Conquer Your Weight

Dr. Sarah Stombaugh: Before we get into the episode, I am thrilled to announce we are launching an online course, The GLP Guide. The GLP guide is a must have resource for patients who have been prescribed any of the GLP medications such as Wegovy, Ozempic, semaglutide, Zepbound, Mounjaro, tirzepatide, Saxenda, liraglutide. There are a lot of them and this course is available for anyone to purchase. We often hear from people who haven't been given much information about their GLP medications. No one has told them how to handle side effects, what nutrition recommendations they should follow, or what to expect in the longterm. And it can be really intimidating and simply frustrating to feel like you're alone in your weight loss journey. With the GLP guide, you'll get access to all of the answers to the most common questions for patients using GLP medications, not sure how to use your pen, struggling with nausea, wondering how to travel with your medications. We've got you covered for only $97 for one year access. This is an opportunity you do not want to miss. The course is launching on October 1st. For more information and sign up, please visit www.sarahstombaughmd.com/glp. You don't have to be on this journey alone. We are here to guide you. And now for today's episode, this is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight podcast. Announcer: Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Hello everyone and welcome to this week's episode of the Conquer Your Weight podcast. We are talking about a topic that is really important and I believe not talked about enough in the weight loss space, which is weight loss in patients with a history of or even active eating disorder. How is this approach to how can we best support this patient population? Because it's really important to be able to support patients, any patient who needs it, but to make sure that we're also providing trauma-informed eating disorder, informed appropriate care for our patients who need that level of support. So I'm really excited to get into this topic. This is a topic that, as I've mentioned in some of the more recent episodes, I have been going through topics recently and realizing, oh my goodness, I am coming up on 100 episodes in this podcast. And there are certain topics which are very common things I talk about frequently yet I have not had a podcast topic on yet. So this is one of those, and I'm excited to talk to you about it today. But the invitation that I have for you all, my dear listener, thank you so much for listening. If you have been listening to my podcast and thinking, oh my goodness, I cannot believe Dr. Stombaugh has not addressed x, y, z topic, I want you to reach out and let me know. You can shoot us an email at info@sarahstombaughmd.com. I'll put that email address in the show notes so you don't have to spell Stombaugh correctly. I know that that is not always the easiest thing to do. We'll pop that information in the show notes. We have gotten some listeners reaching out, giving their suggestions for episodes and everyone that rolls in, I am exactly like, oh my gosh, how have I not talked about that? And so I am building those responses for the next few podcast episodes and I am really excited about that. So if you have a question wondering how you can get support in your own weight loss journey, why don't you shoot me an email, ask me that question, and I will make a podcast episode just for you and for everyone else to listen to that response as well. So thank you for those of you who have emailed me with some of those suggestions. And if there is anything that you're thinking about that you would love to hear that answer, you just let us know by email and we will make a podcast episode for you. And if we already have a podcast that addresses that, we'll reply and copy that podcast episode as well because there's a lot. And if you are relatively new to joining us, you may have missed those amongst the other episodes. Alright, so let's go ahead and dive into today's episode. We are talking about weight loss for patients with a history of eating disorder. And this is a very important topic, but it's a group of patients who are often undertreated or even ignored because of almost fear from providers that we will not be able to treat this patient population appropriately. So let me talk a little bit. Eating disorders of course are a very broad category. When we think of eating disorders, we think of eating disorders that are restrictive. So typically these are eating disorders like anorexia, for example, eating disorders that are more purged or rather binge oriented. So binge eating disorder or bulimia for example, and then purging disorders, bulimia for example, are binging episodes followed then by purging it's very common you have these textbook diagnoses of different official eating disorders. But the reality is there are many people who fit a sort of mixed picture or don't formally meet a criteria for an eating disorder, but definitely have times where they feel maybe out of control with their eating, have times where they've been really restrictive with their eating. We do have an episode dedicated to binge eating disorder as well as a follow-up episode with my dear friend, Dr. Megan Melo, where we talk about emotional eating and how that can be very much related to binge eating disorder. So binge eating disorder is definitely one of the most common eating disorders that we see in the medical weight loss space, and it makes sense. People who have bingeing episodes are more likely to struggle with their weight because of those bingeing episodes. And so that makes a lot of sense and we do have good medications and therapy tools that can be supportive. And there are a lot of other people for whom, especially restrictive eating disorders like anorexia or versions of that where patients who have had a remote history of that eating disorder now years later are actually struggling with pretty clinically significant obesity, but they are terrified to get back to that place where they were restrictive, where they were really hyper-focused on their food. And so I would like to spend some time today talking about that, how we can support anybody, but especially patients who have that history of restrictive eating disorder or maybe a purging eating disorder of reconnecting with their body, relearning their hunger, their satiety learning what type of foods fuel their body and what we as providers should be looking for to make sure that we are best supporting this patient population. So let's talk a little bit about that. One of the things that I think is really important in a medical weight loss intake is that in addition to talking about medical history and social history and medications and family history and taking a physical exam and all of these other things that are very important about the intake, I think it is crucial that we screen every patient in a obesity clinic, a medical weight loss clinic, that we are screening them for history of or active eating disorder. Now again, this can look like any type of eating disorder, but I want to know what is someone's relationship with food? In which ways have they struggled with that in the past or currently so that we know both now and throughout their journey what level of support and how we can best support them. One of the things that's really challenging is that in our society, even people who do not meet formal criteria for an eating disorder may have self-identified in a period of their life that they were really struggling with, let's say restrictive thoughts for example, and periods of time where maybe even had a very significant weight loss. But one of the things that's really challenging about the diagnosis of anorexia, for example, is that part of the diagnosis is actually that someone has a BMI of less than 18.5, so they have a below normal body weight. And so with patients with obesity, however, that is not always the case, but someone may still otherwise fit the picture. So let me give you some numbers as an example. Let's say that someone has a starting body weight of 250 pounds. They start having restrictive eating behaviors, really engaging in that behavior really completely similarly to a patient who otherwise has anorexia and meets that criteria from a body mass standpoint. And they may not actually get to a body weight that is considered below normal. Maybe they even bring their weight into the normal range, maybe their friends, their family, and sometimes even their doctors are praising them because they have lost weight. And let's say they've brought their body mass or their body weight rather from 250 pounds to 150 pounds and have brought their weight into the normal body mass index range, they may be getting praise for their weight loss even if that weight loss was obtained from very restrictive eating patterns. And so anorexia in particular, a lot of patients who are struggling with this feel like it feels almost good to have that restriction when they get praise from other people. It can really almost be fuel on the fire then that can further drive that behavior. And so especially for a patient who is losing weight in a way that is not really healthy, maybe they're not eating at all, maybe they're experiencing dizziness because they haven't had enough food or water or electrolytes, people who are really feeling physically unwell and haven't been eating much at all on the outside maybe being praised because they've brought their weight now into a healthy range. So this is very common in my practice that patients may have experienced this in the past and then never formally got an eating disorder diagnosis, not because they didn't have one, but because no one asked or nobody screened for it, and now years later, they're struggling with their weight in a more clinically significant way and they're worried because the way by which they've brought their weight down in the past has not been healthy and they recognize that that's been challenging. So especially I treat a lot of patients across the age span, but most of my patients are in their middle age, 30, 40, 50, 60, some less than some older than, but most of 'em are in that sort of middle adult range. And what's very common in my practice is patients who are, let's say in their late forties or in their fifties that as teenagers or in women in their early twenties had pretty significant restrictive eating disorder and eating disorder diagnosis and treatment especially a couple of decades ago, looked a lot different than it did today. So the way that a lot of people have learned to sort of treat themselves or the support that they got, even if they did get sort of real clinical help at that time, if it was a long time ago, a lot of people have learned to really disengage from their body, disengage from what are their hunger signals, what are their satiety signals, what is the role that food is supposed to play in our body in terms of how does food fuel our body when we eat proteins, when we eat fats, when we eat carbohydrates, when we eat fiber, how do these things fuel our body and what role should those be playing? That's a piece that has been missing. And so while even they may have struggled with a restrictive eating disorder in the past, if they have completely disengaged from themselves and their signals and what their body needs, people find themselves sometimes 5, 10, 20 years later down the road, now they're struggling with really clinically significant excess weight and they don't know how to lose that in a way that is not going to be restrictive in a way that's not going to end them up in the hospital because that's been the case for some of my patients before. So every single patient that comes into a medical weight loss clinic should be screened for and evaluated for either history of or current eating disorders. Now, we're not going to talk as much about the binge eating disorder space because that is certainly very common, but I do have another episode solely dedicated to that. I do see that a lot in my patient population. So thinking about this restrictive eating though, how do we pay attention? Now, if someone has clinically significant excess weight, they have obesity, maybe they have high blood pressure or high cholesterol, maybe they have arthritis of their knees or hips that's been really bothersome or PCOS or acid reflux or fatty liver or prediabetes or any number of conditions, and they're being told by their medical team, Hey, you really need to lose weight. And so what does that look like? What I believe very strongly is that patients need ongoing level of support from someone who is eating disorder formed as well as trauma informed, and that this may and often does also involve the work of a therapist. When we're looking at weight loss, typically someone who comes into my practice does have a goal of losing weight. What I like to focus on really for all of my patients, but especially when we're thinking about that history of restrictive eating disorder, focusing more on health goals and health behaviors rather than focusing on any specific number. So one of the really interesting things is that even in a medical weight loss practice such as mine, I have a good number of patients who have chosen not to be aware of their weight. So I do weigh them. I have offered to patients to not weigh them, although in the case of getting medications covered, for example, if we're going that route or if that makes sense, it is important for us to have that information. But I have patients who get weighed with their eyes closed. I have patients who step on the scale backwards so that they don't have to see the number. Luckily, I have a old school analog scale, so it's not just going to pop up a number and surprise you. You can step on the scale, sort of get your balance before you close your eyes, or you can step on and then turn around without worrying about falling off. I also, even from a telemedicine perspective, I have patients who will turn their cell phone around, turn the camera around so that it's pointing at the scale, and then they will step on the scale with their eyes closed. I can see that number, but they cannot. And so that is actually fairly common in my practice where patients are not aware of their weight, and that can be a really helpful tool for someone who does have that history so that we're able then to focus on what are the foods that you're eating? How are those fueling your body? What does your energy level throughout the day look like? When you wake up in the day throughout the afternoon, if you are exercising or doing activity, does your body feel fueled? Does it feel energized? And are you able to fuel your body in the way that it needs to? Then as we're looking at the movement on the scale, again, that's something that I'm seeing, but many of my patients may not be seeing. What are we seeing in terms of that movement? Am I seeing that that number is dropping really significantly? There are patients for whom their weight may drop three or four pounds per week consistently. That is very concerning. Someone with very, very clinically significant obesity on the order of 500 pounds or larger may see numbers like that. But for a patient who is in a body that weighs 200 pounds or 300 pounds, even losing weight at a rate of one to two pounds per week on average is a really great place to be. And if we start to see that someone is consistently losing much, much more quickly than that, it's really important to check in on what is happening so that we can make sure they're adequately fueling their body because all of the same principles apply regardless in the weight loss journey. Thinking about making sure to get enough protein, for example, making sure that as we're losing weight, we're protecting our muscle mass so that we are able to stay strong and stay active rather than feeling like we're sort of withering away in our weight loss journey. It's important and we're checking in regularly at monthly appointments or some of our weekly group coaching calls, for example, checking in to see what kind of thoughts are coming up because it can be really interesting to see the thoughts of this should be going faster or comments from other people and how we respond to that and paying attention to what sort of traumas may be there from the past, what sort of things we've experienced in the past, and making sure that as it's coming up, we're addressing that in an appropriate way. And I think that this is so important because I have worked with many patients who both have a history of restrictive eating disorder and now have clinically significant obesity, and they have not been able to find a provider who's willing to support them. And so this piece is really, really important. And if you are a patient who has struggled in this way looking for someone, I would err on the side of someone who is certified in eating disorders that can look like a lot of different types of physicians, commonly psychiatrists, commonly family medicine or internal medicine physicians who have gotten more expertise in this area. You may be able to find someone like myself who is in the obesity medicine space, but I would be really cautious as you're looking at potential clinics and potential places to help you because there are often people who are given messages about calorie counting, about macro counting, about losing weight in a certain way. That may seem okay on paper, but when we think about our thoughts and our mind and how we're feeling and are we resurrecting any of those difficult thoughts that we've dealt with in the past, a lot of weight loss programs can really instigate that flaring back up. And so it's really important to protect yourself and put yourself in an environment where you're going to be supportive, where there's not just a focus on weight or maybe not a focus on weight at all, but rather a focus on health behaviors, a focus on reconnecting with your body and what it needs, a focus on learning how to fuel your body with foods that appropriately make sense for your activity level, for your preferences, for all of that. And I will say it is possible, and for my patients who have this history, I am watching them very closely. We're having honest conversations about it. I work closely with eating disorder specialists in my area to make sure that patients who have this history are getting the support that they need. And it's really phenomenal to start to find that patients are finding a freedom around food that they had never had previously, whether they were struggling with their restrictive thoughts, even at a very large body size. This just constant back and forth in terms of, I should do this. I shouldn't do that. I overate now I'm going to undereat. How can I balance this with that? All of those thoughts, we can work through those and we can support those certainly through the work of reconnecting with your body sometimes with the support of certain medications. And I just want you to know that that is absolutely possible. And so if you are someone who has really struggled with the way you think about food, your relationship with food, finding that previous weight loss attempts have been really emotionally challenging for you and have created a lot of strife because there's just this constant tension of should I, shouldn't I, or that restriction piece sneaking up on you? If you find yourself in that position and also know that your weight right now is at a point that losing weight would help to support your overall health goals, like I said, would help your blood pressure or cholesterol or pre-diabetes or PCOS or arthritis or heartburn or fatty liver or whatever it is, I would love to support you in that. I see patients in person in Charlottesville, Virginia. I also see patients by telemedicine throughout the state of Illinois and Virginia. And if you are looking for support, I would love to connect with you, learn how I can best support you in your weight loss goals. If you are not in one of those states, reach out to me anyway. I would love to connect with you, see if there's someone in your state to whom I could refer you. You can learn more about me and join our practice at www.sarahstombaughmd.com. We'll have that information in the show notes as well. Thank you so much for joining me in today's episode. I'll see you all next time.