Eating Disorders: Does Dieting Actually Make Them Worse? (Part 2)

Can you tell if someone has an eating disorder just by looking at them? Dr. Elizabeth Wassenaar debunks the "healthy look" myth and explains why dieting is toxic to recovery. This episode explores the critical "Nine Truths" of eating disorders, the role of genetics, and why early intervention is vital for long-term health. 

Find mental health and addiction treatment near you: https://recovery.com/

In this deep-dive, host Terry McGuire continues the conversation with Dr. Elizabeth Wassenaar, MD, a triple board-certified psychiatrist and the Regional Medical Director at Eating Recovery Center. Dr. Wassenaar leads clinical excellence in treating complex eating disorders and guides families toward sustainable healing. 

We cover the nuances of Binge Eating Disorder (BED)—the most common yet underdiagnosed type—and ARFID (Avoidant Restrictive Food Intake Disorder), a different entity driven by sensory avoidance or fear rather than body image. Dr. Wassenaar also breaks down the four levels of care: Inpatient, Residential, Partial Hospitalization (PHP), and Intensive Outpatient (IOP), helping listeners understand how much containment and support is necessary for true recovery. 

Whether you are a parent looking for signs, a professional seeking evidence-based insights, or someone struggling, this video provides a roadmap for navigating the "crafty" nature of these illnesses. Recovery is possible, but no one has to do it alone. 

Chapters:

00:00 – Intro

01:10 – Can you tell if someone has an eating disorder by looking?

05:02 – Why families are allies, not the cause

06:40 – Is it just a phase? The crisis of adolescence

11:02 – The role of genetics vs. environment

16:32 – Understanding Anorexia, Bulimia, and Binge Eating Disorder

19:46 – What is ARFID? Disinterest and sensory avoidance

24:00 – Why "just eat" or "just stop" is dangerous advice

27:45 – Explaining levels of care: Inpatient to IOP

44:40 – How long does recovery actually take?

52:34 – Common eating disorder behaviors to look for

Questions the Video Answers:

1. Can you look healthy and still have a severe eating disorder?  
2. Why is "you look healthier" a harmful comment?  
3. Do parents cause eating disorders in their children?  
4. Is an eating disorder a phase that teenagers grow out of?  
5. How does malnutrition affect long-term bone health?  
6. Are eating disorders genetic?  
7. What is the most common eating disorder?  
8. Can you have anorexia while in a larger body?  
9. What is Avoidant Restrictive Food Intake Disorder (ARFID)?  
10. Why doesn't dieting work for binge eating disorder?  
11. What is the difference between inpatient and residential treatment?  
12. Why do people with eating disorders feel they aren't "sick enough"?  
13. How does social media affect eating disorder recovery?  
14. What are the common signs of purging besides vomiting?  
15. Where can I find reliable eating disorder treatment?  

#EatingDisorderRecovery #BingeEatingDisorder #MentalHealthMatters

Transcript

SPEAKER_00 0:00

We have this assumption that if you are losing weight, you are moving towards health.

SPEAKER_03 0:06

Dr. Elizabeth Wassenar is the regional medical director at Eating Recovery Center. A triple board certified psychiatrist. She leads clinical excellence in the treatment of eating disorders, guiding families and teams toward recovery and healing.

SPEAKER_00 0:20

Never, ever, ever has an eating disorder gotten better with dieting. The thing that most people with binge eating disorder are prescribed is actually the thing that toxically reinforces the eating disorder.

SPEAKER_03 0:55

I found a list on the Academy for Eating Disorders, or AED, of nine truths about eating disorders. And I just pulled four of them. And I wonder if we can start there. The first is that many people with eating disorders look healthy, yet may be extremely ill.

SPEAKER_00 1:10

Absolutely. And by the way, I love that paper, Nine Truths about eating disorders. I strongly recommend people find it. It's available for free online. And so I think this picks up on a theme that we talked about last week that's so crucial is that you can't tell if someone has an eating disorder by looking at them. Eating disorders can happen to people in a wide, wide variety of sizes and shapes of bodies across a wide weight of bodies. And people who have disordered eating and have an eating disorder may not look like what you think someone with an eating disorder should look like, but that doesn't mean that they don't have an eating disorder and or their life isn't completely upside down because of the eating disorder. I also think that it gets people trapped a little bit if you have a loved one with an eating disorder, because you might feel compelled to say something like, oh, you look so much healthier, or you don't look like you have an eating disorder anymore. Two things with that. One, you might miss that they are still really tortured by the eating disorder. And then again, we get back to the theme we talked about last week, which is when you are making a comment about what you observe about their body, it takes away their agency of being able to determine what's going on in their body. So I think we have to be really careful with how we talk about people's bodies.

SPEAKER_03 2:34

It's interesting because you look so much healthier. Sounds like the right thing to say.

SPEAKER_00 2:39

I know, I know. And it feels like the right thing to say. And it can both undermine how much they're still struggling. And the other thing is so the eating disorder, and you will notice across both of these episodes, I often talk about the eating disorder as a separate entity. And I do that with intention because we know how eating disorders wind themselves through people's identity and then convince them that the eating disorder is the best part of them. And so part of the way that we treat eating disorders is to other the eating disorder. I remove the eating disorder from being part of who you are. It doesn't change the fact that I can understand and in individual relationships, we talk about how the eating disorder has functioned for you and against you. Yeah. When we talk about like the eating disorder doesn't like compliments. And this is true because if you are getting healthier, then you're moving away from the eating disorder. And that can be very threatening to someone who is especially in early recovery. Uh, it can actually be the thing that tips them over to, well, maybe I'll eat two bites less at my lunch today, and then I'll eat four bites less at dinner and it's a slippery slope. Any restriction when you're in early recovery can be the eating disorder re-emerging. So that's why a thing that sounds like a good thing to say to someone, you look so healthy, can actually be very, very harmful.

SPEAKER_03 3:55

So the safest bet is to just basically not comment on someone's appearance or not comment on someone's appearance.

SPEAKER_00 4:01

And or you could say something like, It looked like you worked really hard to eat your meal today. How can I support you? That's okay. Yeah. That's good. That's good. That can be very good. Um, I think it's it's okay to notice that people are working hard. It's okay to notice that they might be struggling. And it is very okay to offer how you can be of support. I think, you know, this is a sort of a nuanced difference to say, I can come alongside you and I want to come alongside you and support you with what you're struggling with versus I'm looking at you. Um and, you know, it it's a different way of being in relationship to be beside someone versus be looking at them. Interesting. It's a judgment thing. I think it's a judgment thing. It's a it sets up a power differential and it really, yeah, it it reinforces some of the things that made the eating disorder start in the first place. Yeah. You're making me think about the disconnection, right?

SPEAKER_03 4:56

When I'm here and you're there, it's very different than when we're next to each other because then we're in it together.

SPEAKER_00 5:02

Exactly.

SPEAKER_03 5:03

Another of the truths from the Academy of Eating Disorders is families are not to blame for eating disorders and can, in fact, be the greatest allies.

SPEAKER_00 5:12

This is so very, very true and so important. This is so important to say because we had a long-held belief that families caused eating disorders and we had to take kids, especially out of their family so that they could recover. Families do not cause eating disorders. Eating disorders are a mental illness. Families are absolutely a part of the process of recovery. They are the greatest ally. Again, we're talking about the fact that you recover in community, and oftentimes your family is a part of that community. Now, this doesn't mean that families intrinsically know how best to show up. So we know that there are environmental factors that can reinforce things that can actually feed into the eating disorder. And families are subject to those as well. We all live in this weight-obsessed diet culture. And so families oftentimes they don't know the right thing to say or they're worried about saying something wrong. And so part of treatment for an eating disorder is actually empowering the family, giving the family the tools that they need to show up in that relationship in a way that the support can be received.

SPEAKER_03 6:23

That would be so helpful because it's like, I don't know. I know if saying you look healthier is wrong, I would need some help. Right.

SPEAKER_00 6:31

And so often when families show up to treatment, well, when a when a person shows up to treatment with a family, the family shows up in a way of defeat and disempowerment. They don't know what to do. Everything they've done has been wrong. They may feel themselves. It will be better if I just stay out of it. That reinforces part of what the eating disorder is saying, which is you're not able to be in relationship. So part of the way a family recovers from an eating disorder is to stay in relationship as messy as it is, but accept the support to allow your family to give and receive help to each other.

SPEAKER_03 7:09

So a third truth about eating disorders, according to the Academy for Eating Disorders, is that an eating disorder is a health crisis, not a phase.

SPEAKER_00 7:18

An eating disorder is not just a thing that is self-limiting, a phase that you go through. Like it like. Right, right. I I think that there's this idea that, you know, all teenagers go through an eating disorder. All teenagers go through blah, blah, blah. It's true that many teenagers experiment with dieting and experiment with disordered eating, but an eating disorder is a mental health diagnosis. It is a, like we've talked about, a crisis. It is something that changes the course of your life when you have the mental illness. And it's not something that's self-limiting. It's not something that you can, you can just wait and see or watch and see. Well, maybe once they're out of high school, it'll get better. This is actually, it's so important because an eating disorder causes some degree of malnutrition, some degree of your body not getting what it needs to grow up to be healthy and strong. And adolescence is a critical period for growth and development of your body. Your bone bones grow and harden, your muscles grow and harden, you know, your whole body changes. Everybody knows. If you have a teenager, their bodies are changing rapidly. And that requires a tremendous amount of energy. And it is the kind of thing that it's hard, it's hard to get back on track if you've missed that window of opportunity, especially with bone health. So it is not something that you can just watch and wait. And then if it doesn't get better in a few years, then we'll do something about it. If you think your child has an eating disorder, I need you to talk to your pediatrician or pediatric provider as soon as possible.

SPEAKER_03 8:49

That's a great point because boy, if your bones and all the rest of it, right? That that is going to follow you through your life.

SPEAKER_00 8:55

Follows you through your whole life. And one of the things that is a little bit of a scary fact, but is important for people to know. So most of the things that malnutrition causes can be recovered with adequate and consistent nutrition, except bone health. We don't have a way to give people healthy bones if they have created bone weakness because of malnutrition. So it is something that will follow you your whole life, even if you are able to receive treatment and you're in recovery and now you're, you know, 40 years down the road, you may still have bones that are weakened because you had an eating disorder as a teenager.

SPEAKER_03 9:30

And when you think of other health conditions, right? We don't wait till we actually have a heart attack. There are warning signs. There are things early on, and we say, you know what? Let's let's just get it checked. Like what's the worst that can happen? It's going to cost us some time and some money, but we'll know. We don't tend to do that with eating disorders.

SPEAKER_00 9:49

I think that's true. Yeah. Oftentimes the thing that brings it to light is a crisis. Yeah. Is a critical lab, is someone who passes out at school or has some other kind of crisis that brings it to attention. And so, you know, I think it's something that's important to proactively talk about. As a parent, um, I would encourage you to look for resources. Like, how do you talk to your kids about protecting them from things that can really hurt them? Social media, um, you know, drugs and alcohol, eating disorders. You know, thinking about as a as a parent, these are things that you can access and you can you can find resources to sort of say, you know, I noticed that you've been changing the way that you've been eating. And as your mom, I'm worried about that. Can you tell me more about what you're doing with your diet right now? Again, we we have a way of engaging in conversation without saying, like, well, I noticed that you stopped eating meat. Are you do you have an eating disorder? Right. And it's not a helpful way to have the conversation. I think that there's a lot of opportunities to for families to empower themselves before the crisis.

SPEAKER_03 10:56

So one more truth about eating disorders, the genes and the environment play pivotal roles.

SPEAKER_00 11:02

They absolutely do. So eating disorders have a very strong genetic component. Uh, and and this is true for anorexia, it's true for bulimia, it's true for binge eating disorder. There's absolutely um some things that we're learning about uh avoidant restrictive food intake disorder or RFID that have genetic components. What we often say is that the genes set up the vulnerability, and then the environment actually pushes you over the edge. So um the there's genetic vulnerability that's not just a family history of eating disorders, a family history of other mental illness can also set up vulnerability. And then there's oftentimes an environmental factor, a trauma, a diet, something that's causing your body to become malnourished or overwhelmed with anxiety that pushes you sort of over that edge. And then there's often maintaining factors. So people may have a genetic vulnerability, they have an environmental trigger, and then they are maintained by living in a diet-obsessed culture that reinforces thinness and or having lack of access to resources that can help them be screened and identify an eating disorder early. These three things combine together to create a real toxic situation.

SPEAKER_03 12:16

So for anyone who did not listen last week or who did but might need a little refresher, can you please just redefine what an eating disorder is and isn't?

SPEAKER_00 12:25

So an eating disorder is a mental illness. It is a biologic, um, brain-based mental illness that manifests with disordered thoughts about food and your body and calories and nutrition, disordered behaviors about food, your body, exercise, nutrition, et cetera. But then also with a significant preoccupation that your worth is tied to the size or shape of your body. You are being judged based on the size and shape of your body, and that you have um you have to sort of maintain this for your worthiness. And then very often there's also a medical component that you are the malnutrition is causing medical compromise in some way, shape, or form.

SPEAKER_03 13:10

I'm understanding the different components, but I got stuck when you were saying your worth, your appeal, your lovability, all those things are connected with the way you look. Kind of feels in society like they are.

SPEAKER_00 13:26

Yeah, that's true. And this is part of why I think eating disorders continue to be so persistent because they are societally reinforced. Yeah. So we know, those of us that live in society, that when you lose weight, people have feelings about that. And oftentimes great. That's right. They think it's good for you. Like this must represent that you are taking care of yourself, that you are healthier. We have this uh assumption that if you are losing weight, you are moving towards health. And this is a very, very dangerous assumption because there are so many ways that we can move towards health that don't change the size or shape of our body. And there are so many ways we lose weight that are not associated with being healthy. So we have this, you know, false dichotomy of these two things.

SPEAKER_03 14:18

And that might be part of when I've heard you say that eating disorders are crafty.

SPEAKER_00 14:23

Is that that same sort of thread? So when I say eating disorders are crafty, what I'm referring to is that uh eating disorder, the mental illness, will do what it can to maintain itself. And so it will try to sneak in through the vulnerable parts of you. Um, I very often advise my patients to be vigilant. That eating disorder is going to try to sneak back in. Part of that is because it it is a really serious, difficult-to-treat mental illness. Mental illness doesn't give up your brain very easily. And that's true across the board. But eating disorders are particularly difficult to notice because a lot of the behaviors are societally reinforced. So a couple of years ago, everybody was doing the fasting thing, right? And it was like this normal thing. It was the this health-driven health-seeking behavior. But if you have an eating disorder, skipping breakfast and lunch is not good for your brain. And so it can look like you're seeking health, but actually it's the eating disorder sneaking back in. The other thing that I will tell people is that eating disorders will very, very often change the way they present. So if you've always, always, your eating disorder has always shown up with you counting calories and um running a balance sheet of in your head of always having just a little bit negative, and you've worked really, really hard on breaking that particular behavior. Now it can show up in a different way. Now maybe it shows up with steps. How many steps do you need to get in a day? How many steps are healthy? 10,000, 14,000, 30,000, maybe just a few more today than yesterday. So it can, it can shift the way that the behavior shows up, but the core of it is still you have to do more, you have to be less, and you are not worthy unless you do these things.

SPEAKER_03 16:17

So we talked a lot about eating disorders by name, and we haven't gone through what sort of the main ones are. And I think when a lot of people hear eating a disorder, you think anorexia, bulimia. And I don't know if those are actually the most common and the most concerning or just the most known.

SPEAKER_00 16:32

They they are the most known. So the kinds of eating disorders are there's anorexia nervosa, which is an eating disorder diagnosis that is associated with having weight suppression. So you are maintaining an artificially weight-suppressed state. And it's important to notice that in the field, we understand that anorexia sometimes looks like you are objectively underweight. And sometimes it looks like you are not objectively underweight, but you are weight suppressed and you are engaging in behaviors that are keeping you weight suppressed. And there's medical compromise associated with both states. So malnutrition is malnutrition, whether you're in a large body or a small body. And it is characterized diagnosively as atypical anorexia, but it, so that's the anorexia nervosa diagnosis that's associated with being in a larger body, but being weight suppressed. But it is very highly associated with medical compromise and highly underrecognized. So just because you have anorexia does not necessarily mean that you are objectively underweight. Bulimia nervosa is an eating disorder that's characterized by engaging in compulsive overeating and then compensatory behaviors. And compensatory behaviors means that you are undoing the food that you took in. So that can look like purging vomiting. It can look like using medications. Um, it can look like using exercise to undo the compulsive eating. And I think it's important for people to know that uh people with bulimia is it's not always like I overeat so I have to purge or I purge so I can overeat. It can look both ways. So oftentimes people think in this idea that if people overeat, they want to get rid of those calories because they're trying to change the size of their body. The purging behavior in and of itself can have uh components that are reinforcing to your brain. So this is something I think it's important for people to recognize about eating disorders. These behaviors that if you don't have an eating disorder, don't feel good. Like being hungry doesn't feel good. Vomiting doesn't feel good. Eating so much that you feel sick, it doesn't feel good. But when you have an eating disorder, it reinforces itself. The brain gets reward from it. And so that's one of the ways that eating disorders are maintained, is that the brain says this is good for us. And in fact, the opposite's bad. So an eating disordered brain will actually say hunger is safe and fullness is dangerous. So that's a little aside on bulimia nervosa. Good. Yeah. Um, binge eating disorder is the most common eating disorder, more common than anorexia nervosa and bulimia nervosa combined. Oh. It is also highly, highly underdiagnosed, very, very often miscategorized or misunderstood as lack of willpower, et cetera. Uh the majority of people with binge eating disorder do live in larger bodies, but not everyone. And binge eating disorder is characterized by compulsive overeating without compensatory behaviors. Okay. Now, that is not to say that binge eating disorder is just about overeating. Very often, individuals with binge eating disorder, um, almost always, have periods of restriction and then overeating. That is driven somewhat by, because when you overeat, then you have less drive to eat and you get into this really toxic cycle. But it can also, again, be driven by society and driven by diet culture. More often than not, when I'm treating someone with a binge eating disorder, at some point they went to see a healthcare professional and the healthcare professional prescribed them a diet. And that diet, becoming undernourished, actually drove their compulsive eating behavior and reinforced the binge eating disorder. It is highly underdiagnosed because if you are an individual with binge eating disorder, you go to your healthcare provider and you say, you know, I've been trying this diet, but then I get really hungry and then I eat more than I meant to, and I feel really sick and it's really embarrassing, and I don't really know what to do about it. Very, very unfortunately, your healthcare provider might just say, Well, you just need to try harder at your diet. You just need to be a better dieter. And not recognizing that what you're describing is binge eating disorder. Yeah. And it has a treatment and it will not get better with dieting. Never, ever, ever has an eating disorder gotten better with dieting. It is uh the thing that most people with binge eating disorder are prescribed is actually the thing that toxically reinforces the eating disorder.

SPEAKER_03 21:17

It's reminding me of another mental illness that no one with anxiety has ever gotten over their anxiety by having someone tell them to stop worrying about it. Exactly. It's like if I could, I wouldn't have anxiety.

SPEAKER_00 21:30

Right. Exactly. Exactly. And I think that, you know, binge eating disorder is is so tough because a core component of binge eating disorder actually is the shame of it. And so it's very, very hard to talk about it. It intrinsic is it in it, is that you are an unworthy person because you lose control around food. And we again, we have the societally held belief around the morality of food and how we consume. And we should enjoy food, but not. Too much. And we should be able to eat whatever we want, but also maintain a certain kind of physique. All of these conflicting messages create an environment where the mental illness again is reinforced by society. And then the last the last eating disorder diagnosis that I don't want to neglect because it's it's different, it's called avoidant restrictive food intake disorder or ARFID. And RPID is a different category, different entity. So it is still an eating disorder in that you will have medical compromise for malnutrition, but the lack of nutritional intake is actually not driven by a wish to change your body or a belief that you will be more acceptable if you change your body. It is more driven by some kind of food avoidance that's either like you don't like the texture of food, you're fearful of what food might do to you, not related to your body size or shape, but you worry you might choke or vomit, andor you are disinterested in eating. And there is a category of people with RFID who actually forget to eat. They don't have hunger cues, they're preoccupied with other things. We see this more and more now, especially with video games and with social media, the way that it hooks the brain. And you just forget to eat to the point that you become malnourished enough that you have to go to the hospital. Uh RFID is a different diagnosis and has sort of a different way that we approach treatment, but nevertheless, it's a serious eating disorder.

SPEAKER_03 23:27

Yeah. We're actually going to be doing an entire episode on it with another, another expert. So I'm going to ask you two questions. I'm going to sound like a total jerk asking, but I'm saying it because I know that implicitly or explicitly, people hear them. And it's, you know, if you are not eating enough, why don't you just sit down and eat some more? I've seen you eat, you know how. And conversely, if I think or society thinks or whatever that that you're eating too much, stop it. Just exercise more control. How dangerous are those things to say or even think?

SPEAKER_00 24:00

They are so, so dangerous to say, to think, to believe. Um, I think, you know, we've talked a bit about how there's a societal misunderstanding that eating disorders are a mental illness. And it is not a vanity thing. It's not a willpower thing. It's not a just do a different behavior. That's not to say behavior change is not part of the treatment for an eating disorder, because it is, but it is supported behavior change. And that behavior change should be supported not only with the sort of support you need to do the thing different, but then also the therapeutic and dietary support to help you have persistent and sustained behavior change. When when we say things like, well, just eat or just stop eating, it absolutely reinforces and undermines to an individual that this is not that big of a deal and I'm the one that's failing, rather than what I hope that they understand that this is a serious illness. And if if you could change your behavior, you would be. And I I say that all the time when people are sitting in my office. If you could have done this before, you wouldn't be here. Nobody wants to go into treatment, travel across the country, take themselves out of work or school, out of their family and community. And so if you are choosing to get help, it's because you couldn't, you can't do this alone. Again, we want to say that with the utmost compassion. Yeah. You cannot do this alone. I'm I'm so sorry that your mental illness and society reinforced that you should have been able to. Sometimes we say in treatment, stop shoulding all over yourself.

unknown 25:42

Yeah.

SPEAKER_00 25:43

Because that should is a shame statement that you should be able to do this. And so I think that just eat or just stop eating, those are should statements. And that is based in shame. No one ever got better in shame. Never.

SPEAKER_03 26:00

You're talking about treatment. And I want to ask you are eating disorders treatable? And what does recovery from an eating disorder look like?

SPEAKER_00 26:09

Recovery looks like you are living each day with making decisions in service of your nutrition, your mental health, your psychological safety, and living your best life without the eating disorder. And that is intentionally a bit vague because it does look a little bit different for every person. Recovery does not look one way, nor does it feel one way. So oftentimes people will be doing all the things that they need to do, but they still feel bad. And that may be what recovery looks like today is that your eating disorder is telling you to do a thing and you're not doing it. And it feels like you're doing something wrong. So I think that recovery is a really imperfect, amorphous entity. It's making choices each day in service of your recovery. I think it's another analogy to the addiction field where we say one day at a time, just today, choose your recovery. Don't worry about tomorrow. Don't worry about yesterday. All you have is today. So I think that recovery looks a lot of different ways. And it is very, very often a combination of behavior, of engaging in values-driven things that matter to you and in being vigilant and noticing how that eating disorder might be trying to sneak back in.

SPEAKER_03 27:37

When we talk about treatment for an eating disorder, are we talking about medical care? Are we talking about mental health care? Are we talking about both? What does it look like? What does the treatment itself look like?

SPEAKER_00 27:46

Yeah. So the treatment itself for an eating disorder looks like multidisciplinary team. This is a buzzword. We use it all the time. And it's a buzzword in the field of mental illness, uh, mental health care. But um multidisciplinary team means that it's not just one thing. Okay. So what it means for an individual with an eating disorder is that you need someone who is on your team who is able to support your medical stability, your psychiatric and psychological stability, your the therapy part of it, and the dietary component. Oftentimes it looks like engaging in uh treatment with different professionals, different specialists. So uh oftentimes you will have a medical doctor or a psychiatric provider who is providing you support for both the medical and or psychiatric safety. The therapist, um, I I very much encourage people to be engaged with an eating disorder-informed therapist. So an eating disorder-informed therapist is someone who knows how to use evidence-based psychotherapy for the eating disorder. Okay. And there are a lot of different kinds of evidence-based psychotherapies for eating disorders. And so for each individual, they might have an individual experience of what that means. But I think it's very important that your therapist knows how the eating disorder, again, might misuse your attempts at getting healthy by sneaking back in. And so, you know, having a therapist that understands how to support someone with an eating disorder means they know how to ask those direct questions about your eating disorder. They don't shy away from it and that they know how to use um psychotherapeutic techniques that are specifically helpful for people with eating disorders. And then an eating disorder-informed dietitian is a critical part of a treatment team because part of the eating disorder is the malnutrition, right? The way you're interacting with food. And not all dietitians are eating disorder-informed. So just like we've said that so many people with binge eating disorder are misprescribed diets. If you are not working with an eating disorder-informed dietitian, they might inadvertently give you advice that actually reinforces your eating disorder. So working with an eating disorder dietitian is such a crucial part of making sure that you are adequately interrupting that malnutrition cycle. You're getting the kind of nutrition you need. All of these pieces can happen in different ways. Uh, many, many people assemble an outpatient team. They call their insurance and they figure out who's in network. They ask their, they ask one member of the team, who else do you work with? Um, they Google eating disorder therapists in my community and start making cold calls and trying to find um resources. There are so many virtual settings now for uh individuals who are eating disorder informed, so that many of the barriers to receiving eating disorder care are now dissolved because you can see a therapist who lives four hours away, but it's still in your state. And so it gives you more options than you ever had before. And yet, assembling all these pieces and also the work of interrupting an eating disorder means that you're nourishing your body regularly, you're interrupting other behaviors, and you're taking care of yourself. That can be a lot to manage. And you have a life. And you have a life. Exactly. So many people do decide, they make the hard decision to go away to treatment. Going into treatment for an eating disorder can mean a lot of different things. Um, but we generally describe there's there's sort of three or four levels of treatment that are generally described in eating disorder world. So um the highest level is going to be inpatient for eating disorders. What that means is that you are in a 24-7 hospital-like environment where very often you're you're being cared for like you were in a hospital. So in a behavioral health hospital. So bathrooms and bedrooms are locked. Um, you have someone who's giving you medications out of a medication room. You're being monitored really, really closely and provided a very high level of support. Probably also means that someone's delivering you the amount of food you need six times a day. This is how often usually people eat an eating disorder treatment. The three snacks and three meals a day. And somebody's watching you eat it, and then they're encouraging you to finish it and they're recording if you didn't. So it is a very high level of support and containment. And it's for people who need that much support and containment. We know that if you have a severe eating disorder, sometimes in the five minutes that your mom walks out of your bedroom to go get um that glass of water that she forgot on your meal, that food goes into the toilet and you don't need it. So, you know, if you are in that place in your eating disorder where it is just creeping in all over the place, um, you may need inpatient care. We can also provide a high level of medical support.

SPEAKER_03 32:46

When I hear that, I think I'm glad to know that that is available for people who need it. And how would you be in that environment and not feel like something's really wrong with you?

SPEAKER_00 32:57

Because it's true that you don't get to that environment unless you have a really severe eating disorder. And, you know, I think this gets back to one of these core things we've been saying uh all along is that, you know, accepting help is actually part of moving towards recovery. And your eating disorder is going to hate it. So your eating disorder is going to tell you two things. One, you're a failure because you need help. Two, you're not sick enough to need this much help. Every single day at these high levels of care, patients are telling their providers, I'm actually not sick enough to be here, like everyone else is, but I'm not. And that is a part of the eating disorder. It actually, part of the eating disorder is it shields you from knowing how bad it is. I believe that you believe that. And here's what these labs are showing me. Here's what this data is showing me. See that you haven't had anything but water in four days. Your body needs calories to survive. And the eating disorder will say, not mine. Mine doesn't. I I'm okay. I have enough reserves. I'm good. An inpatient level of care is a very significant decision. And when you need that much support, you need that much support. And, you know, we've talked a lot about how the eating disorder is crafty and it can sneak in. And one of the ways it sneaks in is by telling you you need less than you actually need. You have a serious eating disorder and you need a very high level of support and containment. Um, but your eating disorder is saying, oh, you can probably do it with less. But it's a way to maintain your eating disorder. And there's a balance. We always want people to be in the lowest level of care that is necessary for them to get the help that get and receive the help that they need. And sometimes we don't know until we try. And then we see, oh my gosh, that eating disorder was a lot craftier than we thought it was.

SPEAKER_03 34:46

Can I say one more thing? Before essential. So I didn't love the way I asked that question because I said something's wrong. And is there is there is something wrong, but is the distinction to be made? Nothing's wrong with you as a human being. There's something wrong. And together we can address it. And you as a human being are wonderful, and you'll feel more in alignment with that after this. Is that am I? I don't even know if I'm right, but I hate, I hate, I don't like that I used the word something's wrong.

SPEAKER_00 35:18

Well, and that's off that's the inner narrative. So that that's a that's an accurate reflection of what the eating disorder is actually telling the individual. But I think you're right that there's there's nothing wrong with you person, you human, living your human life. Um, the eating disorder is making you think something is wrong with you. And also you you may need a high level of care because that eating disorder has really devastated your body and your psyche. And so, you know, I think that it's it's an accurate reflection to say, like, something is wrong. Like I don't know why I can't just sit down and eat. I don't know when I stopped being able to control how often I vomit. I don't know why I can't stop my brain from counting calories. Like, I I really don't know. And very often the individuals who sit with me, they don't know why. It's just that all of a sudden their brain is being held hostage. So I I think it's accurate to say something is really wrong. And you human are absolutely perfect. And for being here, you are wonderful. You deserve to have a lovely, joy-filled, full, messy life. Um, and the eating disorder is wrong.

SPEAKER_03 36:35

And if you are requiring that level of care, I'm assuming if you don't get it, it's not good.

SPEAKER_00 36:41

Yeah. If you are requiring a high level of care. So we've talked already about how eating disorders are not self-limiting, they're not a phase, they are not a thing that people just sort of, if you just kind of like watch and wait, it gets better. Um, and when you are sick enough to need an inpatient level of care, very often you are both medically and psychiatrically highly compromised. And the time between now and crisis is much, much, much shorter. Um, and so when people become aware that they need an inpatient level of care, which you might on your own, you might sort of look at all the data and say, I think I need a lot of help. But more often than not, because of the way the eating disorder works, someone has to tell you you actually need more help than I can give you in this environment, whether it be your outpatient team or in a lower level of care. Your time to get to that level of care and get that much support is very short. You need to get there. These are the sorts of things in our field. Like we, when you are that sick, we have to act quickly because when your body starts to collapse under the weight of malnutrition or lack of weight of malnutrition, you know, your blood sugar falls, your electrolytes become abnormal, you're gonna have heart failure, you can um have um uh fatal hypoglycemia. Um, and so the your risk of death is quite high. And I need people to understand, like this is part of why we talk about like why why it's so serious to understand how serious eating disorders are, because people don't always look like they're walking around right next to death. But if they haven't been eating and they have no glucose stores and their electrolytes are abnormal because all they've been subsisting on is water, their risk of having a seizure, of having a heart attack, of having hypoglycemic crisis is quite high.

SPEAKER_03 38:30

So ideally, we notice and get help earlier. That's right. So yes.

SPEAKER_00 38:36

So hopefully people are able to notice and get into care earlier. So residential level of care is also a 24-hour care environment. So what that means is that you're not living at home, you're living somewhere else, and you're supported by a staff that is helping you get through each day. Um, generally, there's still some degree of both psychiatric and medical support. So we're watching labs, we're watching your vitals, um, we're watching your safety. Um, as we've talked about, suicidality is a really big deal when you are in an eating disorder, both because of the eating disorder and because we're challenging the eating disorder. And so we're watching that very, very closely. But in a residential environment, uh you are you have a little bit more ability to decide about treatment than you do in an inpatient environment. The bathrooms may or may not be locked, the bedrooms may or may not be locked. We are able to trust that you are able to ask for and receive help a bit more than in an inpatient environment, but there's still a quite a high level of containment and support. And you've made the decision, I can't stay at home. I can't be alone at night. I need support with that. The next lower level is called partial hospitalization or PHP. It's a day program. So this is the kind of level of care where you go in the morning and then you go home at night, either to your own house or to maybe a mutual living environment, like you sharing apartments with other patients who are in treatment. During that PHP day, you're getting meals, you're doing therapy, you're seeing your providers, um, you're meeting with your dietitian. So important. Um, and we're monitoring that you're weight restoring or interrupting your behaviors, but you have more freedom. Typically, you can walk in and out of the buildings. You have to make the decision every morning to get up and go in. Um, and you have to make the decision that when you go home at night, you're not just going to use your eating disorder all night long or engage in some other kind of behavior that's going to interrupt your ability to seek recovery. So it's an environment of care that is it's still a lot. You're not be able to work, you can't go to school because you're there every day, but you have more freedom to begin to practice with what recovery looks like for you. The PhD level of care is my favorite level of care because it's where the rubber meets the road. So now we're gonna know. Every day I'm gonna be able to see you and see how it's going, but you have the ability to make decisions in the evenings or through the day about how you show up in treatment. So I think we really see where are the vulnerable places? Where do we need to shore up this treatment plan?

SPEAKER_03 41:05

I'm assuming that's a level of care that people step down to versus start at because you need to learn the skills.

SPEAKER_00 41:12

It it depends on the individual. So um a lot of people start at the PHP level of care and or a PHP is actually a step up because they were in the next lower level of care, which is intensive outpatient. So uh PHP is just this sort of nice middle space where some people are stepping down, some people are stepping up, some people are entering care in this environment. And it's going to really depend on what's going on for you and also how much are you able to interrupt your eating disorder on your own? And again, this is not a willpower or judgment thing. This is just information. And so, you know, what when I'm working with people, I'm I'm always sort of being curious with them, like what is your behavior telling us about how much support you need? Yep. And then we'll go from there. The last level of care is intensive outpatient. And intensive outpatient is um mostly uh it has a lot of group work. That's one part of eating disorder work uh across the the levels of care is there's a large component of what we call milieu therapy, or basically group work. So it's part of being a part of an intentional community of people who are working on similar goals and supporting each other and sometimes not supporting each other. Um, and being a part of an intentional treatment community is in and of itself treatment. IOP or intensive outpatient relies a lot on the milieu part of it. So it relies a lot on being a part of an intentional environment and engaging in groups. You still have support for your meal plan, for behavior interruption, for psychotherapy work. Um, and in some cases, you still see a psychiatrist or a medical provider. But for the most part, you're in your life. Nine to 12 hours a week, you're in program, but the rest of the week, you're going to work, you're going to school, you're doing your family. And it's a time and place, it's a, it's a way to sort of recognize like, how are you able to practice with recovery? We get back to that first question of like, how what decisions do you make each day to serve towards recovery rather than away from it? And IOP is, again, if you've been an outpatient, it's a step up in care. I mean, nine to 12 hours a week is not a small amount of time. Um, for many people, it's a step down. So you've been in a high level of containment and now you're trying to reintegrate to your life. And for some people, this is the very first place they ever encountered treatment. They thought to themselves, I think I have an eating disorder. They went online, they Googled it, they found a treatment facility, they called a number and they said, Here's what's going on. And that intake person said, It does indeed sound like you have an eating disorder. And I'd like to recommend you start in the intensive outpatient level of care. And so it it is, you know, any one of these is a place to start, um, a place to go or a place to end. Um But, you know, I I think that one thing that is very helpful when you think about the levels of care and the spectrum of it is that when you have an eating disorder, we we want to give you the most and least containment that you need. Right. So we we want to be able to meet you where you're at, provide you as much support as you need, but also as much freedom as you can tolerate to practice recovery. And then we want to gradually decrease it over time and allow you to practice with this new level of freedom and not use your eating disorder. What I find is that if someone say had a very serious eating disorder and they required an inpatient level of care. So they needed a lot, a lot, a lot of support and containment. When they're done needing that much support and containment, if they were to drop all the way down to outpatient with nothing else. Now they go back to just seeing people in an outpatient environment going to appointments, that's a lot of change. And as we've talked about, that eating disorder will try to sneak back in. So the way to help yourself be resilient is to let yourself step down through the levels of care, move back up if you need to, accept help if you need it, and then work back down through those levels of care back to your outpatient environment, your outpatient team, your life outside of treatment. Um, and really giving yourself sort of this graduated way of being ready to live a life in recovery.

SPEAKER_03 45:28

That requires money. That requires time. That requires you being able to leave your job and still pay your rent. Yeah. I mean, it's a very and and then the difficulty of the treatment itself. It sounds like a real hard place to be in.

SPEAKER_00 45:40

Yeah. You're you're not wrong that accessing treatment is a privilege and requires that you have the financial ability to do it. And uh it's a travesty of our healthcare system, the way it's set up. And I don't think it's unique to eating disorders. I think most mental health care requires some degree of privilege and access. And because eating disorders are such a difficult disorder, it it does require more. And I don't want to have people feel discouraged. Like if you can't take time off from your job, then don't even try. Still access what you can. And, you know, any way you can interrupt your eating disorder is a day that you are moving towards recovery. So, you know, any single day, any single moment where you choose to eat one more bite of food instead of one less, you are doing the work. Also, I I wish, I wish I could wave a wand and make this kind of treatment accessible for everyone. We do know that uh eating disorders should be covered by insurance. You know, our mental health parity laws tell us that they should not be an exclusion, exclusion or exclusionary uh diagnosis. And so if you are running into that, I encourage you to, you know, uh talk to your healthcare providers, talk to your friends and family, um, ask your insurance self, you know, how can this be? You know, many treatment facilities will try to work with your resources as best that we can. So don't not call just because you think it won't be covered. Most treatment facilities I'm aware of will have a conversation with you and check your benefits without any cost to you. So there's no cost to you to have that conversation with a treatment facility. If you have no insurance at all, you've absolutely no insurance, you're not covered, you're, you know, you're off your parents' plan, et cetera. There are um foundations that provide scholarship, um, both treatment facilities, and then there's an organization called Project Heal that provides scholarship uh for eating disorder treatment. And there's absolutely no doubt that it it's a it's a privilege and that it is a barrier to care for some people, both the cost and the logistics of it.

SPEAKER_03 48:05

And we it's hard because you, you know, you want to provide hope, of course. Um, and we have to be realistic. We do. So this is from the internet. How long does recovery for eating disorders actually take?

SPEAKER_00 48:17

That is not a question I can answer for any individual. Um, because it takes as long as it takes. And that's the real answer. So eating disorders are the kind of illness, and there are some other mental illnesses that are like this, where if if I tell you I need you to change your behavior for the next like 30 days, and then after that, you won't have an eating disorder anymore. Most people can can do it. They they can do it. Like if I have my life back, if I just do this one thing for 30 days, that they will do it, but then the eating disorder comes right back. And so it's the kind of disorder where it takes as long as it takes, and it's going to take every day for the rest of your life to practice the recovery behaviors. We we have some data to say, you know, if you are accepting nutrition, like how long will it take you to weight restore? How long will it take you to become nutritionally stabilized? And that's something that your individual treatment provider should talk with you about. But there's no blanket answer of just, you know, it's not a 14-day course of an antibiotic, and then you're just better. Wouldn't that be nice? Wouldn't that be nice?

SPEAKER_03 49:26

So we're asking questions and answering questions from the internet. I want to ask you a question about the internet. So when you're seeing fads like what I eat in a day, and when you Google healthy recipes and it comes back and you can I I can tell, you know, like this isn't, wait, this is I don't, what did I just tap into here? How do we protect ourselves and the people we care about from being bombarded by information on the internet that will not serve someone with an eating disorder well?

SPEAKER_00 49:57

That is such a good question because it is, it is a sticky and difficult situation. It's it's really hard to Google or find information that supports holistic health and doesn't inadvertently reinforce these sort of thin equals health diet culture and eating disordered ideas. So, you know, I think you mentioned if you Google healthy recipes, I think if I were to Google that, I would get an ad for a GLP1 receptor agonist. You know, it's like it's it's almost impossible to not get some of these um things that are coming across. So what I'll say is one, for yourself, for your loved ones, you need to be vigilant and observe what's coming up on your algorithm with discernment. Um, if I, you know, for children and adolescents that are accessing the internet, I want to know what let's Google things together. Let's look up recipes together. Let's find things that are um actually in service of what are your values and how how can we align that with them? Uh and then, you know, I think as we've we've sort of talked about the social media algorithms, they are very, very reinforcing. If you just even pause on a certain kind of advertisement for too long, it will send you 20 more of those advertisements. And so, you know, we know that if, you know, if you spend time with eating disorder reinforcing content on the social media, then it sends you more of it. And so this is where I would say, you know, be very honest with yourself about your ability to tolerate that kind of information. Take breaks from social media, hand your phone over to your therapist and have them delete, delete, delete. Unfollow is unfriend.

SPEAKER_03 51:42

Like if it's coming and it's just you can block it, you can unfollow it, you can say see less. Yeah. You can't how much it helps, but you can do those.

SPEAKER_00 51:50

You you can, I do think it helps. Um, the other thing I will say, and this can be really hard, is that it's not all media and advertisements. Sometimes it's our friends and family. Oh, yeah. And so we need to also have discernment of like, you know what, I just I can't take any content from this high school friend right now who's posting about her diet or her lifestyle change or whatever that might be. Be judicious. This this is a consumable. You are, you are taking it in. Your brain is changing because of how it interacts with social media. Um, you know, you you can and should be judicious with how you spend your time and take breaks.

SPEAKER_03 52:29

Another internet question is what are common eating disorder behaviors?

SPEAKER_00 52:34

Common eating disorder behaviors are so, you know, the the ones that I think people know about are restrictive eating that can look all sorts of different ways. So it can look like pure caloric restriction or counting calories. It can also look like restricting certain food groups or types. And this can also overlap significantly with bad dieting. So, you know, like maybe like high fructose corn syrup is the thing that the world has decided is the enemy right now. And so, you know, you're you individual are restricting high fructose corn syrup. It looks like you're seeking health, but it's a it's an eating disorder behavior. Purging behaviors, which is to uh compensatory behavior. So you're getting rid of calories, uh, can look like vomiting. It can look like using laxatives or diuretics, it can look like excessive exercising. And so uh that is an eating disordered behavior. Uh, the things that are less common that people might not know about, so uh there's uh chewing and spitting, which is where you chew up food and then you spit it out so that you can have some of the flavor experience of it, but without the calories, water loading or drinking water instead of eating, very, very dangerous behavior because it can disrupt your electrolytes and make you have a seizure. Uh, we see something that's uh sometimes coined um drunchorexia, which means that instead of eating calories, you drink them. Um, there is a very, very difficult overlap of substance misuse and eating disorders, um, especially in college-age students. People with diabetes or who have insulin will sometimes misuse their insulin, and that can be called diabolemia, which is where you are using your diabetic medication to re-to engage in purging or lack of basically you're interfering with your body to take up calories. Um, and then there's a couple of other behaviors that sometimes go along with eating disorders that can be really difficult to talk about. One is called rumination, which is where you bring up food, you chew it, and you re-swallow it. And I know that sounds really gross and really hard for people to hear. It is a behavior we see in eating disorders that sometimes accompanies purging, but not always. The reason why I want to mention it is because these behaviors can have a lot of shame associated with them. And people may have something going on, a behavior, and they think are thinking when they're listening to this, no one's ever even heard of this. No, this is like something my body is doing. It's so weird and gross. It's not. Come tell your eating disorder provider about it. I bet we've heard of it before. And then the last one is compulsive overeating is an eating disorder behavior. So eating past the point of fullness to the point where you're making yourself feel sick, eating a larger amount of food than is sort of typical or then your body needs. If someone has had gastric bypass surgery, this can look like crazing behaviors, eating through the day, andor eating foods that are contraindicated because of your surgical pouch. And if you eat foods that are actually contraindicated or you're not supposed to eat, they can make you sick too. So you can you can have vomiting, you can have something called dumping syndrome. And that can be a natural reaction to you didn't know that bot that food was going to affect you that way. Uh, but it can also be, especially when you're doing it with intention of disrupting your body's ability to take in nutrition, it can be a disordered eating behavior.

SPEAKER_03 56:08

As we wrap up and we are at time, as a doctor who treats people with eating disorders, what do you want to leave as a message for someone who's watched this, maybe both episodes, and is thinking, I think I need to get some help, or I think I need to help somebody I love or care about get some help.

SPEAKER_00 56:28

Yeah. So the the thing I want you to know every day is that treatment works and recovery is possible for eating disorders. So if you are sitting there thinking, I I think I need help, but I'm not sure if I can get help. I'm not sure if I'm helpable, you are. You are helpable. Um, and there is a life beyond an eating disorder. And uh there is treatment available. Um, it will require you to do some work to get to it. It it doesn't just come to you, um, but please ask for help. Remember that no one recovers alone and you shouldn't either. It's not, it's just not possible to recover alone. Alone in an eating disorder is how the eating disorder maintains itself. So please reach out for help. Please remember that you can receive help. You can benefit from treatment. Um, and I think that, you know, as we've sort of said throughout this podcast, so, so important to remember that eating disorders are a real mental illness. Um, they require real evidence-based multidisciplinary treatment. And it does exist. It is available for you.

unknown 57:42

Excellent.

SPEAKER_03 57:43

Thank you so much. I appreciate your time. And if you are looking for treatment, one option to avoid going down the rabbit hole of the internet and finding information that may or may not be reliable is recovery.com. You can look and search your area, your insurance, eating disorders, and anything else you might have and get some information, and at least you'll know it's a reliable starting place. Thank you so much for your time, and we'll be back next week with another topic.