Don’t Call People Out, Call People In

Sep 19

Dr. Liz Woodruff, a mental health expert specializing in eating disorders, joined co-hosts Meagen Rosenthal, Ph.D, and Alexis Lee for The Mayo Lab’s fourth episode of Season 2. Dr. Woodruff shared information about how eating disorders manifest, their prevalence, and the stigma surrounding them.

Dr. Woodruff explained how eating disorders transcend stereotypes and affect individuals of all backgrounds. “I think historically eating disorders have been seen as an issue that affects white, straight, cisgender, affluent women. And it’s true that high rates of eating disorders are seen in those populations, but not only those populations,” she explained.

“In men, we also see high rates of eating disorders, and they can manifest a little bit differently,” Dr. Woodruff said. There are also unique challenges faced by transgender and non-binary communities, which can have an elevated risk for eating disorders.

“Start a conversation and really try to understand instead of being so pitted against each other. I think it might help to come to some better solutions.”

— Dr. Liz Woodruff

Dr. Woodruff underscored the stigma surrounding eating disorders and the shame that people often feel about their behaviors. “And a lot of the people I work with, regardless of gender, will tell me that there's a lot of embarrassment around what they eat. They do what they call performance eating, where they will eat around friends, or they'll eat more around friends and family than they do when they're alone, so that people don't worry or people don't shame them for not eating enough.”

Addressing the underlying psychological issues is critical for those dealing with eating disorders. Focusing solely on the behaviors of the eating disorder may not lead to full resolution. “And if it's not, and only the behaviors of the eating disorder are addressed and resolved, the eating disorder will either not fully resolve itself and one won't recover, or someone might resolve the eating disorder, but their symptoms might shift into substance misuse or any other self-harm, any other kind of maladaptive coping,” Dr. Woodruff said.

When it comes to addressing stigma around eating disorders, Dr. Woodruff recommends community awareness and avoiding judgement of others. “Remember that we never know what someone’s going through. And it’s so easy to judge and say, ‘Oh my gosh, why are they doing that?’ Or, ‘They shouldn’t be doing this.’ But know that usually someone’s body can be a reflection of what they’re struggling with on the inside, whether they’re underweight, overweight, whatever it may be. And so remember that and have compassion. Have compassion for your fellow humans,” she said.

To hear more from Episode 4 of Season 2, scroll down to listen to the episode or read the transcript.

Watch the podcast on YouTube:

Meagan Rosenthal:
I am Meagan Rosenthal.
Alexis Lee:
And I'm Alexis Lee.
Meagan Rosenthal:
And this is the Mayo Lab Podcast.
Alexis Lee:
Well, hello everyone, and welcome back to the Mayo Lab Podcast, season two. My name is Alexis Lee, and as always, I'm joined with Meagan Rosenthal. And we have a very special guest today, and we're diving into the stigma around eating disorders. And we have Dr. Liz Woodruff with us today. Welcome to the podcast, Liz.
Dr. Liz Woodruff:
Thank you.
Meagan Rosenthal:
Welcome. We're so excited to have you. But before we dive in and get really in the nitty-gritty, will you just give us a little bit of background on how you got into this field, what you study, and kind of where you are today?
Dr. Liz Woodruff:
Yeah, yeah, absolutely. So I've been interested just in being a therapist for several decades. As a teenager, I had my own foray into therapy and found it incredibly useful and decided sort of then in there that was what I wanted to do the rest of my life. And there were some moments here and there where I panicked about the idea of going to grad school and extending my education so far beyond undergrad and all the stress of that. So I thought about other little jobs here and there that I quickly decided against because it's just kind of been my calling, I guess, at the risk of sounding hokey. And so I also have in my life been exposed, through loved ones, to eating disorders. And then in grad school ended up working under a professor who was doing a lot of research actually on eating disorders in men and sort of the different ways that eating issues and exercise issues tend to manifest in cisgender men in particular.
And so she was focusing on that research. So I got involved in some of that, did my dissertation on eating and exercise pathology. And then from there, just ended up moving... so this was in Dallas, in the Dallas area. Finished up my graduate work and did a predoctoral internship in Northern California at Stanford at their student counseling center. And actually at the time, I don't know if this is still true, but at the time Stanford had the highest rate of eating disorders of any college campus in the country. And there's really high rates, of course, on any college campus, I think this is true, I'm sure you guys see a lot of this. But really high rates of perfectionism, high achieving, high standards for themselves. And that type of kind of personality or temperament is also at high risk for developing eating disorders.
And so I think the confluence of some of those variables at Stanford puts them at risk for having a high rate of eating disorders. So I specialized in eating disorders while I was there and then just continued from there to develop and hone more and more expertise in working with eating disorders. I've worked in intensive outpatient programs, partial hospitalization programs where I worked really intensively with teenagers and adults who have eating disorders. And now I run, by some really long-winded chain of events that I'm not going to share here maybe a different podcast, I can tell you about how I ended up back in Mississippi. I lived in Natchez as a kid. But back in Mississippi, came here about three years ago. I'm in the greater Jackson area. And I have a private practice here where I am continue to specialize in eating disorders, the whole age range, really, the lifespan. So I'll work with pretty much folks of all ages and presentations of binge-eating disorder, anorexia, bulimia, subclinical eating disorders, the whole gamut.
Alexis Lee:
Wow. I think we found the perfect and the best person to have this conversation with, and I'm really excited. Before, as we get digging into things, in your words, can you tell us the definition of an eating disorder is what it is clinically?
Dr. Liz Woodruff:
Yeah, yeah. Well, there are different types of eating disorders. So they're all defined pretty differently. But if we wanted to give an overarching idea of what an eating disorder itself is, I think I would say that it is when someone is experiencing heavy preoccupation with food, with their weight, with body image and a disproportionate, or I guess when I say disproportionate, what I mean is really much more than one would expect, of one self-esteem or self-worth is sort of couched in how much they're eating or how little they're eating or what their weight is, how much they're exercising, and that there's a sense of an inability to control. Either control if one isn't eating enough and an inability to sort of nourish one's self properly or a lack of control when one feels they're eating too much and is unable to manage in that regard as well.
But the thing about eating disorders is the symptoms themselves manifest physically through food, through the body. But the way I look at it, the way I conceptualize it is that the behaviors and the ways things are manifesting through the body are actually representative of deeper psychological mechanisms that are happening on an underlying level. So if someone's struggling with anger, someone's struggling with sadness, grief, depression, if someone has a trauma history, if someone experiences a really severe struggle in expressing and processing emotion properly, it can manifest through an eating disorder, through the body.
And so while the food and the body are the outward expression of what I'm referring to, they're almost always kind of symbolic of what's going on under the surface. Well, I as a therapist, never just address those behavioral physical manifestations only. We always have to get at sort of what's underlying it in addition to dealing with some of the things that are more acute or more serious that are happening on the surface. Is that clear as mud? That makes sense?
Meagan Rosenthal:
Thank you for that overview. And I think as we continue talking, I think we will likely get into some of the different types of eating disorders as you referred to. But I think that gives us a really great overview to plant our feet on and to start, and I think Alexis shared this with you before, but one of the things that the through theme for this season of the podcast is really thinking about and talking about stigma.
And I would love for us to dive into right off the bat, because when you were outlining some of your background and areas of work that you've done in the past, you hit on something that tweaked in my mind, and this was eating disorders in men. Because we kind of assume, or we think historically, that eating disorders are a function of being a woman or manifest themselves more often in women and not so much in men. But they do. And so I'd love for you to, if you wouldn't mind, walk us through how they present in each of those groups and how they are different and similar to each other as it relates to, because I love what you were talking about too, is this being the food and the control of the body piece of it being a manifestation of stuff that's going on on the inside of us too. So if you wouldn't mind walking through that, I think that'd be really great.
Dr. Liz Woodruff:
Sure, absolutely. Yeah, and it's complicated and really multifaceted. But I would say to try and oversimplify it a little bit, just for ease of understanding and the sake of time, because I could go on forever. You have to be careful with me, because I can just go on and on and on. So keep me in check.
So yeah, I think historically eating disorders have been seen as an issue that affect white, straight, cisgender, affluent women. And it's true that high rates of eating disorders are seen in those populations, but not only those populations. So just to speak very, very briefly on race and ethnicity, there's actually really no discernible difference among different ethnicities and races when it comes to eating disorder prevalence. Now, utilization rates, wouldn't say that because you do see white women seeking resources and seeking treatment more often. But unfortunately, that does not represent the prevalence rates.
And a lot of that, and again, in interest of time, I won't go into lots of detail unless you want to ask later, I'm happy to talk about it. But you see in populations of color, you'll find lower utilization rates, less access often to insurance and effective treatments, stigma and fear around healthcare, around mental healthcare, things like that. And also just lower rates, underdiagnosis. So I think white women are more likely to get diagnosed with an eating disorder because of this myth, because of this stereotype, right? Physicians, for example, therapists may be less likely to assume a woman of color, for example, has an eating disorder because of these myths and these stereotypes. So there are a lot of different reasons.
But at any rate, but in men, we also see high rates of eating disorders, and they can manifest a little bit differently though. So I do think that on average the prevalence rates are lower based on research, but that may be due to stigma. So the rates of eating disorders in men could definitely be under reported, and again, underdiagnosed because of that stereotype, that only women have eating disorders. And I think also even often, parents are the first to notice that their child has an eating disorder and eating disorders tend to develop. Age of onset tends to be in adolescence.
The second most common age of onset would be actually college age. But early adolescents, onset of puberty tends to be the most common time for someone to develop an eating disorder. And so parents tend to be the ones who notice it first. If parents aren't, then probably again, a physician or maybe a school, a teacher, a counselor. But at any rate, I think again, due to that stigma, often parents aren't even noticing if their sons are struggling with food and body image issues.
Again, there's just more of a reticence, I think, to talk about it among boys on average. So again, I want to be clear, I am overgeneralizing here, so I'm not catching all the nuances, but what we tend to see with men is actually sort of split down the middle. So whereas the vast majority of cisgender women want to be thinner, and that's just what the research demonstrates. And again, I say vast majority, not everyone, but the majority of women who report body dissatisfaction want to be thinner. The vast majority of men or boys who report body dissatisfaction, about 50% of them want to be smaller. And actually, about 50% of them want to be larger. So you'll see different presentation in behavior. And I want to actually backtrack and make sure I made that clear. Not every woman wants to be thinner. I think that's sort the way I phrased it. What I meant was the vast majority of women who are unhappy with their bodies, who have already dissatisfaction want to be thinner.
So with men, it's cisgender men, it's about 50/50. And so with the men who want to be thinner, you might see more of an anorexic presentation, people who are restricting food intake, trying to lose weight. But actually with the cis men who want to be larger, you may be more likely to see something like risky muscle building behaviors like using steroids, excessive weightlifting, lifting weights through injury, injuring oneself, and a real preoccupation and an obsession with building muscle and becoming larger. And there's actually a clinical term for that called muscle dysmorphia when it becomes really extreme. And it used to be called reverse anorexia. So meaning that one has a distorted view of what their body looks like, they think they're much smaller than they actually are, and they believe that they need to gain a lot of muscle and get much larger, and they can engage in some really risky behaviors around that.
And one last thing I want to say on gender, which is really important, is that actually we see exceedingly high rates of eating disorders in the... sorry, let me turn my notifications off. High rates of eating disorders in the trans and the non-binary communities. So trans folks are at a much higher risk of eating disorders than cisgender communities are. And a lot of this is related to oppression, to transphobia, to experiences around prejudice, to feeling scared. And then a lot of it is related to feeling dysphoric in one's body and wanting one's felt sense of gender to match what the world outside sees. And so in particular, if folks are struggling to get access to gender affirming care or in their community aren't, people in their lives aren't affirming gender, sometimes they'll resort to disordered eating to work to change their bodies to match their felt sense of gender. And so that's really an underrepresented community and one that I think we need a lot of awareness around just because the rates are staggering.
And then, sorry, one last piece to that too is that in addition, when working with trans folks, for example, you'll find that trans folks who have eating disorders often have high rates of suicidal ideation as well. And that's true in the queer community in general. And there's a lot of research on this, and I'd be happy at the end if you want me to share any of those resources. The Trevor Project did an amazing study, the biggest of its kind, exploring eating disorders in the queer community. And so they found that, again, this is where a lot of this data comes from in terms of the trans and non-binary communities. And again, they found that for trans folks, there are higher rates of suicidal ideation in general. But in particular, that's true when you also have disordered eating on board. So that was a lot of-
Meagan Rosenthal:
No, that was great. That was awesome, and thank you for broadening that out and capturing the nuance of what each of those different populations face as it relates to disordered eating and all of those different kinds of things. Because I think that one of the things that we're really digging into in the season of the podcast is actually the weeds, is getting into the muck and getting into the complexity of some of these things with the proviso being like, nobody's going to listen to us go on for four hours. But to really get in and understand what those differences look like.
And so I'd love if we could just kind of do a little transition here to think through the stigma related to disordered eating. And start off really, if you could walk us through in the folks that you work with around this condition, what is the stigma that individuals are facing as they are thinking about or reaching out for care? And you can cover any and all of the populations that you've talked about so far or however you want to manage that. Because I imagine based on what you've said so far, that the stigma that each of those groups face is going to be slightly different because of the body that they inhabit or the place from which they come.
Dr. Liz Woodruff:
Yeah, absolutely. And I think the stigma, it varies based on diagnosis as well or based on type of eating disorder that one has. And so I think maybe I'll start with that piece of it. And then within that, I'll talk about gender differences too and stigma. So anorexia is considered a restrictive eating disorder, and I imagine most folks are familiar with it to some extent, at least as far as having the sense that anorexia tends to be when someone is not eating enough, they're eating a low amount of calories based on what they need for their expected body weight, for their level of activity, that sort of thing. And they tend to be very underweight, not always. And so that's another reason I think we have stereotypes about people who have anorexia, that they look really, really underweight, they're frighteningly thin. You can tell by looking at someone whether they have anorexia or not, and that's not true, right? Anorexia actually can happen in all different body types, and someone can be dangerously restricting their food intake, but they may not be severely underweight.
And so that's something that is, I think, a misnomer out there. But also, let's see. I think in terms of the shame, as much as we live in a culture that tends to hyper value thinness, and especially for women to idealize a thin body, there's also this mixed messaging I think that we get in our culture that you need to be thin, but you also need to eat enough. And you need to be thin, but you shouldn't be dieting. And if you have to diet, then there's something wrong with you. And there's just this sort of mixed messaging that happens. And often you'll see, now this is really going to age me, and in fact, it's probably going to age me so much that a lot of people listening won't even know who I'm talking about. But that's okay. I have no shame, no ageism here. But when I was maybe in college, a long time ago, let's see, I'm sure some of you remember Paris Hilton-
Meagan Rosenthal:
Yeah, yeah. Now I just aged myself.
Dr. Liz Woodruff:
Thank you, Meagan. I really appreciate you being in solidarity with me here. Of course, Alexis has no idea who we're talking about.
Alexis Lee:
I know exactly who we're talking about. Don't worry, don't worry. Millennial, don't worry.
Dr. Liz Woodruff:
Yes. Okay, got it. So Paris Hilton. And do you remember Nicole Richie, her sidekick? That they did whatever that show was together where they were living on a farm?
Alexis Lee:
Oh, yes.
Meagan Rosenthal:
I do, I do. Yeah.
Dr. Liz Woodruff:
Well, I am bringing this up because I remember very distinctly that Nicole Richie was considered when she was on that show, people talked about how they thought she was fat and she was overweight, and Paris Hilton was so thin. And there was this really gross, perverted kind of focus on her body and body shaming her. And then she developed anorexia and she lost a frightening amount of weight and became quite thin. And then I remember seeing magazines, this was back when magazines still existed, and people go to the internet for everything too. But I remember seeing a magazine cover shaming her for being too thin. And so I remember that actually very distinctly because it hit me how impossible it is. And so I think that as much as we feel this pressure in our culture, particular women, whether cisgender or transgender to be thin, there's also a stigma around not nourishing one's body enough and having to try too hard to be thin. And there's a stigma around not eating enough.
And a lot of the people I work with, regardless of gender, will tell me that there's a lot of embarrassment around what they eat. They do what they call performance eating, where they will eat around friends, or they'll eat more around friends and family than they do when they're alone, so that people don't worry or people don't shame them for not eating enough. Despite what people might think... because hear a lot of glorification of anorexia in our culture too. I hear people say things all the time like, "I wish I could be anorexic. I would never be able to do that." I think it really speaks to just the glorification of thinness and the reverence paid to people who can restrict their food intake. So I think as much as there is that sense, there is also a lot of shame inherent in having anorexia.
And just for folks who don't have any familiarity with the illness, when someone has anorexia, it is an excruciating way to move through the world. There is an extraordinary focus on weight and body and food, and it takes up all of one's head space and one's world, and life becomes smaller and smaller and smaller. And not to mention, when your brain is in a state of starvation and when your body's really weak, you're pretty miserable physically and emotionally the vast majority of the time. So I think for those reasons, there can be stigma too when it comes to anorexia. So I'll move on next to bulimia. [inaudible 00:21:53] have questions about that?
Meagan Rosenthal:
No, no, no, I think I'm good. Alexis?
Alexis Lee:
This is great. This is awesome. Thank you.
Dr. Liz Woodruff:
So I think with any illness like bulimia, you'll find even more stigma and a lot more shame. I think on average, it actually is a little bit easier to hide bulimia than anorexia because folks with anorexia, like I said, they tend to be restrictive. And even if you can't tell by looking at them that they're underweight or that they have an eating disorder, you can often tell by some of their behaviors around food. They may be skipping meals, they're eating extremely, quote, healthy, but just really low calorie, that sort of thing. But with bulimia, folks, with bulimia tend, and again I'm generalizing here, but they tend to eat a little more like someone who doesn't have an eating disorder when it comes to their day-to-day eating. They're not going to necessarily be as restrictive. Sometimes they might. But on average, you're not going to see the extreme restriction in food intake.
But what you'll see is binge-eating is secret usually. So binge-eating is when someone consumes a really high amount of calories that would be much higher than what we would expect someone to eat in one sitting. So that could be eating entire bag of chips, an entire large pizza and a carton of ice cream might be considered a binge or having an entire birthday cake. I've had patients who've eaten an entire box of cliff bars as a binge. And also often when someone's binge-eating, they have this experience almost of having an out of body and sensation. So dissociation is actually the clinical term for that. But it's when someone is not emotionally present, they're not mentally present, that they feel like they're not in their bodies. And that's one of the functions of a binge is that it helps someone... and ultimately, this is not necessarily an adaptive thing, but when someone's really overwhelmed with emotion or trauma, binge-eating can help to dissociate or detach from those emotions.
And so often though, after a binge, an extreme sense of guilt and shame may come up. So there's a lot of stigma and shame around the binging. And we probably don't have to talk a whole lot about that because I think generally in our culture, we understand that there's so much stigma associated with what someone might consider, quote, overeating or being out of control and not having willpower. So the stigma there and then the guilt and shame might lead someone to engage in what are called compensatory behaviors, but trying to get rid of the food just consumed. So that could be through vomiting. After eating, that can be through excessive exercise. Sometimes it can actually be restricting. If someone has a really significant binge, they might not eat for the rest of the day, or they might try not to eat tomorrow as a way to compensate for the calories that they had during the binge.
And in particular, with the binge and purging through vomiting, there's an immense amount of stigma and shame around that. And so generally, what I find with my patients is they're extremely secretive about their disorder. And whereas, again, anorexia is a little bit more difficult to conceal, I've worked with folks who have been dealing with bulimia for sometimes 20, even 40 years, and no one knows, no one's ever known. And they've done such a job of keeping it a secret, and they're so embarrassed of it because of the stigma attached to that. I think with binge-eating disorder, again, you'll find a lot of stigma. It wasn't until very recently in the last, I'm looking at my DMM book, I forget when it came out, but it was quite recently in the last five, eight years or so, I forget. But the most recent diagnostic manual for mental illness includes binge-eating disorder, but that wasn't included previously.
And so I think in the past, folks who had binge-eating disorder were just shamed and told that they had no control and that they needed to diet. That is not a solution to binge-eating. In fact, dieting tends to reinforce and perpetuate the binge-eating because restricting our food intake makes us eat more.
Alexis Lee:
Yeah. Right.
Dr. Liz Woodruff:
And so actually, not an antidote dieting. It's an intuitive response to a binge, but it is not a useful one. But there's a lot of folks with binge-eating disorder, they won't even seek mental health treatment because of that stigma. They may not even know themselves that it's a mental illness. They may just think, "I'm so lazy, I have no willpower. What's wrong with me?" And so it's sort of a sense of that internalized stigma as well.
Voiceover:
You are listening to the Mayo Lab Podcast. For more information and resources, visit themayolab.com. Now, back to the episode.
Meagan Rosenthal:
Well, and I think I'm going to pause for a second because you mentioned binge-eating disorder being added to the DSM manual. And could you talk us through, just for folks who might not understand, why that's such a significant addition for folks who are suffering with this condition? Because I think that it'll help folks understand that it is a real condition. It has, like any other, we were talking in some of the previous episodes about substance use disorder being a chronic condition just like diabetes, just like hypertension. And so if you could walk us through why that's a really important addition from your perspective as a clinician,
Alexis Lee:
And also add, going onto that of why eating disorders in general are included in the mental health illness category.
Dr. Liz Woodruff:
That's a great question. Actually, I'm going to start with that and that'll segue into the-
Alexis Lee:
Perfect.
Dr. Liz Woodruff:
So yeah, eating disorders are considered a mental illness because there is an underlying psychiatric psychological component. Sort of what I was mentioning right at the beginning, and that's sort of hard to explain without ample time. So I'm trying to think of a really nice compact way to explain it.
But again, an eating disorder is a physical concrete behavioral manifestation of a deeper psychological struggle. So often, it may be anxiety, it may be trauma, it may be struggles in one's family, all these different variables, genetics too, work together to contribute to an eating disorder. But it is always, there's a deeper underlying psychological component that has to be addressed. And if it's not, and only the behaviors of the eating disorder are addressed and resolved, the eating disorder will either not fully resolve itself and one won't recover, or someone might resolve the eating disorder, but their symptoms might shift into substance misuse or any other self-harm, any other kind of maladaptive coping. But the way I look at it is it's almost invariably an eating disorder as a response to unprocessed emotion, unprocessed trauma, things that somebody cannot put into words that they can't even reflect on because it's too big and hard and difficult and they haven't had the support they needed, whether it was in childhood or at any point in their lives, to manage those big, hard, difficult things.
And that's why eating disorders are in the DSM, in the mental illness diagnostic manual, because it is a physical manifestation of a psychiatric problem. Binge-eating disorder is in that category. But historically, in the medical community for example, folks who have binge-eating disorder were not seen as having a psychiatric problem or an emotional problem. They were seen as having a weight problem. And it was seen almost more as a character defect. You don't have willpower, you need to cut back on your food intake. What's wrong with you? Not a curiosity about, okay, what is it that's leading you to overeat? Is there some way you're using food to cope and manage stress or emotion? What's going on that's contributing to this? And now that binge-eating disorder has been included in this manual, it's facilitated, encouraged a curiosity rather than a judgment about someone who's got issues around binge-eating or overeating.
And I think within the community of folks who have binge-eating disorder themselves, it's helped them to recognize, okay, this isn't just that I am deficient, this is that I have a psychological condition that leads me to use food to manage. And if I can adjust those underlying struggles, then I can find a way to manage without having to turn to food. So again, sort of oversimplified, but that is in a nutshell, the way I might explain it. And so it's really helped folks get the help they need and actually heal from the problem as opposed to just continuing to shame them and keep encouraging them to diet, which is only fueling the problem, in my opinion.
Alexis Lee:
And I think what you're saying is such a great move and a step towards in our communities especially and practitioners in general to help to de-stigmatize this and just meet people where they are and say it's not your fault in a way. And what you were saying earlier about it's people often hide it, and it's very hard to recognize that when it's happening in someone. What advice would you give to family members and really close unit friends around the person struggling? What signs would you look for? What changes in behavior things? If they're suspecting maybe something, what would be the first thing you would point them to?
Dr. Liz Woodruff:
Yeah. So in terms of signs, again, that will vary based on the presentation, but psychological signs might be withdrawal, that their less engaged socially than they used to. You find that they're isolating a lot. Depressed mood, keeping things to themselves, spending a lot of time, I think I mentioned that already, but isolated. Refusing to eat around others. I think with any eating disorder, you're going to find that to an extent. With binge-eating or bulimia, you might find large quantities of food disappearing from the cabinet or something. With bulimia, you might find food wrappers in the trash can in the bathroom. People shouldn't be eating in the bathroom typically, right?
And with bulimia, you'll find, so the glands around the face, they're called the parotid glands. But you'll find that they tend to be swollen. So you'll see swollen cheeks, swollen glands, in folks with bulimia. In folks with anorexia, of course, extreme weight loss. If someone's lost their period, if they're a cisgender woman, you'll often find that folks who have anorexia will lose their periods. A real preoccupation with food, talking about food all the time, and obsession with food, cooking food, cooking food for others, but not eating it. Baking lots of things but not eating it. The list really goes on. I think that probably captures the most telltale signs that come to mind immediately.
And then in terms of how to broach this with loved ones, it can be extremely delicate. And I think naming that dilemma can be really useful. Saying something like, "Look, I feel a lot of hesitation to bring this up because I don't want to upset you or push you away. And on the other hand, I fear that I would be really neglectful if I didn't talk about this with you, and that I am worried. I've noticed these things, and I just want you to know I'm here for you." And if you're a friend or a sibling or something, just saying, "I'm here for you, if you want to talk." If you're a parent, I think sometimes being a little more proactive and saying, "Let's go talk to someone about this." Or get to the student counseling center, or I'm sure there are folks there that can actively help to assess for an eating disorder and then help to triage for appropriate resources.
And there was one other thing. And I mentioned earlier this idea of curiosity. Help me understand what is it that instead of, "This is so bad. Why are you doing this? This is going to kill you." Which is our instinct, because it's terrifying. And I can't tell you how many times I want to say that to patients, and I probably have more than once in my life said that to patients. But expressing some curiosity. As much as I'm worried and I'm scared, and I want to tell you, "What are you thinking?" Also, I can imagine there's a lot going on for you, and it's really complicated. So why do you feel the need to do this? Or what is it that skipping meals is doing? Or how does throwing up after a meal, what's the function of that? Why do you feel the need to do that? Expressing some curiosity.
Meagan Rosenthal:
I just love that idea because I always feel like when I have been placed in these kinds of situations in the past, my gut reaction is like, "Oh my God, what are you you doing? Stop." But the thought as you were talking about kind of what expressing curiosity allows you to do, it really takes you out of that knee-jerk gut reaction to, "Oh my God, stop," to thinking and opening yourself up to asking questions about what is happening and allowing that person the opportunity and the space to articulate what they're feeling and how whatever action it is that they're engaging in is they think it's helping them to get them to a better place. You said this earlier, one of the things that is the cause of these actions is unprocessed stuff, emotional, physical, trauma, all of those different kinds of things. And so I can see there being value in helping people find words to describe what it is that they're doing.
And then you're not hopefully turning them off because we know already too, if you freak out, because they already feel all of this shame and guilt and a sense that what they're doing and what they're doing to their bodies or not doing to their bodies isn't a good thing. Folks know this. And then you just drive them deeper into a hole and they're never going to come back out of it again. So I love that as an approach. And what you said too about naming this fear of talking about it upfront to say... because I think that's the other thing that I struggle with sometimes too, thinking about these things is like, yeah, but if I say something, it's going to make it worse, or they're never going to want to talk to me again. And I love that you shared that, no, that's not actually the case. You're opening up this dialogue with this other person, and you're expressing your care and love for them and concerned that something's not right, but that you're there and that you want to be helpful to them. So I think that's all amazing.
Dr. Liz Woodruff:
Right. And back to that idea of stigma, that if we can help someone recognize we don't carry that stigma, or we're trying to understand instead of judge, that can help to, again, like you said, open up the space instead of-
Meagan Rosenthal:
Yeah. That's amazing.
Alexis Lee:
I want to ask what you think we could be doing to better be more proactive in spaces of K through 12 schooling and then also on college campuses?
Dr. Liz Woodruff:
That is a really, really good question. And I think education, K through 12, I think education for parents is actually of utmost importance. And back to that idea of what signs to look for and then what do we do when we suspect that there's a struggle? So I think that's one piece.
So within the medical community, there can be a lot of... I'm trying to think how to say this politically correct. There can be a lot of unconscious bias around weight, I think. Again, and this is just cultural, so no judgment. Really, truly no judgment at all, because I think it's really pervasive in our culture that there's just this misnomer that a thin body is a healthy body. And so a lot of times there is, I've had people end up with eating disorders in my office after maybe a physician told them as kids that they were at risk for obesity and they needed to go on a diet.
So not to say that the physician caused the eating disorder, not at all. But that was the impetus for the development of the eating disorder. All these other variables would've been in place that led to the eating disorder. But if we don't educate our medical providers, our parents, teachers, that we need to be really conscientious about the way we talk about weight and our own biases around weight and thinness, that we don't want to perpetuate those in our kids. That we want to talk more about health and being nourished properly and getting the right amount of exercise and exercise being about joy rather than just calorie burning and weight loss, and really kind of providing education around how we can help kids understand weight, food, exercise, bodies. Not from this model that we've had for so many decades of we have to be thin and we have to be lean, but instead about health and wellness and wholeness.
And also, I think it starts probably at an even more fundamental level around helping our kids deal with their emotions. Learn mindfulness skills, things like that. So I know for me, 100 years ago when I was in K through 12, there was no emphasis whatsoever on learning to manage my emotions or learn any kind of mindful awareness or anything like that. I think that's changing a little bit, but we've got a long way to go.
And so if we could help our kids learn better how to deal with stressors, et cetera, I think we would see reduced rates of mental illness in general. I don't think it would eradicate it by any means. But in terms of college campuses, I would say similarly, and lots of outreach, lots of education, lots of awareness, education around eating disorders. Both for the student body, but also among the faculty. Increasing awareness around resources too. When I was in undergrad, I didn't even know that we had a student counseling center. I'm sure someone told me, but I didn't really have this awareness that I had 15 free sessions a year or whatever it was at the time. So knowing too, that there are resources and making sure that students have access to those and that they're aware of how to gain access, that sort of thing.
I think those would be my first knee-jerk reaction kind of ideas. But again, I'm sure that's something we could just brainstorm about for an eternity, about the ways we could-
Meagan Rosenthal:
You're not wrong. You're not wrong. But I think those are all really great ways to start. And I love the thinking through reorienting how we think about our bodies for our younger kids, and thinking about relationship to food and thinking about it being something to nourish you and finding the exercise and being whatever, doing those kinds of things that makes you happy. I just love those ideas. I would be curious to know, and I just want to pick your brain on this, because I think there's been a lot of conversation around the body positivity and that movement to say all bodies are good bodies. And fundamentally, obviously no disagreement with that. But how do you balance that off? Especially I'm thinking from the clinical community because we have a large body of evidence and data to support the negative outcomes that come from having too much or excess weight and not monitoring the whole health, as you said, of people in those circumstances.
And so what's the right solution to that conversation? Because I think it's really complicated in asking for a clinician to say to a child or a child's parents, "They're moving in a not great direction as it relates to their weight. We need to do something about that." It comes from a good place. It comes from a place of not wanting them to have negative outcomes later in life. But also, I totally hear what you're saying around that maybe being a catalyst to spiraling in a not good direction either. So from your perspective and expertise, what's the right balance to those conversations?
Dr. Liz Woodruff:
Yeah. Well, I think it's extraordinarily nuanced, and so much of it, unfortunately, is case by case. So I don't know that there's a great sort of panacea, if you will, or a great solution that can capture all those nuances in the whole country, for example. But I think that it is not black and white. It is not binary sort of issue, unfortunately. As much as our minds want to turn things into binaries, because it makes it so much easier to find that solution, it isn't. And you're exactly right that there needs to be an emphasis on having a healthy relationship with food from either direction, that we have an understanding of the things that are good for us to nourish our bodies, that are going to fuel our bodies, but that aren't going to hurt our bodies. But also we need to eat enough to fuel our bodies and nourish our bodies, otherwise that hurts our bodies.
And so I think within... and this is a much broader discussion, I guess, but what I'm about to say, but education within the medical community, education within the community at large, parents and the college community, that eating disorders are a real threat and that we need to promote not just weight loss and thinness, but we need to promote a healthy relationship with food, whatever that looks like. And I think on the other side of that, it's really the same thing that both sides we're trying to promote actually the same thing, but the language gets conflated. And then the two sides seem like they're in opposition, and then they start fighting with each other.
And I think what the problem in that is on both sides is a lack of consciousness about what we're really trying to do here. And so I'm familiar with folks who have tried to promote this idea of health at every size, that all bodies are good bodies, and they've gotten death threats from people who say, "Well, this is dangerous." And then the reverse is true. I know people who are sort of spearheading more of the fighting obesity, and people in the health at every size body positivity camp are enraged about it. But the sides aren't listening to each other. And if we could bridge this gap, and as a friend of mine says, call people in instead of call people out, and actually start a conversation... yeah, isn't that great?
Alexis Lee:
Yeah, yeah.
Dr. Liz Woodruff:
Start a conversation and really try to understand instead of being so pitted against each other, I think it might help to come to some better solutions. So if you have ideas about how we can do that, I'm all ears.
Meagan Rosenthal:
Well, I want to say maybe two things, but probably three. I'm going to work through them. What I love most, the kind of first thing that kind of popped out in my head around this is that there isn't one, there's not one single solution to this problem. And one of the things that we've come back to over and over again in this season of the podcast is really that, look, this is so complicated, and if it was easy, we wouldn't have to talk about it because it'd already be solved. And so how do we get used to and become more comfortable with the fact that there isn't an easy solution to this, and it's not going to be a single magic pill or a single silver bullet that's going to solve all of these problems. I think we need to think about that in a different way than we historically have.
We're all looking for the panacea, the one solution that, bang, everything's roses and sunshine. And that's not the human condition, that's not how the world works. I think also your observation about really both sides of this debate such that it is, it's really, actually, we're all after the same thing, people who are living good, healthy lives that are able to function in the world in a way that makes them happy, that's the goal. And you're totally right that everyone's talking past each other, because as I have been the recipient of emails on this campus from folks who are concerned about some events that were being held around disordered eating, and how can you possibly promote this in a state that has such an epidemic of obesity? And it's like, I see what you're saying, I do, but there's this other side of this.
And it was just like, at the time, I didn't have the language to really dive into that and have a conversation. But I think what you're saying, so that's why it struck me. So right here, I'm like, "Oh, yeah, you're right." And inviting people into the discussion versus calling them out, that is such a antithesis of our current environment. But I love that as an idea. So being curious, inviting them into the discussion, asking questions to understand that perspective, like what a novel set of ideas in this space. I just love it. I just love it.
Alexis Lee:
It's going to be something that people are going to be like, "Wow, why didn't I think of that earlier?"
Meagan Rosenthal:
Right? Right. Yes, that's so brilliant.
Dr. Liz Woodruff:
I don't always practice what I preach, by the way. I often get locked into one side or the other too. And your question helps me to kind of zoom out, Meagan, and remember like, okay, it is so nuanced, and yes, I understand the concerns around obesity in the state. And at the same time, I would argue a little bit that on a college campus when it comes to eating disorders, that's not really probably as much of a concern as... but again, even if it is an obesity issue, that if we just understand it as a behavioral manifestation and as a acute symptom that needs to be eradicated or eliminated, we're missing what this is truly about.
Because generally, it's either going to be about, again, something that's more psychological, emotional, or other variables like poverty and lack of access to healthy food and things like this. So there's so many variables that contribute to this problem, and just telling somebody they need to lose weight and need to go on a diet is really missing the larger picture too. So back to that idea, just curiosity and discussion in general about what needs to be done and how we can help tackle the issues.
Meagan Rosenthal:
Yeah, this is incredible. Alexis, did you have a question? You look like you might be asking.
Alexis Lee:
No, I was going to move into wrap up if there were no other questions.
Meagan Rosenthal:
Perfect.
Alexis Lee:
I love the segue of curiosity and having a conversation and calling people in, and that's what we want to do with this podcast. So if you could give three takeaways for our audience, Liz, of what's one thing they could do for themselves to have a different conversation with themselves about eating disorders, what's something they could do with their family units and what's something they could do in their communities?
Dr. Liz Woodruff:
Yeah, yeah. I would say... and are we talking for folks in general or folks who think they might have some struggles with food?
Alexis Lee:
I think folks in general.
Dr. Liz Woodruff:
I would say examine your own, and maybe exam is not the best word, that's too severe of a word, but get curious about your own stigma around food, eating disorders, et cetera, weight, obesity, all of these things. Get curious about your own relationship with food and exercise, because I think we all have some struggles here or there. You don't just have to have an eating disorder to have any kind... if you are a human who lives in the United States, you've probably had some kind of hangups around food, exercise, weight, et cetera, at some point in your life. So just getting curious about your own relationship, your own stigma, et cetera, around food and weight and exercise.
And what was the second piece?
Alexis Lee:
Family units.
Dr. Liz Woodruff:
Yeah, family unit. Thinking about how these things manifest in your family unit as well. What have your family's ideas been about food and weight and dieting and things like that? What do you notice about that? Where does some of your beliefs about these things, how do they stem from some of your family's perspectives?
And then I would say from a community standpoint, to notice your judgments about others and really try and if you notice... because again, we all do it. We all do it. And I am ashamed to admit I do too. But I caught myself having a judgment about something the other day that I'm not even going to share. And I caught myself though, and I reflected on it, and I got curious about it. And so that's what I would encourage you to do when it comes to your community is notice your own biases. Notice your own judgments about folks, whether you think they're really thin, whether you think they're fat, whether you think, oh my God, I can't believe that person's eating that. Or if you think, "Oh my God, I wish I was anorexic," remember that comment I made earlier. Notice these things because we tend to be so unconscious about our relationships with food and bodies, et cetera. So just try to get more mindful about that.
And remember that we never know what someone's going through. And it's so easy to judge and say, "Oh my gosh, why are they doing that?" Or, "They shouldn't be doing this" or, da, da, da. But know that usually someone's body can be a reflection of what they're struggling with on the inside, whether they're underweight, overweight, whatever it may be. And so remember that and have compassion. Have compassion for your fellow humans.
Meagan Rosenthal:
Yes. Yeah. Thank you for all of your wisdom and sharing your knowledge and expertise in this area. I think you said this earlier, it's a topic that we don't necessarily have a lot of conversations in the open about, and I want to thank you for helping us get on the other side of that, right? We recognize that it's a problem. Let's start figuring out ways that we can solve that problem. And thank you also for providing our listeners with some things that they can start doing right away. I think that that is part of what we hope to accomplish with this podcast is really giving everybody a little bit of homework that's not scary or hard, but just things that we can start thinking about and being more mindful, as you said, in this space. Because it's easy to go full zombie, unconscious, just like go do the thing without really being thoughtful about what that looks like and the consequences of that action.
As always, folks, please let us know how you make out with Dr. Woodruff's thoughts and recommendations for you, your family, and our community. And please join us next time for the Mayo Lab Podcast. Have a good day.
Dr. Liz Woodruff:
Thank you.
Voiceover:
Thank you for joining us on this episode of the Mayo Lab Podcast. The Mayo Lab Podcast is produced by Dr. Natasha Jeter, Dr. Meagan Rosenthal, Alexis Lee, Slade Lewis, and Hannah Finch. This podcast was recorded at Broadcast Studio in Oxford, Mississippi. The show was mixed and mastered by Clay Jones, and our original music was composed by Slade Lewis. The Mayo Lab podcast is brought to you by the William McGee Institute for Student Wellbeing. For more information on the Mayo Lab Podcast, head over to themayolab.com and follow us on social media, @TheMayoLab. If you enjoyed listening to the Mayo Lab Podcast, we'd love for you to subscribe, rate, and give a review on iTunes, Spotify, or wherever you are listening to this podcast. This podcast represents the opinions of Dr. Meagan Rosenthal, Alexis Lee, and their guests on the show. This podcast is not intended to be a substitute for the medical advice of a licensed counselor or a physician. The listener should consult with their mental health professional in any matters relating to his or her health, or the health of a child.