Therapeutic dietary interventions such as an elimination diet, a cardiometabolic diet, intermittent fasting, or caloric reduction, are some of the most important tools we have in functional medicine. Transitioning to healthful eating can for some patients be a joyous experience of liberation, but then for others it can be restrictive and problematic, and sometimes fall in the continuum of eating disorders. How do we tease this out? How do we screen for vulnerability in disordered eating and support patients who fall within this spectrum? In this episode of New Frontiers, Dr. Carolyn Fisher PhD, a licensed clinical psychologist who specializes in helping individuals with binge eating, emotional eating, chronic dieting, and other medical conditions heal their relationships with food. Today we discuss the importance of identifying disordered eating tendencies before guiding patients into dietary changes, tools to recognize those at risk, what is involved in treating eating disorders, and how to discuss weight in a sensitive manner with patients. This needs to be front and center in our minds, perhaps more now than ever, as we rely heavily on therapeutic dietary interventions to address chronic disease. Stay tuned, leave us a comment, and subscribe to stay up to date on our latest content! ~DrKF
The Impact of Therapeutic Dietary Interventions on Disordered Eating
Therapeutic dietary interventions are a foundational tool we use in functional medicine to guide individuals to better health. But when do elimination diets, fasting diets, reduction of calories, and other dietary changes contribute to disordered eating? What is the impact of restrictive diets in individuals with a history of disordered eating and how can we reframe dietary restriction to instead focus on healing and nourishment? In today’s episode of New Frontiers, we speak to Dr. Carolyn Fisher, a licensed clinical psychologist at Eating and Behavioral Health Associates who specializes in helping individuals with binge eating, emotional eating, chronic dieting, and various medical conditions heal their relationships with food through evidence-based practices. Dr. Fisher discusses how to empower individuals to navigate healthy eating habits and shares clinical tools to screen for disordered eating.
In this episode of New Frontiers, learn about:
- The spectrum of disordered eating and orthorexia
- Tools to identify patients who are vulnerable to disordered eating
- The most common eating disorder
- Questions to guide patient encounters around food, dieting, and eating habits
- The bi-directional relationship between eating disorder and GI symptoms
- The Eating Disorder Examination: EDE-Q 7
- Eating disorder treatment
- Orthorexia tests and tools
- How to discuss weight in a sensitive and useful way with patients
- Recognizing weight bias and stigma
- Addressing disordered eating before implementing dietary changes
Dr. Kara Fitzgerald: Hi, everybody. Welcome to New Frontiers in Functional Medicine where we are interviewing the best minds in functional medicine and today is no exception. I’m eager to talk about disordered eating, orthorexia, really looking at this through a functional lens, both what we can do to support our clients, how we can evaluate for it, are some of the restrictive diets we’re prescribing contributing. So to that end, I have with me today, Dr. Carolyn Fisher, let me give you her background. I think you’ll see that she’s ideal for us on this conversation.
She is a licensed clinical psychologist at Eating and Behavioral Health Associates. This is an eating disorder-focused private practice in Columbus, Ohio. Dr. Fisher specializes in helping individuals with binge eating, emotional eating, chronic dieting and various medical conditions heal their relationships with food through evidence-based practices. She’s passionate about helping individuals foster a mind-body connection to empower them to make individual values-based choices surrounding health and eating.
Dr. Fisher obtained her doctorate in clinical health psychology at the University of Cincinnati, completed her APA accredited internship at Ann Arbor VA and postdoc training at Cleveland Clinic. Prior to joining eating and behavioral health, Dr. Fisher was a staff psychologist at the Cleveland Clinic and assistant professor at Cleveland Clinic Lerner College for Medicine at Case Western Reserve University.
Dr. Fisher has been actively involved in research and presentations regarding the treatment of binge eating and the relationship between diabetes and disordered eating. Dr. Fisher. Welcome to New Frontiers.
Dr. Carolyn Fisher: Thank you so much for that introduction. I am so excited to be here and really so grateful to be having this conversation today. So thank you.
Dr. Kara Fitzgerald: It’s an important conversation, it’s timely. It’s a topic that needs to be on the minds of all clinicians and I want to bring it to my peers in functional medicine. Let’s just jump right in. Why is it? Why is this topic relevant to us in functional medicine?
Dr. Carolyn Fisher: I think that this is hugely relevant here, and I want to start maybe with just describing some clinical anecdotes here about what I’ve seen and then you get into how this would specifically be relevant. I have time and time again seen the impact of restrictive diets or dietary restraint clinically in individuals with disordered eating. And so when I talk about that, there’s a whole spectrum there, which we can talk about.
But seeing individuals who come to see me after some type of “success” with their dietary program and afterwards their eating behaviors, their dis-ordered eating re-emerging and we need to remember that individuals might do well on a program for a period of time. It’s the long-term cyclical nature of eating disorders that can be problematic, that can lead someone to continue to seek services if these eating disorder symptoms aren’t being addressed or dealt with. And so we can mask that I think for a period of time with a program, with a diet program. But I’m often seeing them with like weight regain or weight cycling.
And so we see that these behaviors are often underlying the interventions that we might be providing short term. Also, along these lines, perhaps I’ve been working with somebody maybe for working on their binge eating, developing a healthy relationship with food, working towards weight acceptance or perhaps told in a visit that they should try a certain diet to help with their symptoms or health goals. And in those situations I worry that a full assessment regarding their history and their behaviors isn’t always being done.
So these individuals with problematic eating behaviors might be put on these programs and it might actually be doing more harm when it comes to their relationship with food and potentially their health goals too. And I’ll talk about that over the long term.
Dr. Kara Fitzgerald: I just want to say, so I think we need to evolve our tool kit in functional medicine to be able to identify who’s vulnerable, so I want to circle back and talk to you about that. But it sounds to me and I want to be as clear as possible here, you’re probably seeing patients who’ve sought out a provider maybe in functional medicine or integrative medicine, or perhaps they’ve even bought a book or used Dr. Google and maybe initiated an elimination diet or gluten and dairy-free diet is pretty classic.
Is that true? So you’re seeing people who are attempting to do right by their health fall into this?
Dr. Carolyn Fisher: Yes, the extremes. So being able to be successful with this for a period of time, and then falling into the other extreme of like, what happens when I’m off of whatever program it was. And that’s when the eating disorder symptoms or some type of disordered eating might reemerge there, so exactly.
Dr. Kara Fitzgerald: And the restriction could be the trigger, I would imagine.
Dr. Carolyn Fisher: Yes. That is a complicated relationship, but certainly yes. Restricting for a period of time can absolutely lead to, we have some data to say that that would lead to binge eating, overeating and then also cognitively these all or nothing thinking patterns that can be really prevalent as well.
Dr. Kara Fitzgerald: Okay. All right.. I just want to zoom back a little bit and ask you about statistics on eating disorders. The incidence of it these days, men, women, and children, who might be vulnerable? Are we seeing an increase?
Dr. Carolyn Fisher: Yeah. When we think about our diagnosed eating disorders, we have bulimia, anorexia binge-eating, but obviously, there’s more to it than that. And statistic-wise, binge eating disorder, which didn’t become a specific diagnosis until 2015 is actually the most common eating disorder that we see. And that affects about 3.5% of women and 2% of men over the course of their life. Bulimia nervosa would affect about 1% of women and 0.1% of men, and anorexia 0.3% of women and 0.1% of men. So definitely the most rare.
There’s, we’ll get into that, but other forms of eating disorders too that make these stats maybe on the lower end of what we actually see when it comes to disordered eating. And as for who’s vulnerable? Anyone.
Dr. Kara Fitzgerald: Really?
Dr. Carolyn Fisher: I think that we have perhaps an image of who is vulnerable, we maybe think of young white women developing an eating disorder and not perhaps have an image of what that looks like. But the reality is that it can affect all genders, all age groups. So 13% of individuals over the age of 50 have eating disorder symptoms, so it’s not just younger individuals and it’s all races, socioeconomic statuses. Anyone is vulnerable. Obviously there are certain individuals that might have more of a risk than others.
A lot of that is medic, but also environmental and psychological. But really it could be affecting any individual at any weight too.
Dr. Kara Fitzgerald: That’s fascinating. I think that really changes our classic belief or certainly thinking that I’ve had where we might see, well, like you said, that young white girls or folks with an anxiety disorder or those on an addiction continuum. But the fact that anyone is vulnerable, I think is very significant. Are you seeing an increase in incidents?
Dr. Carolyn Fisher: Yeah. That’s a really important question, I think. Over time, we definitely have seen a rise in eating disorders worldwide, which is interesting. And perhaps a product of what’s going on culturally, also recognizing eating disorders a little bit more, being able to see that it is more prevalent than we’ve ever thought.
Dr. Kara Fitzgerald: Right. And when binge eating was actually recognized in 2015, I’m sure that contributed just to the increase in incidents just certainly.
Dr. Carolyn Fisher: Totally.
Dr. Kara Fitzgerald: And then you suggested that probably the incidence is greater than the stance that you gave me. Earlier, you and I were talking about orthorexia or you mentioned elimination diets and so forth. When you say that you think the incidence is greater and there are eating patterns that might fall under an eating disorder heading, but are not yet recognized, would that be some of what’s contributing to these greater numbers? And can you speak to that? Or if there’s another contributor that I’m not mentioning, just speak to that.
Dr. Carolyn Fisher: Yes. I think that the spectrum of eating disorder behaviors may not be reflected in these numbers. That’s what is important to remember that when I say that it could be larger than what these numbers are saying. Yeah, we have a lot of problematic disordered eating behaviors that we see that are not well captured. And so that’s just important to remember.
Dr. Kara Fitzgerald: But what are those? What do those look like?
Dr. Carolyn Fisher: Like I’ve been saying it is on, you can think about it on a spectrum. So if we have one end of thinking about it as normal eating or more intuitive eating, the other end we have are diagnosable eating disorders that I have mentioned. And in the middle, we have a range of behaviors that can vary in severity and impairment, hence that kind of spectrum approach and include a lot of different types of behaviors, orthorexia being one of them. So that’s kind of that unhealthy obsession with being healthy, and we’ll talk more about that, hopefully.
But restricting food intake, trying to control our portions, calorie counting, really eating only certain types of foods or avoiding certain food groups, regularly eating past the point of being full or feeling out of control with our eating, more chaotic eating, so going long periods without eating, and then perhaps eating an uncomfortably large amount and then doing that regularly. Skipping meals can also be a form of disordered eating, graze eating, so kind of more of that like snacking throughout the day.
Dieting, so eating in a way that’s kind of ignoring our body’s cues and accepting a more external way of eating. And I think with dieting too, and we can talk more about this element, we want to think about what’s the intention behind the diet. Is it to lose weight, to control our weight? Because that can be a little bit more problematic than just dieting in and of itself. Obviously, binging or purging, any way that we’re trying to get rid of calories that we consume, whether it’s through laxative, exercise, that kind of thing.
Dr. Kara Fitzgerald: Perfect.
Dr. Carolyn Fisher: So these may not be the same like extent as an eating disorder, but they’re definitely able to fall within that spectrum. And the reality too is that a lot of these behaviors are normalized and reinforced.
Dr. Kara Fitzgerald: Yes, yes, yes. But you know what? We have to tease… My healthy eating is your eating disorder, so it’s like we have to tease that out. We’ve all grown up in a culture that promotes really bad eating habits. If you go to the grocery store, most of the food isn’t particularly healthful. And I think just thinking at this now as I’m saying it out loud, I think we’ve promoted eating disorders just from the standard American diet being the standard American diet.
So transitioning to healthful eating can for some be this joyous experience of liberation, but then for others, it can be restrictive and problematic and fall in the continuum of eating disorders. And I imagine that can be challenging to tease out. Would you say that’s true?
Dr. Carolyn Fisher: Absolutely. Yes. Because there are unmeasurable factors there. The behaviors potentially could look the same, let’s say unmeasurable, but less tangible factors that could be playing into that. How am I looking at food? Is it taking over my life? Am I obsessing about what I’m eating? Am I starting to limit my social involvement because I’m really concerned about what’s going to be available food-wise. And so there are these other factors too that could be moving somebody further on that spectrum towards more of having an eating disorder.
Versus I’m eating in a way that feels values consistent to me and that is working…
Dr. Kara Fitzgerald: Yes.
Dr. Carolyn Fisher: … in a way that feels good to me. And that’s what can be hard to exactly tease apart.
Dr. Kara Fitzgerald: Wow. But I can see the line of questions that you’re putting forward would help you obviously.
Dr. Carolyn Fisher: Mm-hmm (affirmative).
Dr. Kara Fitzgerald: How much is this consuming your world? How much is it impacting you emotionally, your wellbeing? You and I were chatting about GI dysfunction, GI disorders and eating disorders and that just those two being very intimately connected. Can you speak about it?
Dr. Carolyn Fisher: Yes. Thank you for this question. I think this is really important to consider and understand, especially… Well, in both of our worlds, but definitely in the world of functional medicine. We want to remember first off that these GI symptoms are incredibly common across that eating disorder spectrum. So up to 96% of individuals with eating disorders can experience some type of GI symptoms. So a lot of these individuals may be landing in your office, right?
Dr. Kara Fitzgerald: Sure.
Dr. Carolyn Fisher: And so remembering that this relationship is bi-directional, so the GI symptoms can contribute to an eating disorder by having this hypersensitivity to our physical gut symptoms and potentially eating in a more restrictive way to help to manage our symptoms. We can develop a fear of eating and over time, this contributing to the avoidance of certain foods, aversions, and that can set a stage for the development of an eating disorder. And on the other side too, eating disorders can cause GI symptoms.
So yeah, the behaviors and the symptoms themselves can lead to the symptoms. Before getting into the details about that, I wanted to just mention what GI symptoms might be seen in individuals with an eating disorder. A lot of this pertains to disorders of the gut-brain interaction, and so we might be seeing heartburn, constipation, diarrhea, bloating, abdominal distension, nausea, feeling really full after meals, feeling really full quickly, the stomach emptying and intestinal permeability, and then general IBS.
And so all of these symptoms can make eating really uncomfortable physically and remembering the eating might already be very mentally uncomfortable for somebody and exacerbate these fears of fatness with bloating or abdominal distension. And so this can further contribute to food avoidance or food aversions.
Dr. Kara Fitzgerald: We see this in practice just all the time and we tend to come at it, while certainly I’m more comfortable swimming in the pond of addressing the gastrointestinal issues. I’m just more versed in that.
Dr. Carolyn Fisher: No, I think that’s so important that we are able to address this in also a way that’s sensitive to an individual’s symptom, their eating disorder history as well. That we’re doing in a way that is yeah, very sensitive to the individual. And to… Sorry, go ahead.
Dr. Kara Fitzgerald: Okay. I’ll put this in there so you can continue with what you’re saying and then maybe speak to this. We’ve been dialoguing about this quite a bit in functional medicine and in my practice in particular where we’ve got a number… We have a strong nutrition program here and there are about… it’s a very collaborative model here with physicians, naturopathic physicians and nutritionists, and so this has been a topic of conversation.
We need some tools in this setting. We don’t have a psychologist or a psychiatrist on board. I think A, we need to do some co-management and figure out who in our community we can co-manage with, but B, what are some basic tools for us to tease out who’s presenting with an eating disorder, who’s vulnerable. So if you can speak to that with what you were saying, that would be great.
Dr. Carolyn Fisher: Here is where I think it’s important to be asking and assessing. Making sure that this is something that we’re incorporating in our visits is some type of assessment of an eating disorder history. We know the Eating Disorder Examination, the EDE-Q 7-item is a well validated measure to screen for eating disorders. And that can be a quick way to assess different kind of components of the eating disorder, so it’s going to assess cognitive behavioral components.
It has three scales, the dietary restraint, shape, weight over-evaluation and body dissatisfaction. And that’s important because it’s those elements, this really being preoccupied with our body shape and weight, this fear of gaining weight, dietary restraint, that can contribute to the development of an eating disorder. And so we want to potentially use this assessment to one, be able to identify people with maybe an active eating disorder, but also potentially use these scales to flag individuals that might be coming at this with significant body image disturbance or significant overevaluation of shape or weight.
Because that’s those specific components can be problematic when it comes to dieting or engaging in one of these programs. Dieting in and of itself isn’t going to cause an eating disorder for every patient. It’s some of these more cognitive factors that we may not be measuring with all of our patients that might help us to identify some individuals that are at risk.
Dr. Kara Fitzgerald: And then we would consider modifying how we might start with them and check in with them. So the seven-items EDE-Q, folks we will link to this on our show notes. I know at a recent IFM Conference, we were actively dialoguing in the chat when Valter Longo was presenting on the Fasting Mimicking Diet. We were talking quite a bit about how we’re evaluating and what tools we’re using in practice. A lot of us are prescribing the Fasting Mimicking Diet routinely or variations of this, or time-restricted eating.
And of course we’re prescribing all sorts of therapeutic dietary interventions with our patients. It’s one of the most important tools that we have in functional medicine. But we absolutely need to be thinking about this component. This needs to be just front and center in our minds, I think. Perhaps more now than ever as this sort of era of time-restrictive eating is a tool that has some nice research behind it, and we’re using it a little more in practice.
But I think that that’s also increasing the vulnerability in functional medicine of precipitating eating disorders or allowing for the continuation of eating disorders in those who present to us with one and who we haven’t adequately evaluated.
Dr. Carolyn Fisher: Absolutely.
Dr. Kara Fitzgerald: Any comments on that?
Dr. Carolyn Fisher: Yeah. I think that you’re right, we have to be careful about the restrictive component, but also recognizing, to your point that these interventions are evidence-based and they are effective and that you’re using them for a reason. And so yes, being able to really identify individuals that might be more at risk. Because our literature is also mixed. Restriction in and of itself is not causing an eating disorder. There’s other factors that might be going on there that could be impacting the development of an eating disorder.
So it’s not saying that it’s all bad, it is being able to identify who’s more at risk. And there’s also the more cognitive element of dietary restraint of trying to control our diet that’s also important. So separate, but related to restricting our eating, that idea of controlling our eating or wanting to control our eating can also be problematic. And maybe over the short term, like I mentioned before, maybe it’s not over the short term, but what happens long-term once I’m off of this diet? Am I going back to some of these disordered eating behaviors?
So it’s definitely important to take an individualized approach with all of this. It’s not like this is bad or this is good, but being able to really assess for this with the individual and make an individualized plan.
Dr. Kara Fitzgerald: Right. Yeah. That makes sense. A good friend of mine fasts, he does a water fast every Thursday. That’s not something that I would be able to do. I can do very mild time-restricted eating, but doing that would be really triggering for me. But however, it is absolutely within bounds for him. He’s been able to adopt it and it hasn’t precipitated any abnormal eating patterns, at least in my observation.
And many of our patients are able to do this, I think in a healthful way, but I do think you’re absolutely right that we need to be looking for it. And the incidence is greater than I think what we’re recognizing, just referring back to your initial comment on the statistics. Anything else on what we need to understand when working with individuals with disordered eating or histories in functional medicine specifically? Anything?
Dr. Carolyn Fisher: I think that having an understanding of perhaps like what they’ve been through from an eating disorder perspective, that they might be coming into this with a rigidity with their food and their eating, and that they might have rules surrounding food eating. And so just being careful what we’re reinforcing. But otherwise I think that we covered a lot of those important pieces there.
Dr. Kara Fitzgerald: What is it an eating disorder treatment typically look like?
Dr. Carolyn Fisher: This is going to consist of a multi-disciplinary team typically. So having a psychiatrist, a mental health provider, a nutritionist, a physician working together with the individual to make sure, one, they’re medically stable and then also be stabilizing their eating and working towards acknowledging and responding to internal cues. So that’s an important piece. Two, that these individuals might have done some significant work to tune in with their bodies to respond to their internal cues and having an external rule structure, rules surrounding their eating might go against what they’ve been kind of working on.
It comes down to breaking down some of their food rules and targeting factors that contribute to eating disorder behaviors, such as body image, disturbance, stress, anxiety, perfectionism, self-esteem. And thinking too about how nutrition interventions might have looked different than those within functional medicine. So being mindful and aware of the pillars on which an individual’s recovery might’ve been built.
Dr. Kara Fitzgerald: Can you speak to that? I think the classic perhaps healthful diet isn’t necessarily one that we’re going to be prescribing in functional medicine. How-
Dr. Carolyn Fisher: Yeah. Individuals are working to increase variety, so to allow all foods. To eat consistently, to eat regularly, to listen to and respond to their internal cues, to develop a sense of trust with themselves surrounding eating, and that requires listening to those internal cues. Removing food fears, so that kind of gets into like what’s the language that we’re using surrounding the food. And potentially working towards intuitive eating with all of this.
Dr. Kara Fitzgerald: That’s so interesting. We touched on orthorexia a little bit at the beginning and maybe what that is. There are some publications using this term and I think it’s moving into recognition more. So give me a definition and how to be aware of it in our world in functional medicine.
Dr. Carolyn Fisher: Sure. Like you’re mentioning, it’s not an official diagnosis, but some criteria have been proposed for diagnosing this. And I’m referencing Siena and colleagues from 2019 and they came up with some evidence-based criteria of having an obsessional or pathological preoccupation with health and nutrition having emotional consequences. So distress or anxiety associated with not adhering to their self-imposed nutritional rules and having psycho-social impairment in areas of their life, as well as malnutrition or weight loss.
And so like we talked about before, this can be a gray area, right?
Dr. Kara Fitzgerald: Mm-hmm (affirmative).
Dr. Carolyn Fisher: Shouldn’t be hard to tease apart, and so that’s where really asking about how anxiety provoking is you’re eating to you? Are you’re thinking about food a lot? Is it taking a toll on other areas in your life that you value? And there are some different tools that you can use to assess orthorexia if you’re looking at that specifically. There’s the orthorexia self-tests and the Orto- 15 that are some tools. And I can send those to you too to help to assess for this in an evidence-based way.
Dr. Kara Fitzgerald: Perfect. Yeah, that would be great. And again, folks, we’ll put that in the show notes. And I think we talked about this with the EDE-Q, but this needs to be collaborative. And I think because it’s becoming more front and center in the world of functional medicine, I think we will find these partnerships and build them. And I know a lot of my colleagues already have, but we don’t have a lot of time nor the expertise to be able to address any eating disorder.
So the seven-item EDE-Q would be a good tool. Anything else? Certainly we ask patients in our intake questionnaire about obvious histories for eating disorders, but I would imagine that would miss a lot if somebody didn’t have a history of bulimia or anorexia or something like that.
Dr. Carolyn Fisher: Mm-hmm (affirmative).
Dr. Kara Fitzgerald: Go ahead.
Dr. Carolyn Fisher: Wondering if there are some additional ways to be assessing for this?
Dr. Kara Fitzgerald: Yeah. Would you recommend leaning on the EDE-Q, which seems pretty fabulous and that it’s brief and probably useful in our setting and anything beyond that?
Dr. Carolyn Fisher: Yeah. There are a lot of measures for assessing eating disorders. I was trying to think of one that had a lower number of items for you guys, because some of them can be like around 30 items. And so this one does have really good psychometric properties and is well validated, and I think would be a great tool in addition to the interview. I don’t know if you guys do any paperwork beforehand, but it could be as simple as just asking on piece of paper. I think you might get more information that way than in an interview.
Do you have an eating disorder or history of an eating disorder? So just asking that question. And it might feel more anonymous for somebody to write it on the paper rather than bring it up in the appointment.
Dr. Kara Fitzgerald: Yeah. And we do do those broad stroke questions, history of eating disorder, but I’m thinking that we will miss those who are vulnerable with those broad stroke questions. So perhaps including… I know that we’ve been discussing here in our practice, including a more sensitive questionnaire with our intake materials.
Dr. Carolyn Fisher: I think this would be a good one that is quick too.
Dr. Kara Fitzgerald: Good. Okay. How do we talk about weight? Clearly, it’s a big issue for a lot of the folks coming to us, it’s an area of interest. People come to us wanting to lose weight. If I were to do a chart analysis, probably the majority of the patients that come to practice have considered themselves to have a weight issue. Whether that’s objectively true or not isn’t always the case, but how do you speak about weight and in a sensitive and useful way?
Dr. Carolyn Fisher: No, that’s a really important question and I’m glad you’re asking, because it can go awry in many settings. I think starting with what you’re saying is that are the individuals we’re seeing, our patients, they are thinking about weight, even if it may not be on your radar as something that is going on with them or contributing to their challenges. And it’s probably on their mind, and so recognizing that, and that when we start talking about food and manipulating our eating, that weight might be popping into somebody’s mind like should I be losing weight? Should I expect to lose weight? Maybe that’s their primary goal.
And so backing up and recognizing that weight bias is prevalent and it’s unfortunately a socially acceptable and reinforced prejudice that we have. And so it can make it really difficult to approach this topic. And individuals that have negative stereotypes about individuals at higher weights often fail to recognize their bias. And they might believe that it’s somebody’s own fault and that they should be held accountable.
So just remembering that individuals at higher weights are vulnerable to having experienced stigma in healthcare settings. So even if they’re not getting it in your practice, they might’ve had it before. And we also might be unintentionally communicating subtle forms of bias. At least-
Dr. Kara Fitzgerald: What would that look like? Can you give me an example?
Dr. Carolyn Fisher: Yeah. That could be not having your office well set up for individuals at higher weights. So maybe there is not a chair that feels comfortable for them or the blood pressure cuff doesn’t fit. Or scale that isn’t going to allow for that weight capacity. And so making sure that our office is set up, even if we have the best intentions, that’s a subtle form of weight bias that is going to affect an individual and potentially make them uncomfortable.
And so also when working with these patients, we want to first recognize and open up to any of our own biases, so do that self-exploration. And when working with these individuals, acknowledge that the etiology of obesity is complicated and that there are factors that can contribute to our weight outside of our own actions or behaviors. A lot of individuals have internalized that weight bias and feel like this is my fault, I’ve caused this. And so to have a provider that isn’t reinforcing that can be really healing and convey some empathy and understanding. Were you going to say something?
Dr. Kara Fitzgerald: I’m just going back to the gut-brain metabolic access. More and more data I’m sure you’re familiar with is coming out on the microbiome really influencing body size, body weight. We don’t have a whole lot of tools yet, but I think the evidence is really pointing to there being a much deeper and challenging issue to confront in some obese individuals. Comments on that?
Dr. Carolyn Fisher: Yes. That’s a really important factor to be conveying to our patients to say like, “Hey, I understand there’s a lot going on biologically that’s going to make it really hard for you to not just lose weight, but to maintain a weight loss. That our biology, our microbiome, our genetics, our set point might be working against us at times based on our histories, our eating histories or our weight histories, our genetics.” And so I think that that can be potentially validating for somebody that has been working really hard to try to lose weight and not having been as successful as they would’ve liked to be. So feeling heard and understood in that way, I think is huge.
Dr. Kara Fitzgerald: Yeah. It just brings so many different questions to mind. And again, going back to the gut, we certainly do… It’s an area that we start our focus on and we do work hard at changing the microbiome and improving intestinal permeability and so forth. And we can absolutely see people lose weight fabulously well but not always. We’re not always successful, and from that vantage point, we need to just support them in being as healthy as they can be regardless of their body size. Comments on that?
Dr. Carolyn Fisher: Absolutely. No, I think that’s exactly right and working with the offering of the tools that you’re able to offer. You have this wonderful toolbox of evidence-based treatments to help individuals and I think a lot of it can come back to also just stabilizing an individual is eating and learning what foods are going to help to promote my microbiome or to create a healthy microbiome. And so-
Dr. Kara Fitzgerald: Yes.
Dr. Carolyn Fisher: … you guys are able to offer so much of that. And that’s not always going to be a cure for somebody’s weight, and so we need to think about how we’re viewing weight and are we looking at it as a problem that needs to be solved? Or can we work towards embracing this idea of health at every size that I am taking positive steps to live a life that feels meaningful, healthy and engaging to me, and I can do that at any size.
Dr. Kara Fitzgerald: Right. I think it’s important and I think it’s a bit of… It will entail some movement, I think in functional medicine where we’re looking at optimal health, lower BMIs, et cetera, just again, in keeping with the science. And yet we need to be extremely sensitive to the fact that some individuals, that’s not appropriate. That will in fact trigger disordered eating. And so we need to really meet them where they’re at.
And we put a lot of time and attention in that, meeting individuals where they’re at in functional medicine. So I think we can walk this walk and walk this balance.
Dr. Carolyn Fisher: Mm-hmm (affirmative). It just requires some flexibility and maybe a little bit of a paradigm shift where I’m not looking at that BMI as that primary outcome of interest for all individuals, but taking this individual’s health into account. And at times perhaps separating their health from their BMI or their weight.
Dr. Kara Fitzgerald: I think of the high harm reduction model, which grew out of… Actually I think it might’ve been started here in Connecticut where they were doing needle exchanges with heroin addicts. So they weren’t attempting to cure the addiction as much as just support them in reducing the incidence of hepatitis and HIV and so forth. I’m thinking about patients that I’ve had with some degree of disordered eating requiring say a gluten-elimination diet or a dairy-elimination.
And if that’s pushed too aggressively, we can see a flare in the disordered eating. And so there’s something about doing the best you can with this. Can you speak to that? I’m sure you’ve worked with this in your practice.
Dr. Carolyn Fisher: I think it is, as cliche as it might sound, is all about the balance and recognizing that it may not always be appropriate to be putting somebody on a specific plan to eliminate food. And that that might help with their symptoms if we have them eliminate gluten, perhaps they’re getting a relief in whatever their symptom is, or maybe they’re losing weight if that’s their goal. But what are we doing long-term? Are we promoting long-term gut health, long-term weight management?
And what you’re speaking to is how sometimes these eliminations or reductions can cause problems behaviorally. And so I would say, like from my perspective healing from disordered eating should come first. And we want to be careful about not doing anything that’s going to kind of be harmful to their overarching goals and eating disorder treatment, even if it does provide the short-term relief. And so it is being able to look at this big picture and to recognize that yeah, I could help with their symptoms right now, but is that really what’s going to help this individual long-term?
Dr. Kara Fitzgerald: It’s such important point and I think a good point for us to wrap up. It’s a balance, I can see that it requires a team approach. I agree with you that the disordered eating has to be addressed first or likely we will continue to fail. Maybe we’ll see fabulous short-term outcome as you speak to, but long-term, they continue in the cycle of disordered eating. I think that’s an important point to make.
Dr. Fisher, I just want to thank you again for joining me on New Frontiers today, just in bringing some important light and attention to an area that really deserves more attention than it’s been getting recently.
Dr. Carolyn Fisher: It is my pleasure. I appreciate the opportunity to have this conversation and your openness to having this conversation. So thank you for having me.
Dr. Kara Fitzgerald: And that wraps up another amazing conversation with a great mind in functional medicine. I am so glad that you could join me. None of this would be possible, through the years, without our generous, wonderful sponsors, including Integrative Therapeutics, Metagenics, and Biotics. These are companies that I trust, and I use with my patients, every single day. Visit them at IntegativePro.com, BioticsResearch.com, and Metagenics.com. Please tell them that I sent you and thank them for making New Frontiers in Functional Medicine possible.
And one more thing? Leave a review and a thumbs-up on iTunes or Soundcloud or wherever you’re hearing my voice. These kinds of comments will promote New Frontiers in Functional Medicine getting the word on functional medicine out there to greater community. And for that, I thank you.
Dr. Carolyn Fisher is a licensed clinical psychologist at Eating and Behavioral Health Associates, LLC, an eating disorder-focused private practice in Columbus, Ohio. Dr. Fisher specializes in helping individuals with binge eating, emotional eating, chronic dieting, and various medical conditions, heal their relationships with food through evidence-based practices. Dr. Fisher is passionate about helping individuals foster a mind-body connection to empower them to make individual, values-based choices surrounding health and eating.
Dr. Fisher obtained her doctorate in clinical health psychology at the University of Cincinnati, completed her APA-accredited internship at the Ann Arbor VA, and her postdoctoral training at the Cleveland Clinic. Prior to joining Eating and Behavioral Health, Dr. Fisher was a staff psychologist at the Cleveland Clinic and assistant professor at Cleveland Clinic Lerner College of Medicine at Case Western Reserve University. Dr. Fisher has been actively involved in research and presentations regarding the treatment of binge eating and the relationship between diabetes and disordered eating.
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