:17

I’ve heard of some providers giving sick estrogen and then cyclical progesterone, with the thought process that this should jump start a cycle. Does that work?

Dr. Jennifer Gaudiani  48:28

No. So it’s so interesting. I think this has improved. But it remains, uh, painfully still present the the wrong way to do this. So many patients who at age 15, with hypothalamic hypogonadism. That is, they’ve lost their period due to nutrition oriented, stress oriented, loss of the period, loss of sex hormone. They put them on the pill. And then they say, Oh, so you’re having a period now, so you must be all better. Well, first of all, almost everybody with a uterus and a vagina, whom you put on the birth control pill will drop some blood each month.

Dr. Jennifer Gaudiani  49:07

And there may be really compelling reasons mood stability or terrible, horrible, heavy periods that are making your life miserable. Where you need to be on birth control the pill. Okay, but let’s be clear, we have not fixed the lack of period problem. That is still being encompassed in the body that is suffering from not getting what it needs. By contrast, while patch estrogen is not birth control, patch estrogen bypasses what we call hepatic first metabolism, first pass metabolism. That means your liver processes a certain amount of the estrogen when it’s taken by pill, so that it can’t get to the bones. 

Dr. Jennifer Gaudiani  49:45

Patch estrogen gets to the bones. And we can’t just give somebody what we call unopposed estrogen. That is estrogen patch all year long, and no progesterone. Because that risks building up the uterine lining until it’s so thick. It has the potential to turn cancerous. So let’s say that we have somebody who’s 14. They’ve been trying for a couple of months now, as hard as they can to really make progress in recovery. And maybe they’ve made progress, maybe they haven’t, but they’re not, like, right on the brink of really getting their period back. So that’s the kind of patient who we really encourage we might check an estradiol level. Maybe. 

Dr. Jennifer Gaudiani  50:23

If we want to just see, hey, this is less than 50. You clearly need this. But on the whole, if there’s budgetary constraints we put them on the patch. And we do say, once a month, for about 10 days each night, you’ll take some progesterone at bedtime. Because that’s when our natural progesterone surges. It helps us sleep, it calms down our bodies. And then maybe around day seven, you’re going to have a little bleeding. Maybe not. Your period hasn’t come back yet. 

Dr. Jennifer Gaudiani  50:52

We can only say your period has come back when you are off of all hormones, and it comes back on its own.

Lindsey Lusson  50:59

Yeah, thank you for unpacking that. I feel like it’s really frustrating for patients when they’re seeing their doctors as a, obviously, a doctor. A position of medical authority. And they can’t argue with them. Especially like a teenager and like white coat syndrome. I mean, you’re really just kind of like, I can’t tell you the number of times I left doctors offices in tears. Like I was like, well, nobody can fix me. Like, this is just the end and this is this is my life. So thank you for explaining that. 

Lindsey Lusson  51:26

In having conversations with a lot of clients around fertility with history of eating disorder, I’ve come across a handful of people who have experienced Primary ovarian insufficiency, POI, FSH levels, like 50. Like sky high, like just, there’s no question, like, that’s what’s going on with your body. Do you know of any evidence that connects having an eating disorder to decreased ovarian reserve, or even premature menopause or premature ovarian insufficiency?

Dr. Jennifer Gaudiani  52:00

I have not read any literature. That’s it, and I will look after our conversation. I’ll go in and dive in. But to my knowledge, that should not be what hypothalamic hypogonadism does. It should just put everything on ice. Then it should come back to wherever it was going to be. So I do suspect that that person was likely just destined to have premature ovarian failure.

Lindsey Lusson  52:24

And that’s kind of, that’s kind of where I was going with it too. Was like, maybe there’s some underlying autoimmune or additional stressor. But, yeah, it’s not a common pattern. I have seen some clients present with slightly elevated FSH during… I don’t know that their body’s headed there. But, or if we’re just like, capturing a snapshot of something that looks like it’s something that it’s not. It’s definitely a complex picture. 

Lindsey Lusson  52:47

And I do feel like majority of women are just told to start IVF. What do you think about people you know… I feel like this is another obvious gray area, controversial area. But the use of fertility treatment in clients with eating disorders, especially maybe when somebody might be out of weight or a BMI that might put them at kind of high risk for pregnancy.

Dr. Jennifer Gaudiani  53:11

An interesting study of a private fertility clinic… I think it was somewhere in Northern Europe, showed that 20% of individuals presenting for assisted fertility, when asked by private questionnaire, admitted to having an eating disorder that…

Lindsey Lusson  53:28

they haven’t had as well. I think that that’s pretty astounding. 

Dr. Jennifer Gaudiani  53:32

Yeah, pretty astounding, because that is way higher than population prevalence. So my deep belief having cared for many of my patients through pregnancy, which I love doing… As long as they’ve gotten into a good recovery spot. And I love, I love my patients no matter what. But it is very nerve wracking to support someone who was actively in their ED while they’re pregnant. Because you just know, like, Oh mama, oh baby, this is going to be really, really tough. 

Dr. Jennifer Gaudiani  53:59

The truth is, is that I always believe someone should allow their body weight to rise, allow their food to increase. If they can’t say they might say like, Oh, I’ve always been lean. I’m functioning well. Why would I gain weight before pregnancy if I don’t have to? I think maybe I just need assisted fertility. 

Dr. Jennifer Gaudiani  54:19

I think if somebody is loath to put on X number of pounds in order to allow their body naturally to cycle. They should not be getting pregnant, which requires the increased food and the weight gain and the body changes. Some of which are permanent. They’re just not ready yet. Yeah. So I always, at my like, casual, offhand is like, eat more and gain 10 pounds, and then let’s talk,

Lindsey Lusson  54:42

Yeah, for sure. I know, and I think that that’s so, so hard for people to reconcile. Because I hear the lie and I get this because I also felt this way too. Well, I don’t care about gaining weight when I get pregnant. I know that I need to gain weight then, but I don’t even want to gain five pounds now. Like it just doesn’t feel necessary or purposeful. It’ll make more sense when I’m pregnant. 

Lindsey Lusson  55:09

And some people do a great job of healing their body image when they’re pregnant. Sometimes can do make strides in their eating disorder recovery when they’re pregnant. In my experience of working with kind of 300 plus women on this issue, that’s not the typical case for people. 

Dr. Jennifer Gaudiani  55:28

I think that’s right. I think that that’s right. And look, our society is so fat phobic that we are programmed to fear weight gain. No matter what it comes from. So it’s not that I lack compassion for that. It’s perfectly understandable from the context of what we’re told. And if you’re about to embark on pregnancy and motherhood, boy, do you want to be in a really good place. With demonstrating you can consistently care for yourself, tenderly, emotionally, nutritionally, physically, before you’re meant to role model that for little people. 

Lindsey Lusson  56:05

And I always tell people that, like, if you’re uncomfortable having your routine shaken up a little bit now, when you have this tiny little human… Not even just like the first year this as like a mother of teenage girls. But like so, much of your routine is going to change during motherhood. So it’s so worth it. 

Lindsey Lusson  56:25

But thank you so much for your time. As a quick wrap up question, what would you say to somebody who is listening to this and they’re like, I just don’t think that I’m sick enough. I don’t deserve getting support. Any lost words of wisdom before we let you go. I know you got to go.

Dr. Jennifer Gaudiani  56:39

Yeah, no, I love that question. When it comes to deserving that is really complicated and it’s rooted in our whole background and our sense of self. What I like to say instead is relinquish the concept of judgment of deserving or not to some other power. Can you feel grateful that you are choosing to care for yourself through all the fear in a way that’s congruent with your values? And how you believe you could live your life. 

Dr. Jennifer Gaudiani  57:08

Can you feel grateful for that? Because if we can stay in that gratitude place of like this is terrifying, but today I’m going to increase my portions. Today I’m going to sit with fullness all day. I’m going to sit with body changes. I might even sit with athletic performance changes for a period of time while I care for myself. If I can sit in gratitude for making changes towards the life I envision for myself, that’s sufficient.

Lindsey Lusson  57:33

Incredible, incredible. Dr, G, thank you so much for your time. We might have to do a part two, because I could literally talk to you for hours…

Dr. Jennifer Gaudiani  57:39

I would love that. Thank you for everything you do 

Lindsey Lusson  57:44

Absolutely. Thanks so much. Dr, G, have a great rest of your day. 

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