All right, welcome back to the podcast. I am joined today with a internal medicine eating disorder specialist, Jennifer Gaudiani, and she worked eight years in Colorado at

one of the leaders of acute center for eating disorders at Denver Health. That was like an impatient eating disorder stabilization center. And then she has worked seven years at her own clinic, Gaudiani clinic since 2016. And so she has written a book called Sick Enough, which is a guide to the medical complications of eating disorder. And

she was introduced to me by another person on this podcast, Sally Vanderweil. She is an impracticed therapist in Perth, Australia. And she is, you know, it's always good to know from someone who treats a lot of people who the experts are sometimes in fields that I am not like, you know, I'm not seeing eating disorder patients every day. And so it's really helpful to know from people, okay, this is a true expert.

So it's great to have her recommend Jennifer who wants to go by Dr. G. And Dr. G also has a podcast and has been on other podcasts. And so if this is something that speaks to you that you want to learn more about, I'm sure this can be just an intro. So, okay, I want to just jump into it.

Dr. G, what topics in eating disorders do you think are the most poorly understood by other physicians and therapists?

It's a really long list. And I too continue to learn on a daily basis. You know, I think one of the most important ones is the idea that someone with an eating disorder lives in an emaciated body.

That's pretty much the stereotype that you've got a young, white, wealthy, underweight woman who is the stereotypical person with an eating disorder. But the reality is that a truly tiny fraction of the total population of individuals with eating disorders are actually visibly emaciated.

The vast majority of individuals with eating disorders, you would walk by in the street without looking twice. They either have body weights that would be considered so-called normal or being larger bodies.

So, when medical providers are engaging with a patient, they might have a bias to think this person is fine or healthy or lamentably needs to be advised to lose weight, just never something I recommend.

And in fact, that does quite a lot of harm. So, I would say that's one of the most important stereotypes to debunk from the get go.

Okay. And how did you come upon this realization?

Well, I've been in the field for 15 years now. So, I've done a lot of work in it. And it's not only my direct clinical observation, but the studies all fully back this up.

The incidence of anorexia nervosa 0.1% of the population of so-called atypical anorexia nervosa, a term I dislike because the individuals have all of the same psychological manifestations and suffering as those of anorexia and all of the same dieting, restricting, eating disorder behaviors, they just don't happen to be emaciated.

Those probably represent more like 3% of the population. And those of binge eating disorder are equal across genders where there's a slight skew towards female patients in the first two.

And that's going to be 4-ish percent where bulimia nervosa comes in maybe around 2-ish percent. So, just by the numbers, anorexia nervosa represents a very small number. And I think actually the relative incidences still overrepresent emaciated anorexia nervosa because historically, even though they're still not nearly enough funding and research money.

In this, it has historically gone more towards anorexia nervosa. So, I still think that that population, while absolutely deserving and wonderful and vital, is overrepresented in our numbers.

Okay, so when you were working at the acute center for eating disorders, I understand this is kind of like a specialty and patient setting for people with eating disorders. Did you have criteria for how you would admit people or was it insurance-based? Like, this is what insurance will pay for?

That's a great question. Yeah. So, when I was medical director at acute, which is the nation's top medical stabilization hospital for critically ill adults with anorexia nervosa, we would typically accept patients who couldn't be cared for at any other level of United States eating disorder care.

There are super programs around the U.S. that have very high acuity in patient and residential settings, but the patients we took at acute were too medically compromised both by weight and by organ system to be able to receive care there safely. So, when we were at acute, they needed to have round the clock cardiac monitoring, a multidisciplinary approach, a one-on-one approach, etc.

Okay, because I'm seeing like there's a contrast between that sort of like you have to be sick enough to get in here, right? And your book, which is sick enough, like you don't have to necessarily look too sick to receive the needed treatment. So, can you talk about that sort of dichotomy there?

I love that question. Yeah, it's actually one of the reasons that I left acute. You know, I love those patients. I love that team. That work is what brought me into this field, and I am eternally grateful, but the reality is that even the patients who would admit to acute almost to a person within 24 hours of admission would tell me, Dr. G, I'm so embarrassed to be here.

I know I'm not sick enough to receive this care. And that was the first time I ever heard that construct, which seemed mind-blowing to me, because of course these individuals, and I'm never going to use BMI numbers or weight numbers, because I don't want to trigger anybody.

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