Maintenance Phase - Eating Disorders

Episode Date: March 30, 2021

Fat people have them too! This week, special guest Erin Harrop tells us about one of America's most under-diagnosed and misunderstood problems. Along the way we talk about elbow bumps, Twitter etiquette and '90s sweatpants. Our content warnings are becoming increasingly threatening.Here's Erin's faculty page and a bunch of her research!Support us: Subscribe on PatreonDonate on PayPalGet Maintenance Phase shirts, stickers and moreThanks to Mitra Kaboli for production support and Doctor Dreamchip for our lovely theme song!Support the show

Hi everybody and welcome to Maintenance Faze, the podcast where we don't give a fuck what the BMI says about eating disorders. We care what? People with eating disorders have to say about eating disorders. Every tagline has to be negative about the BMI from now on. This is a BMI roasting podcast. My name's Aubrey Gordon, and I am here with my co-host, Michael Hobbs. Hello.

If you'd like to support the show, you can do that at patreon.com slash maintenance phase. You can also get t-shirts from us at T-Public. And today we have a really rich and potentially triggering conversation that we wanted to share with you all and to give you a little heads up about. Rich and triggering. It's really the sweet spot that we aim for.

I mean, it's good, but don't listen. It's a great conversation that you should never hear. So, okay, listeners, this is us. This is now. We recorded this episode a couple months ago with one of our great friends, this is us, this is now, we recorded this episode a couple months ago with one of our great friends, Aaron Harap. And because it's our first guest episode, we forgot to do a lot of like basic housekeeping stuff.

I played the rough cut for my boyfriend and my boyfriend was like, who is this woman who you're talking to? Like you don't really introduce her in any detailed way, which I feel bad about because Aaron's like a friend of mine. So we just like went into the chatting without really saying that she's a clinician for eating disorders. So she actually sees patients and she's also a researcher who specifically studies eating

disorders in fat people. We also wanted to mention that because we're talking in pretty unvarnished terms about eating disorders, that there is mention of specific calorie counts and a couple of instances, there are mentions of specific weights and a couple of instances. If that's not something you're up for hearing at the moment, you can just pass this episode right on by

as a fat person who has had a eating disorder, this was a real mind blower to me personally. Although Aubrey is actually absent for much of this episode because she had a weed whacker in the background. And so when I was editing it, I would go through and you'd be like, that reminds me of the biggest nightmares to record like this was First so if this episode is difficult for you to listen to know that it was also difficult for us to make it For logistical reasons I really like how many of our intros are just like please don't list of this

We will pay you So without any more of our current ado I know, just, we will pay you to stop it from now. So without any more of our current ado, here is our conversation with Erin from December. Michael Hobbs and Aubrey Gordon's special guest today is Erin Harrop. Yay! Hi, Erin.

Hi. I want to give a good intro for you, but I don't even know what you do now because you wrote your dissertation, so you're done. So like, what are you? Working for the University of Denver, I'm one of their incoming assistant professors right now. Very exciting.

So I met Aaron two years ago, three years ago, when I was writing my article about the obesity epidemic and we sort of stayed in touch after the article. And Aaron, I've been thinking about you a lot in last five months because you were the last person I hung out with before quarantine. Me too. What? Do you remember that lunch?

We got lunch at a Korean restaurant in early March. We did an elbow bump? Yes, exactly. It was that weird time where it's like, are we allowed to see people like neither one of us knew and we were like scrupulously not sharing food? I was like, those dumplings look good and you were like, don't touch them. But today unfortunately, we are not here to talk about Korean food and handshakes. We are here to talk about Aaron's work, which is about eating disorders among fat people. They happen. They happen. And so I mean, Aaron, you want to

just like give us sort of an overview of this issue and like what people should know about it as like a little encapsulation? Well, I think one of the things that we run into when we talk about eating disorders is that we have this kind of preconceived notion of who are the people with eating disorders. And if I were to ask you like, okay, picture somebody with an eating disorder right now in your mind. You would probably be thinking of a young adolescent cis female. You'd probably picture her being pretty thin and you'd probably have maybe some sociocultural dialogue about her not wanting to eat or being afraid of certain foods, maybe running a lot at a gym on a treadmill. Yeah. And this isn't to say that young cisgender females, through our thin, don't get eating

disorders. They absolutely do. But I guess it is to say that the picture is a lot bigger than what we paint. You know, we see people who are very young starting to restrict, but we also have it in middle-aged folks and aging folks as well. In addition to different races, socioeconomic classes, and then body size. And then I definitely gender sexual orientation.

Yeah, I have the disease of queerness and also the disease of fatness. Also the disease of meetings are looking bad. Nailed it. To me, as someone who's obsessed with things that are true, but do not receive very much media coverage, I mean, the most shocking thing to me about your work is just the sort of the headline finding that it appears that the vast majority of people with eating disorders are fat people. Yeah.

My area of specialty looks at anorexia and atypical anorexia. And literally, the difference between the two is a weight. They have the exact same kind of manifestation in terms of behaviors and physical consequences and psychological consequences and what folks are actually doing and thinking and feeling. But whether or not somebody gets one diagnosis or the other is defined based on BMI.

Are there other implications of the difference between typical and atypical? Like does it affect your ability to get insurance reimbursement and stuff? So atypical is considered a different category of eating disorder from anorexia. Basically the other category of like something's going on with you, but you're not quite textbook

in any particular way. Oh, so it's like not real anorexia is like how the medical field considers it. Yes, it's a different code in the ICD 10 and in our DSM. It's a different code. And that significantly impacts people's abilities to get care. Super interesting as you're talking about all of this that it really feels like quite a bit of the ceiling for how we understand eating disorders and who we can recognize them in is really sort of set by, you know, our own existing biases about fatness and fat people, but also about like a wide range of communities, right? Like part of the reason that we don't like see and think about eating disorders in people of color

I would imagine is that there's like zero representation of what that looks like or eating disorders in people who are living below the poverty line or what have you right? Absolutely. For other eating disorders like bulimia and binge eating disorder, they're supposed to be behaviorally defined where we're looking at frequency and occurrence of binging, impurging, and compensatory behaviors. But what I'm finding and what people are reporting to me in my research is that clinicians seem to be more in tune to how a person is like physically presenting when they're delivering some of those diagnoses.

So I have people in my study that never, ever qualified for a diagnosis of binge eating disorder, but we're given that diagnosis, and I would say it's likely because they were fat. Because the doctor's like, well, you must be binge eating, basically. Exactly, exactly.

I think oftentimes we're diagnosing like, how a body looks to us as clinicians, instead of really asking all the questions. Also anecdotally, just from having talked to a lot of fat people over a long period of time, I can't tell you how many people seek out inpatient treatment for their eating disorders and then are met with clinic staff who say things like,

I don't think you really need to be here. It doesn't look like you've missed a meal in a while. Ooh. That stuff also plays in, even if it's not sort of like formally written down somewhere, if you're not actively screening for that kind of behavior and have like pretty strict policies in place and that kind of thing,

that that is also a way that fat folks sort of get pushed out of even seeing ourselves as having eating disorders, right? Absolutely. I would say that that's one of the most distressing and common findings that I found in my dissertation research is the number of people presenting for care and being told that this is not actually a problem in this year delusional. Even when it was accompanied by physical markers, you know,

like vomiting blood. Jesus. Fainting repeatedly. Like the menstrual cycles, a pulse that was, you know, in the low 30s, which is not good. And that's hospitalizable. If a adolescent came into the emergency room where I work with a pulse of 33, they would absolutely be admitted. And also, didn't I read that in your dissertation, Erin, that the average time between somebody having these severe eating disorder behaviors and actually getting care was like three years or something. So people are living with this for a really long time. 11.6 years.

11.6 years. Jesus Christ. One of the things, so Dr. Jennifer Gaudiani, who's a physician, who I also interviewed for my article, and was really nice. She wrote a book on kind of different ways that bodies manifest starvation. One of the things that I think, like we picture people who are starving and we assume that everybody

reacts the same way. And you know, we picture kind of what we've seen in like human rights violations, you know, like kind of protruding bones kind of situation. And that does happen for some folks. And it doesn't happen for some folks. So we did starvation studies back before we had IRBs that kept our research a bit more ethical back in the good old Tuskegee days Just like whatever fucked up thing you can think of they're like yeah, do it sure the madman era of research It's amazing what you could get away with yeah, we're just gonna hit people with sledge hammers and see what happens But we did we starved people in that area, to determine what happens to a body when it's starved.

We starved healthy men who were physically active and otherwise normal and healthy. We put them on a diet, I think it was about 1600 calories, somewhere between 15 and 16 hundred, which is not even a particularly low caloric benchmark by today's standards when we hear about some of these crash diets that people are doing. I mean, I've heard people that are given recommendations for a 1200 calorie a day diet. And, you know, one person tried to cut off his finger because he experienced so much psychosis

in that experiment. As people became obsessed with food, they read recipes all the time. They started developing some of the eating behaviors that we see in folks with eating disorders, like cutting their food up into small pieces and trying to eat over a long period of time to make it last longer.

And then we also saw the physical consequences and then how long people were messed up because of that one instance of starvation in their lives. But what that study shows me is that like, A, the effects of starvation are extreme no matter how they play out just in a physical sense. You know, and something that Jennifer Gaudiani points out in her book is that starving bodies look and respond differently. And so you can see some people that get sick very quickly and they get emaciated very quickly. And some of that also has to do with how large their bodies are before they start restricting. You know, if you have somebody who's already relatively thin and they start

restricting and they lose a certain percentage of their body weight, it can become clear pretty quickly that they are reaching and a quote unhealthy place in their weight loss. If you take someone in a fat body, I mean, they could lose half their body weight before people even think that it's at all a concern. And for the most of that time, people are going to be congratulating them. Yeah. So that sort of that image of eating disorders that we have, what you're saying is that it's

the minority of people who are in a starvation state who are going to look like that. I would say that based on what I'm seeing, that would be true. But I don't know if we have quite enough research, like most of the research that we have on people who are starving, we're already set a BMI component for them to be in the study. Right. So we'll say that in order for people to qualify for this study on an anorexia, they need to have a BMI below 18.5 or 17.5 depending on what we're specifically

looking for and what time period in history. But what I would say from what we know about behaviors in terms of how fat people with eating disorders also eat is that there is a large percentage of folks that are restricting who are in larger bodies. I think that's what we do know because we've never really captured just everybody who's restricting or engaging in self-starvation practices. I mean, I've interviewed people who are like 250 pounds and severely restricting their diet and aren't getting their period.

Yes, yes. Which is just like a huge red flag for like your body is in crisis. Yes. In the study that I did, which had a range of BMI's for people presenting, it had kind of down to, you know, just above a normal, all the way up to a BMI of around 60,

I think, that we're presenting with things like orthostasis, which is when your body stops regulating. It's blood pressure in response to like changes in altitude, like if you sit down and then stand up Oh wow. We are seeing higher rates of orthostasis where bodies are like they're not able to adjust to make those adjustments So when these people walk up stairs climb a ladder Stand up people can fall loose consciousness because their body that basic homeostasis function of like regulating your blood pressure to move.

Yeah, homeostasis. It's not happening. So you're basically saying that there are fat people in a starvation state. Yes, and that there are people who are like right now hospitalized for starvation. Like they are there because they are medically unstable and unable to be in the public, and they are in what we call, quote, obese bodies. I mean, you know, one of the things that's become more common colloquially is for somebody to talk about, you know, keto or intermittent fasting or these various fad diets.

And then somebody will sort of jump into their replies and be like, actually, what you're describing is an eating disorder. And so how do we sort of draw the line between people going on a diet for, you know, whatever it's New Year's, and like, actually disordered worrying behavior? That's the question at the century. I was hoping you could solve this. I'm sure there's no divergent opinions on this. I'm sure it's not an open debate among scholars at all.

So just solve it for us, please. What I'm about to say is 100% correct and undivided. Good. But for me, the line comes from a psychology standpoint. It comes down to how much does this interfere with your life. Sometimes when I'm with people, I'll put my hands in a little circle. And I'll say, if this is you, and then if this other hand is like your thoughts

about food and your thoughts about exercise and any kind of planning that goes into a binge or a purge or anything like that or what you're thinking about your button, how big it is or your body and how much you wanna change it and the plans that you have and like, how much of those do those two circles overlap? For many people with eating disorders, those circles are right on top of each other.

Maybe there's just kind of like a sliver of stuff that they are thinking about or devoting time and energy to that's not related to their body, food or exercise. You know, but like if you're like, okay, well, if I think about this 10% of my day, am I okay with that? I also wonder if, because there's so much gray area, that that's one of the reasons why we rely on weight so much. Because it's like, if somebody's weight is low or somebody's lost X% of their body weight in X weeks, then it just gives us a way to see that there's the signs of this.

But the problem is that then, once we only rely on weight, then we miss the majority of people who have eating disorders and aren't under 110 pounds or whatever. Yeah. One of the biggest predictors of weight gain is this repeated weight cycling, repeated attempts to try and lose weight so that the longer a person tries

to lose weight, often instead of a steady decline in their weight, which would be maybe what they were picturing might happen, what we see as a steady incline in a person's weight, which then often reinforces that cycle for trying to lose weight, right? Because they're at a higher place. One thing I would say with that kind of relying on weight

is we often miss people who have had disorders for long periods of time. Because often when you are restricting and engaging in starvation, the first times that you are doing that, your first weight loss attempts tend to be times when you experience greater weight loss faster. With more repeated attempts, it's almost

as if the body kind of buffers itself. It kind of is like, oh, well, we're going into starvation mode again. And maybe it doesn't take as long. And so it kind of defends that, that set point of it, that it's at a little bit more rigorously. And so you might see, we might catch people in their first attempts at losing weight. We might catch the eating disorder faster than for people who have been doing this for quite a while. And maybe their bodies have just gotten used to, you know, people in my study, there, you know, there is, there is a person who, like her body was just really used to surviving

on very, very little food, you know. And by the time that she made it to my study and got a diagnosis and started treatment, she was in a larger body and her body had just adapted. And she was working overnight, staying up most of the time during the day, going to school and surviving on, I'm not even going to mention the amount that she's surviving on because I think it would be too triggering for listeners, but it's really remarkable how we can miss people for such long periods of time because bodies get used to it.

And some bodies don't. Some bodies just give out. Part of what sort of makes all of this so much trickier is these sort of myths that we have around diet and weight loss. This belief that weight loss is a simple endeavor of calories in versus calories out. So if you really were having fewer calories in and more calories out, you would look different.

We really have been sort of conditioned to recognize this one thing. And when that's combined with all of the stuff that we think we know about dieting and weight loss, which is like overwhelmingly just totally wrong, that that creates this, you know, sort of huge gap for people who sort of fall outside of that image to sort of fall into that gap, right? And sort of misdiagnosis, mis treatment, miss all of this stuff that they pretty deeply need. Absolutely. I think one of the things that makes you a good researcher on this and a good clinician is that a lot of this is like what you've been through yourself. Do you mind if we kind of walk through your own story

and how you got interested in this? Sure, yeah. So I definitely grew up in one of those white households in the 90s. Snack wells. Oh my God. Oh my God. Rice cakes.

Yeah. And lots of concern over fat. And even down to things in a really gendered way where the 2% milk was my dad's milk and the nonfat milk was my mom's milk, I could kind of take those messages that I got that I received about fatness being bad or fat being bad in general.

And the way that I interpreted those messages was that fat was always bad. I kind of took those messages with a child's mind and just took everything to this extreme point. And so, you know, I mean, I can remember, doing like exercises is a five year old. This is something that I have to do and just feeling very driven in that.

I can imagine the exact sweatpants you were wearing. Oh my God. They were pink and they had cuffs at the bottom. Yeah. I would have had those pants if I was allowed to have them. Yeah. And I think too, like the body dysmorphia started at that age too.

Like I can remember getting like, I don't know, do you guys have like student of the week things when you were in elementary school? Yeah. I remember guys have like student of the week things when you were in elementary school? Yeah. I remember getting this like student of the week picture back and I was in third grade. So I was like eight years old and like,

I was wearing like this one piece turquoise and magenta. It was really 80s, 90s wear. Oh, like a two tone top. And I was growing out my bangs. So they were like smack dab in the middle of my head, like a fountain. I remember like getting this photo and like I refused to take it home to my mom

and I like hid it because I was so embarrassed at how my body looked. Looking at this photo now, like, cause I have it and like I'm just a normal eight year old kid. Yeah. From the kind of that age, I started really paying a lot more attention to what I was eating, cutting more and more things out of my diet, you know, skipping breakfast, skipping lunch, you know, the types of things of how and eating disorder develops.

Side by side, being an athlete and on cross country and volleyball and basketball and like doing all the sports and then kind of like not really surviving and fueling my body much for it but also feeling like okay I don't need that like I can live without it and if I can live without it then it's not a need it's a want right by the time I reached you know 15 years old, my friends had a little intervention with my parents. And we're like, dude, Aaron's not okay. From that moment, my parents took me to my doctor. My doctor diagnosed me with anorexia. Also, my family was low income. We had no insurance. There wasn't really a way to treat it. You know, my parents took me to a few

nutritionists. I saw a counselor for a while, but I just kept getting worse. And I did end up in one of those bodies like you see in the daytime television, looking pretty scary and medically unstable. You know, it was uncertain if I was gonna like survive my adolescence or not, you know? And because I never got treatment, I would get like a little bit better, but all those behaviors were still going on. Like my mom would give me insure, and I'm like watering it down.

So you just like muddled through basically? Like keeping these behaviors, but hiding them essentially? Pretty much, yeah. Yeah. Like I'm still amazed that I like past high school and college, you know what I mean? Like because it took up so much of my time. I'm just waiting for the part of your story where you tell us that you finally got treatment

because someone tweeted it at you. Like what? You're describing as an eating disorder. Yeah. The flat back. It's all responsibility to shit on people on Twitter. Yes. So when I got to college, I did gain some weight.

I started to look like less scary. And I think people kind of relaxed after that. Like, once I was kind of like out of this place where it's like, OK, well, I'm not like fainting anymore. And I'm not as underweight as I was. You know, I was still at that point like purging multiple times a day and restricting, but like, it passed.

Like I was passable in normal society, you know? It continued in this kind of like internal civil war until my third year of college, essentially like it had become so out of control again and I was playing collegiate sports. I needed to go in for like a physical or something like that and my heart rate was too unstable and they said that I had lost my clearance to play rugby

and you know for me like I was like, okay, well, I'll just keep doing what I'm doing. I kept at it and eventually I lost clearance to even attend school and was basically kicked out by the academic team of affairs because of that heart condition that I had. I had restricted myself to a place where I was too unstable to be on campus because I was like, I'm a 4.0 student. School in my eating disorder was all I really had going on for me. You know, like, at this point in time, like, I was in a larger body while these things were happening. I mean, it was larger than it had been before.

So it wasn't like a fat body at this point in time. I was like, I'm a 4.0 student. School in my eating disorder was all I really had going on for me. know, like at this point in time, like I was in a larger body while these things were happening. I mean, it was larger than it had been before. So it wasn't like a fat body at this point in time, but it was still like, I was still thinking in my head, like, well, I was so much worse when I was 15. Why is it now that I'm having heart failure? I was having heart failure because from the age of 15 to 21, you know, I hadn't really been eating. Right.

And also it gave you the larger body, gave people a license to like not look too into, like, oh, I haven't really seen Aaron eating that much. Yeah. Like you don't assume that somebody in a larger body is like vomiting a couple times a day. It doesn't cross your mind because we've been trained. Exactly.

So well, to only see these like extreme physical symptoms as a sign of an eating disorder. Yeah, partway through that body restoration process, someone had asked me directly about it or something and I was like, well, yeah, I'm in the middle of, of refeeding and they were like, why would you be trying to gain weight because like your body looks perfect right now as it is? Right. You know, and it's like, well, this isn't quite perfect.

This is actually pretty sick. Right. Right. This is also sort of like a maxim in fat activism work is sort of that what we diagnose as disordered in thin people, we prescribe and fat people and congratulate in fat people. Absolutely. Right. I feel very familiar with the other end of that, which is like, you can't have a needing disorder.

You're too fat. It's not possible. And if you do, then I'm just gonna give you a vi-vance because it's clearly binge eating disorder, right? And the other end of that is it also works against folks who are not necessarily fat, right? Because you sort of get this like your body is perfect as it is.

You don't need to change it. Right. You look gorgeous. Yes. Which just reinforces that same framework of thinking that there is a right kind of body to have and that your body is being monitored by the people around you. Right. Yes. So did you eventually get into treatment?

I did. So yeah, I was kicked out of school and then basically found a doctor who was willing to work with me in a dietician who was see me for sliding fee and a therapist who saw me through this like grant for needy women or something. But yeah, I did get treatment and I mean, it was life changing for me at that point. Like, I'd known that I'd needed treatments since I was 15 and I'd been trying, I have like literally two plastic boxes

that are like knee high full of like the journals of me trying to like think my way out of it and figure it out and get help. Just over years of trying to like treat myself by reading books or, you know, getting the very limited treatment that was available. And then finally, to be in a place where it was like, I had people who knew and understood and like could figure out what was going on my body. And they, you know, really working with one of those doctors was the first time where I like really saw like how

devastated my body had become. You know, like I'd lost muscle tone in my face, muscle atrophy in my back so that I couldn't like stand up correctly. I had that orthostasis where I would fall if I stood up too quickly. My body was literally like going offline, you know, all of those things that, you know, just start shutting down. And all these things were getting better. I was getting my period back. I was no longer orthostatic. All these things were kind of coming back online. You know, I could have a baby now if I wanted to. I didn't, but like I could have, but in my head,

like my body was wrong because I was like gaining more weight than my doctor said I should gain. You know, and all of my fears are coming true, right? Like all the things that my eating disorder said about being fat and whatever, like this is true. And yeah, I ended up like having the experience of getting to go back to treatment, you know, four or five years later in a fat body, you know. And again, I was experiencing the same symptoms that I had as a kid.

I still had the overexercise, I had the purging behaviors, and I had the restriction. And I was restricting things like water that really, that's not adding calories to you. It's literally just hydrating your body and letting your kidneys and your heart work normally. And so I was sick. And I still, inpatient, in a hospital for eating disorders, had a therapist

tell me that I didn't need to be there, and that she didn't believe I had an eating disorder. And I was like, she was like, Erin, why are you here? And I was like, because I have an eating disorder, I really want to get better. And she was like, but like, why are you here? And I was like, because I want to get better. And she's like, look at all these, look at all these people that are here. Do you see how thin they are? And I was like, yeah. And she's like, they're the ones who really need help. You're fine. It was so poignant because it was like, okay, like the only people, the people that should be able to help me that are supposed to be experts in this don't even believe that my insurance is right for covering me to be here.

No way. You know. And also, they're telling you exactly the same thing that your disorder is telling you, right? Like they're echoing back to you, all of the disorder thinking that is like the entire purpose why you're there is to break the cycle of disorder thinking and they're telling you the same thing, word for word.

You don't deserve to be here. Yes. You know, and at that point in time, of disorder thinking and they're telling you the same thing, word for word. You don't deserve to be here. Yes. You know, and at that point in time, like, I had a solid head on my shoulders. I'd experienced what recovery was like in that previous time when I'd gotten better. I knew that they were telling me something wrong. And I also, like, didn't have the strength of myself yet and my voice to be able to kind of speak back to it. Right. I was in my head. I was hoping you, like, threw a drink in her face or something. strength of myself yet and my voice to be able to kind of speak back to it.

Right. I was in my head. I was hoping you like through a drink in her face or something. I was imagining like a real housewives situation. Here's like scratching at each other for a couple of minutes, but that's probably not what happened in real life. You come back with the hat boxes from a pretty woman and go, I did publish an article on that interaction. so that was my slapback, I think. That's, yeah, that's the academic equivalent of the brain woman. Oh my god.

Is the idea like that you wish you could have conveyed to those people, you know, if you think of the sort of three square meals a day or like the food, pyramid, or whatever sort of we're supposed to be eating. Is the idea that simply some people, they're just gonna be larger than other people. And that's just like the situation, and we should all just accept it. I just think that nourished healthy bodies come in a lot of diverse sizes. Like we know that human beings occur on a bell curve. We know that height is a bell curve. We know that weight is a bell curve. We know that weight is a bell curve. There's, I mean, lab values are bell curves, right? Like temperatures, not everybody is a 98.6.

Like I wish we focused on people being like nourished as opposed to a specific size. I do think that potentially, if my body story was different, you know, maybe if my eating disorder had lots lasted for a smaller portion of my life, maybe my body would be different today. I don't know that. I hear that's a common thing that many people think about is like, if I'd never started dieting or if I'd never had an eating disorder, how big would my body be today? I don't know. I and it doesn't really matter because that's not a reality that I can access. But what I do know is that like I was a thin child,

I had a major eating disorder. And now when my lab values are good and when my homeostasis is good in terms of like, oh, my blood pressure is working, my, you know, I'm not dehydrated, I have good blood sugars. Like when those things happen, my body is larger than when it was before.

You know, that's a hard thing for someone with an eating disorder to accept because we are taught that thin is healthy and fat is unhealthy. But, you know, at least for me, like this is where my body's been happy. And this is where I've been able to, you know, have a child and, a child and sustain the kind of life that I want to live. I just graduated this summer and I went through my masters and my doctoral program without any medical leaves of absences. And for me, that's a huge deal. That's like, you know, eight years of school that I did not have to leave because of an eating disorder. And by comparison, it took me eight years to get my undergrad degree because of the number of medical absences that I had to take. And so I did a master's in a doctorate

in that time and had a kid. And this is yet another reason why it's so important for doctors and just people in general to not use weight as a marker of health because there's a lot of people who they come in and according to their BMI, they should lose 20% of their body weight. But if that person has had a needing disorder, them being at a stable weight is a fucking huge accomplishment. And without knowing that, and without asking them, like, let's talk through your history of weight, like, shut the fuck up, like, for some people, they are fine at the weight that they are,

and being told that they need to lose weight is like a very dangerous thing to be telling people without knowing what they've done to attempt to lose weight in the past. Yeah. And, yes, absolutely, ask folks about, particularly about their histories with disorder eating, but also recognizing that based on everything we've talked about

today, some folks may not know because even honestly knowing that you have an eating disorder is a privilege, right? Yes. It absolutely should not be. But currently it is. So also like, figuring out, you know, these are murky waters. We're all going to kind of muddle through a little bit. Right. But the muddling through is much better than the assuming that everyone has the same sort of history or that you can tell what someone needs for me

as a healthcare provider just based on their appearance. So there's a lot of it. And also like how do we define recovery, you know? Sometimes people define recovery by like maintaining a certain weight. So for me, like I would have been considered recovered even in impatient because I was still above the weight that the eating disorder center made for me. So Aaron, you sort of mentioned a couple of times your dissertation in here. I'm super fascinated by like any and all new research. What was the focus of your

dissertation and what were some of the findings that you came away from it with? So the focus of my dissertation was really to try and shine a light on the specific experience of atypical anorexia and to try to understand it. And particularly I was interested in some of those medical experiences that I think Aubrey alluded to a little bit with like, what happens when people try and get care? And like, does it result in people actually getting care or do they get shut down? Like, what happens and how long does it take them and what kind of gets in the way? So I basically recruited 39 people that had atypical anorexia,

a little more than a quarter of them, so a little more than 25% had never had treatment at all. And for many of them, they were kind of diagnosed through the study. We did an eating disorder assessment as part of the study. And then I followed them for a year with their disorder. They filled out kind of those quantitative scales so that we could see how people's body image and depression, anxiety, substance use, how it went over the course of a year.

And then I talked with them in three in depth interviews at the beginning of the study six months in and then at the very end. And those interviews addressed like how did their disorder develop? What was it like trying to get health care for their disorder and how has it been trying to get better? You know, we had about 30% of the sample that was folks of color. About 20% by the end of the study had come out as genderqueer or trans. In terms of ages, people were anywhere from 18.

Like I got one lovely volunteer who came like on her 18th birthday and was like, I wanna be in this study. And then up to, I think 76 was our oldest participant. And some of those people had, you know, journeys of 30, 40 years of struggling with this eating disorder. Right. I was gonna say,

especially considering the kinds of sort of medical impacts that we were talking about earlier, right? Yes. If you are falling down when you try to stand up, someone who normally has a period and starts missing your period, and that is happening, those are significant sort of medical outcomes. When we talk about this kind of like bias and stigma stuff in treatment, it isn't just sort of like a nice bonus. It is in many cases like very much,

I would imagine it a matter of life and death, yeah? Mm-hmm, absolutely. And like some of those long-term consequences that we mentioned earlier, like when you don't get your period for that long, that has a big impact on things like bone density, arthritis, osteoporosis. In the moment, it's like, okay, like, I'm not getting my period, yay? But down the line, when these things become

more chronic, it can have some really significant impacts on your quality of life later on. And also, didn't a lot of your participants try to get treatment at various points and weren't successful? Yes. The most compelling results for me weren't part of the, you know, like yes, people waited a long time, but people were actively engaging with their medical systems trying to get help for many of them. People presented with things that should have been caught, like those sentinel symptoms of starvation, like somebody missing their period, like somebody fainting, it should at least be occurring to us. And the fact that people were reporting these symptoms and not hiding them and presenting for care and still being told essentially, you're

too fat to have an eating disorder by many people. Right. It just completely made that, you know, what could have been a very short time without treatment a very long time. It's also darkly funny because the whole point of people need to be thin is for their health. It's weird to be like, no, you'll obviously be healthier when you're thin. When most people in the population would recognize vomiting blood, passing out when you stand up out of a chair, as straight forward health risks, and it might just be better for someone to be fat and be able to stand up regularly.

Then the alternative. It seems like a pretty easy dilemma. Yeah, and I know that I'm relying on some more extreme cases to make a point, but like this is happening, and honestly, these types of physical consequences were not uncommon. Right. So what do we know, or what do we sort of think about prevalence of eating disorders as it stands? One thing that impacts prevalence rates is how people are defining their the disease of atypical anorexia and how they're either asking people or not asking people to screening questions. So for instance, one of the studies that I found that had one of the lowest rates of prevalence

for any country was a study that required people to be between a body mass index of 17.5 and 24. So if you were above a certain weight, it was impossible for you to have a typical anorexia, basically. Yes, the typical patient with atypical anorexia in some of our larger studies tends to have a higher weight than a BMI of 24. Like basically if you require people to lose

a greater percentage of weight, they'll be less people that meet that criteria. You know, one study in 2017 used three different cutoffs and they found that like with the lowest cutoff, there was you know, somewhere between like six and 13% of people that could qualify for that diagnosis. Shit, that's high in the population. Six to 13% of Americans.

Yeah. Wow. Jesus, God. This was a relatively small at B study. There were only like 2,500 people. So I don't know how much I would trust that specifically. Right. 2500 people, so I don't know how much I would trust that specifically. Right.

But at their highest, relying on a higher level of weight loss, they kind of estimated somewhere between 2.8%, which seems more in line with other findings from other studies. Do you remember at our lunch at the Korean restaurant that I was trying to convince you to write a book about this that would become a massive bestseller? Yeah, there's a lot of people that are crying out for help and Aren't getting it because nobody wants to admit that this is an actual thing and so I Continue to believe that you should do that and go on Oprah and talk about it. I So would love to do that

Yeah, I mean it just feels like such a desperately needed to do that. Yeah, I mean, it just feels like such a desperately needed conversation. And one of those places where you sort of peel back the very thin veneer of like, I'm concerned about your health. And that is used to propel so much of this stuff, right? That is like undoubtedly really terrible for your health. Right.

And it just feels like just this one entry point into a conversation, both about eating disorders and about weight stigma sort of turns both of those conversations sort of on their ear a little bit. Yes, the whole idea of refusing to acknowledge the fact that somebody has an eating disorder unless they're below a certain weight. Like basically, unless their eating disorder

is so severe that they're about to die, just feels bananas to me. It's like, we only want to treat alcoholism if you've had four drunk driving accidents. Sorry, if you've had three drunk driving accidents, I don't see the problem. It's like, what? You're mistaking the effect for the disease. Yes.

Also, it runs counter to like everything that anyone in public health will tell you about anything. Yes. Also, it runs counter to like everything that anyone in public health will tell you about anything. Yes. It's like no one in public health or in epidemiology is like, hey, you know what? Just sit on it. See what happens. Yes. Wait for it to get worse. Wait, I glee 10 to 11 years. And then we'll just see how it plays out. I mean, what do we know about eating disorders among ethnic minorities, gender minorities? Like, what are the intersectional aspects of this? So generally that they tend to be elevated in populations with trauma. Yeah. I do have a colleague who has been running some data

out of a treatment center and looking at specifically with indigenous folks, the gains that they make in treatment, they're struggling to maintain when they're discharged. If the treatment environment is so different from the environment that you're discharging home to, there could be a mismatch in terms of building skills. And that is something that even in my dissertation work, we definitely found with folks, particularly from racial and cultural minorities,

where in treatment, they're eating almond butter and toast or something, or quinoa and something else. And they're not learning how to cook with the foods that their family uses. White nutritionists don't know what to do with the kind of foods that these folks are used to eating with their families. And so there's this mismatch of like what it looks like to be a recovering person

when we see it through such a white lens that it's like, okay, like I can't see my own recovery anywhere in this picture recovery that you've painted for me. Right. That like the foods that we can see of as being healthy are so framed up by the whiteness of the people making those determinations, right? There was a great piece in the New York Times recently about sort of the whiteness of diatetics. A number of dieticians of color talked about sort of the training that they had gotten that was overwhelmingly just like Mexican food is bad for you. That was just sort of throwing out entire nation's worth of food, right? Rather than going, what are the nutritional values of these different things? Part of what makes something healthy is that people actually eat it.

Yes. Also, yes. So there's like word on the street, big diagnosis that's getting like increasingly sort of like more and more media coverage, but isn't necessarily set in the DSM is orthorexia. What are some of the other diagnoses that folks should maybe be aware of? So with orthorexia, so it's restrictive in that people are very much limiting what and how much they eat, and there's a lot of specific concern around the cleanliness and the types of foods that they are eating. So essentially, it's a way of kind of like ethical eating or clean eating going like to a pathological place,

to a point where a person's no longer able to nurture themselves. For me, that type of disorder kind of fits within anorexia in terms of the types of food fears. It's just kind of a more specific type of food fear that we're seeing pop up. Other kind of up and coming eating disorders. With initially indie eating disorders. The eating disorder is putting out in peace.

Getting on the ground floor everybody. Purchase disorder is where people are not necessarily restricting, but they're still having that purging behavior. So they might eat a normal meal. They're not binging. They're not sitting down and eating a whole large pizza and a cord of ice cream. They are eating kind of a normal meal,

but then they're throwing up afterwards. And then the other two that I would say to just have on your radar One is called and I don't even know how much common this term is, but like the adonis complex, and this is something that we see in a lot of young males cis males, although I would say that this also comes up especially for gender queer folks would say that this also comes up, especially for gender queer folks. People who become very obsessed with how large they are, how large their muscles are, and how low body percent fat and that type of thing. So we might see people that become really compulsive with things like exercise, weight

lifting, that kind of thing. Then we see this kind of especially and kind of more testosteroney places. Just say gay men. It's okay. It's like gay men. Well, testosteroney is the San Francisco treat. So I'm glad we got that. I'm glad we got that.

I as a gay guy who's been on 10 billion first dates, there is a sense of like feeling out other people to see like how bad is their body dysmorphia. I have gay male friends who like literally won't eat in front of somebody until the seventh or eighth date because they have all these like emotional issues around sort of him seeing me eat is going to make him think that I'll be fat later. Like it's super fucked up. I don't know if that's of rises to the level of an eating disorder, but like there's a lot of pathological body and food shit in gay male culture. I'm sure we're not the only people to get the adonis thing but that seems like extremely familiar to me.

Overrepresented. You said there was one other one, Aaron. The other one I would say would be our fed. It stands for avoidant and restrictive feeding intake disorder and this tends to happen often with younger kids, although it does happen all the way up through adulthood. And it tends to be people who are feeding a verse, but instead of it being kind of driven by this sociocultural narrative of like food makes you fat, I don't want to be fat. They are kind of pushed away from food by things like textures or fears. Not fears are becoming fat, but a fear of choking. Maybe you had some really

bad steak once and you had food poisoning for three days. And now you've gotten to a place where you just can't eat me, even though you're not ethically opposed to eating meat, you just, you would like to, but you can't bring yourself to potentially go through that again. Like we see it resulting in bodies that look very emaciated and we also see this in larger body kids where maybe they're only comfortable eating, you know, highly processed foods. Like those are the only things that they are kind of willing to experiment with. And for them to like try eating like a slice of avocado would be like mind-warping for them

because it's slimy and gushy. Right. I mean, there are people that come into clinic that eat five or less foods. Oh, wow. But Mike, you mentioned sort of this like pretty common Twitter interaction, which is somebody tweets something or posts elsewhere on social media something about their keto or their whatever it is that they're doing. Someone else jumps in and goes, no, that's an eating disorder. I'm gonna go out on a limb and imagine that particular intervention, not especially effective.

Yes. So like as folks are listening to this, I'm sure that they are having the response that I'm having, which is as you're talking about sort of how this stuff shows up going, oh, I think I know someone who meets this criteria. Oh, uh-oh. Yeah. So you're hearing this, you're recognizing behaviors in someone that you know. Yeah. What next? Yeah, what should we tweet at random people who talk about their diet and exercise on the internet? Who should I be harassing and how? If it's somebody that you know and know well

and care about and have some kind of relationship with, I think you can always ask them how they're doing, and you can reflect back like, hey, I'm seeing you post a lot about X, Y, or Z, it seems to be taking up a lot of your time. How do you feel about that? You know, like something that kind of opens up the discussion, I think we can get into trouble when we start saying like,

this is terrible and this is what you should do. And you need treatment now, right? Like I think that the kind of finger pointing can be really hard. And especially for somebody that might be actually legitimately knowing that they're struggling, it could be kind of embarrassing to realize that maybe something that they thought was more secret is something that's being noticed. Erin, you mentioned earlier eating disorders sort of showing up in elders. I'm curious about are there ways that that sort of disorder eating looks different?

First thing from the research is that there's often like different reasons why these eating disorders happen. Some of the things that we don't necessarily take into account as much when folks are younger. So obviously for some people, it could be an eating disorder relapse, like something that they are, they experienced as a younger person and like it has been kind of reactivated for them. One thing we do know about eating disorders is they're often triggered by transitional events in a person's life. So that's why things like puberty, going to college, having a baby or postpartum, often those types of events, life events can be associated with higher eating disorder behaviors or triggers.

So if you think about old age, you know, transitioning out of independent living or into a higher level of care can be that same type of transitional experience that leaves a person feeling out of control or triggered in a way that an eating disorder becomes, you know, a bigger part of their lives for the first time, even for some folks. Yeah, I would imagine even just something like retirement, right? Yeah, yeah, I pulled away from your longstanding identity as sort of a certain kind of person who knows how to do a certain kind of thing, right? That that is a pretty massive role shift.

And we had two participants in the study that that was true for them. And one who had basically waited her entire adult life and just said, okay, well, when I retire, that's when I'll try and figure out my eating disorder. Oh, wow. And so that was why she got care, you know, in her late, I think she was 67 when she got care for the first time.

She was just like, I don't have time to do it now. Of course, yeah. Good God. I mean, we should not need a reminder that like everyone has problems, but like sometimes we do need a reminder that like these are universal issues, and they're not just Little white teenage girls. They're everybody and yeah, sometimes you just need a little like oh 67 year olds too

Okay, fat people disabled people. Yeah men men. Yeah, I've didn't literally all of them Aubrey I know about that. Literally every single one. My condolences, bud. Thanks so much for coming on, Aaron. This was great. Thanks for having me. This was, you know me. I'll take any opportunity. I have to talk about this research. Why Bump? We didn't go to that Korean restaurant anymore because now you live in Denver and it's going to be harder. Yeah. Well, I'll be back in Seattle. Yeah, and we can, we can, we can bump elbows on Zoom next time.

Yes. So where can people find your work, Aaron? And what is your mother's made name and social security number? So the people can still be your identity online. Well, I totally need to actually get a web page. I don't have one yet, but yeah, Google Scholar, my DU faculty page will be up probably the end of this week.

Okay. Are you on Twitter? Like, what is your preferred medium for shouting at people about their dietary habits? Where do you do that? I am a little old school. I usually do Facebook, but I'm trying to transition over to Twitter because that's where all the academics are. You're just still shouting at people out of cars. When you want to comment on them, throwing sandwiches at them, you know. Yeah.

So that's where listeners should find Aaron, just walk around Denver until she throws something at you. It'll be something soft. She'll throw something soft. Yes. Like a tuna salad, like a tuna salad. That's what I'm saying. a salad like a tuna salad. Thank you.