Kerry: 0:29

Hi everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller, and today we have a very special guest, Dr. Rebecca Berens. Welcome to the podcast.

Rebecca: 0:38

Yeah. Thanks so much for having me.

Kerry: 0:40

Yes. I always like to have everybody introduce yourself. So why don't you tell us a little bit about who you are and what you do.

Rebecca: 0:46

So I'm a family medicine physician and I have a private practice in the suburbs of Houston, Texas. And I've been open for just over six years now in my private practice. So yeah, very excited.

Kerry: 0:57

I didn't realize you were open that long. That's amazing. Yeah. I know you're doing, you know very well and wonderful things, so. one of the things that we wanted to talk about today is your niche within your I guess in your private pri primary practice. How did you get into what you do with your practice? Why don't you just start there?

Rebecca: 1:14

Yeah. Yeah. I would, I guess if you wanna call it my niche is I tend to take care of a lot of patients who are in recovery from disordered eating. And this was totally by accident. That just happened this way. But really I I take care of a lot of patients who have struggled with either weight stigma or bias around their weight when they've gone to doctor's visits or they've struggled with a disordered eating and they avoid going to doctors after that because of, triggering comments that have been made or, unhelpful diet advice that they have been given. And so I really enjoy working with those patients to help them maintain their healthy relationship with food while also managing their chronic health conditions. And like I said, it was a total accident that I ended up in this niche, but I, I had an eating disorder when I was in college. And so when I was in medical school, I very much approached my learning and training from the understanding and the lens of how well-meaning medical comments can actually be pretty harmful. And so I've always taken a weight neutral approach to healthcare and giving people balanced and non triggering and non-judgmental advice.

Kerry: 2:17

So it's funny how sometimes we attract certain patients, but it just happens sometimes. And then other things that you had said was basically other doctors giving like advice, meaning I always wanna think that we're doing better in this department, especially maybe in recent years, but I think there's definitely still some, doctors who didn't have any sort of weight training. So they don't know how to talk to patients properly or use, kind words or they think they're doing well and meaning, and then, it definitely ends up being triggering. Having a, doctor like you is definitely, a great plus. But when people hear this word disordered eating, so many of us think of like extreme or rare conditions. How do you define disordered eating in everyday clinical practice?

Rebecca: 3:00

Yeah so you know, there's disordered eating and then there's eating disorders, which are like the, there's DSM specific criteria for diagnosing those disorders. And there's a lot of overlap between those two things. But really the way I would look at it is if someone has an eating pattern that is having an outsize impact on their life and social functioning. They're spending a lot of time in their day focusing on weighing, measuring food, thinking about food, planning food if it's becoming something that's taking away from other aspects of their life. I would consider that disordered eating, but to get neat criteria for an eating disorder by the DSM criteria they're very specific criteria with that. For anorexia nervosa for example, there's, significant restriction in dietary intake that then results in health complications. Often it's significant weight loss, but in some cases there may not be as significant weight loss as people might expect, and there can still be significant health complications. So that's just as an example. But all that to say, like there's, you can have disordered eating without having an eating disorder, but it's having an impact on your life in some way that is that is harmful. And I think, to a point that you made before, like I think a lot of. Medical dietary advice falls in the disordered eating category, unfortunately. And some of that is because, we have this ingrained weight bias in our medical research, in our medical training. So even things that you think that you're meaning well and you're trying to give people like good, balanced advice. Where did that advice come from? If it came from a place of we have this assumption that if you are this weight, you are unhealthy, and if you are doing this thing, you are unhealthy. By default, any advice that we give in that category is gonna be gonna be flawed. So it's it's really important to keep in mind where that is coming from. But at that's what I've seen is like when people are going for something that's very restrictive, that is very prescribed especially if you're doing like, weighing, measuring, that person is then unable to like go out to their local restaurant and find something that will fit in the plan to eat that is already starting to disrupt their functioning. And so it's something that is important to, to keep in mind when we're giving our patients dietary advice.

Kerry: 5:10

It's definitely a balancing act and you don't know how certain people are going to respond as well. Some may not have any issues with that, but some may, take it to the next level and have, an impact on their life. How do you think diet culture kind of shows up in primary care and wellness spaces giving medical advice?

Rebecca: 5:29

Yeah. So I think obviously diet culture is heavily ingrained in our culture and has been for many generations. But just amplified by social media, of course, because we have all these very image focused platforms where people are sharing pictures of themselves, pictures of the food they're eating in a very aesthetic environment. So it's, it becomes it becomes so. Normalized and ingrained in people as this is good. But I think that where it crosses over into like primary care and wellness advice is again, there's a lot of assumptions of oh, if you lose weight, that is a good thing for your health. So if anything that helps you lose weight is good for you which is obviously not true. But, there's, there, there becomes this sort of automatic association of like certain health behaviors or health outcomes are, this is a benefit, this is a good thing. And so now everything associated with that becomes a good thing. And of course, like on social media, there's a lot of influencers that specifically profit and are paid to sell certain supplements, certain diet programs, certain fitness programs fitness outfits all these things that are specifically targeted on social media to, to sell to people. And it, it starts to, they will use kernels of truth. They will use true health information integrated into their sort of sales pitch. So it becomes one and the same to people. So people are like, oh yeah, this is good, this is healthy, this is and I even see doctors do this. There's just this assumption that oh yeah, this is associated with weight loss, so this is healthy so I can recommend this to patients. And not going through the exercise of what is the actual evidence for this? What are the potential harms? It just becomes this sort of association, implicit association that we have made with all these wellness associated behaviors that, integrates it into regular medical advice that's actually based on evidence. And it can become really difficult to start teasing those things out because they have been so tied together and ingrained just from our daily social media consumption

Kerry: 7:26

It's like an information overload. And I guess back in the day there was not that much and you would, listen to the dietary guidelines of the, government and things like that. And I just wanna bring up that one like, um, like the ad for smoking, right? Like they, the ad for smoking like says, yeah, smoke'cause it'll help you lose weight. And they have a, a thin women smoking in the ad. And I think that just like gives that, like you said, the pervasive knowledge that being skinny is good and then you see that all the time. Like still even obviously worse I think with the social media thing. So it's, I don't even know, I'm probably even guilty of whatever I post online too, of, maybe of what you just said too. I wouldn't be surprised. So it's, I can't imagine, being on the other side trying to tease it all apart. do you think specific patients are more at risk for developing disordered eating patterns, even if they're not recognizing it?

Rebecca: 8:16

Absolutely. One thing that I think is really interesting that I don't think a lot of doctors even realize, but certainly patients don't, is like there's a heavy genetic component to developing an eating disorder, like a, DSM diagnosis, eating disorder. It is heavily genetic. And not to say that just having the gene alone will make you get this condition. But it's, again, it's like with so many things in medicine, it's that constellation of the genetic predisposition, environmental factors, socioeconomic factors, some triggering event, and then it develops, right? And so that is very often the case with with eating disorders. There's a lot of overlap with conditions like A DHD and autism, for example, which again, we know are heavily genetic. So like you said, one patient may receive that information they may be able to regulate it and manage it without any outsize impact on their life. But another patient may take that and run with it and make it, take it to an extreme. And some of that is, is like genetically predisposed. There's also, of course the, like the socioeconomic factors. So we know that having a history of food insecurity greatly increases your risk of disordered eating and eating disorders. If you grew up not knowing, if you were gonna have. Dinner on the table when you got home, or if you were gonna run out of food before the end of the month, you might be more inclined to say. When food is available, eat more because I don't know if I'm gonna have enough later. And so there's all of these really complex interactions between our genetics our environment, our upbringing, the psychological factors. There's heavy comorbidity with trauma history sexual assault, depression, anxiety. So a lot of these things are interwoven. And it's not so straightforward or simple, but that's why it is also important to keep in mind that you don't know. Necessarily for an individual patient sitting in front of you, what their risk level might be. And so that's why it's important I think, to approach everyone from a very balanced perspective and to get, to really get the feedback from how the patient is receiving that information. And I think what I often see is sometimes the information, it appears that the patient's like really excited about it and oh, this sounds great. Like this is something I can do, but it's. It's actually their brain is taking that to that extreme. Like we see this a lot with patients who go to maybe a functional medicine practitioner or some sort of maybe an alternative pro practitioner that's recommending a very restrictive diet and they are like, oh, this is gonna be great. I can totally do this. It's changing my life. And like initially it can seem like it's going really well for that patient. And then it just falls apart. And so I think it's really important to be able to keep in mind like the balance for that patient and and understanding their motivations and and experience of a given behavior that they're engaging in.

Kerry: 10:48

How do you, as a family physician, how do you balance, like assessing their nutrition, metabolic health, and weight related concerns without, reinforcing shame or triggering old patterns?

Rebecca: 10:58

Yeah, I think the biggest thing is never making an assumption.'cause I think this is actually one of the most harmful ways that weight stigma and bias show up in healthcare is like a patient may show up who has say pre-diabetes and high cholesterol and high blood pressure right. And I think there's this implicit assumption, we may not even realize we're making at times that like, oh, this person is not eating right, they're not exercising. They're, doing X, y, Z thing and that's why they have all these conditions when in actuality they may be eating a balanced diet and moving as much as they can. And, there's just other factors in their life and in their genetic predisposition that are contributing to them developing that condition. But a lot of times it goes in with this assumption of oh, you just need to do this. And then the patient what they're hearing is I'm already doing all of that and I still have this problem, so you're just telling me that no matter what I do, I'm screwed. And so then like, why would they come back? And there's also a lot of judgment I think that comes in intentional or unintentional that comes with giving the standard advice without actually asking the patient what are your current behaviors? So I think a lot of times it's those assumptions that are really harmful. But I think when you're approaching a patient, I always look at it as, what are all of the major sort of pillars that impact a person's health, right? So what is their not just about what do you eat and how much do you move? Which I think is the default that we always focus on. But what's your living situation like, what kind of work do you do? What sort of stressors are in your life? How are you managing that stress? Do you have social connections? Do you have a community behind you helping you or are you alone? What's your sleep like? I always hear so much of the patients that I see, it's actually their sleep. That is the biggest problem and not what they're eating or how they're moving, but they're so sleep deprived. May, they maybe multiple working, multiple jobs. They have may have young kids they're Doing this like intense exercise program that's making them wake up super early and so they're actually like cutting themselves short on sleep. It's just looking at all of those behaviors, substance use, caffeine, alcohol, smoking, looking at all of it as a big picture and asking the questions, not making any assumptions. And then I always tell people I, I will look at what's most on fire, which, like I said in my case, often I find is sleep is the thing that's most on fire for people. And addressing that first, rather than immediately going to you just need to cut out this food and do this exercise program and take this medicine to help you lose weight. Which I think often ends up being the default.'cause I think we assume that we have the most control over our diet and exercise and less control over other things. But, that doesn't mean we shouldn't try to make improvements in areas like sleep, for example. That have such an impact on our metabolic health.

Kerry: 13:30

No, I love your, I don't wanna call it a rant, but on sleep it's great. I A big thing that we are focusing on in our practice as well. Making sure there isn't a sleep disorder or sleep apnea and things like that is super important. Sleep deprivation, can, elevate hunger hormone, cortisol, everything. Like how are you going to, make whatever decisions that you feel would make you healthier when you're, having all of those hormones not working for you. what are some red flags that some clinicians should look out for that may suggest disorder eating?

Rebecca: 14:00

That's a great question. So I think when I am seeing a new patient, I never will make assumption about their nutrition or dietary history. So I just as a baseline for all my new patients, I'll ask gimme an example of like your day, your usual day in terms of eating eating and drinking fluids. So what do you have for breakfast, lunch, dinner, snacks fluids that you drink. And we'll go back to maybe 24, like the last 24 hours and just run through it. And you can pick up some flags there. I always ask about times too. So if someone tells me like, oh, I I only eat in this specific eating window, if they're doing intermittent fasting or I skip this meal, or I never eat after this time. There's a lot of like very specific time restrictions around eating. Which again, I think is like often very promoted by some medical doctors. But it can be a red flag that there's maybe some some more rigidity around that than is helpful for the patient. And then noticing if there's any food groups missing. So if they're, specifically not eating certain food groups. Again, there are people who do not eat certain food groups. They may be vegetarian, they may be vegan. This is not automatically a sign that you have disordered eating, but it's a red flag that like we need to dig in a little bit deeper and make sure you're actually meeting all of your nutritional needs within that more restrictive diet. And what is the motivation behind that restriction? Is it something that's cultural or religious, or is it something that they're doing because they think it's going to make them lose weight or to control their body size or shape in some way? I always ask too if they've had any major weight fluctuations, either loss or of weight or gain of weight in the, in their history and their lowest adult weight and their highest adult weight. Just to get a sense of has there been a lot of weight cycling? So one of the most common forms of disordered eating that I see is chronic dieting. So like people will go on a very restrictive fad diet, lose a ton of weight diet's completely not sustainable or appropriate, and then they go back to eating the way they before and they regain weight and usually end up at a higher weight than they started. And that process repeating over and over again actually has a huge impact on developing metabolic health issues like particularly fatty liver. And I think seeing that sort of history and that pattern is an interesting sort of red flag again. And then I do directly ask the question, have you ever made yourself throw up or used a laxative or a diet pill or a diuretic to try to compensate for food that you ate? Or have you ever used exercise in a way that was specifically to compensate for amount an amount of food that you were eating? Are you counting calories and then making sure you're exercising X number of calories to compensate for that?'Cause I think a lot of patients are doing this without ever disclosing it.'cause there's a lot of shame and stigma around it. And asking the direct question opens up the space that like, hey, like this is a thing that happens. I ask everyone this question and let's talk about it if this is something that's affected you so that we can try to help you manage it. And so I think just being informed enough to know about the behaviors that a lot of people are engaging in and asking the question, because that's the other thing. I think a lot of people think this is very rare. It's really not that rare. It's really,

Kerry: 17:01

You, how much, what percent of the population do you think actually has it?

Rebecca: 17:05

So I think the stats that we have are probably very much under reporting. But binge eating disorder, for example, is estimated around 2% of the population. And anorexia and bulimia are approximately between one to 2%, I believe maybe less than two, probably around 1%. It also depends of course on like the life phase that you're in. And I think there's also this assumption that it's like the adolescent affluent female is the person that has the eating disorder, but that is absolutely not the case. Like it affects people of all genders, of all ages. And yeah, so I think it's binge eating disorder is the most common of the eating disorders, but the others are still fairly common. And the big thing that I think a lot of doctors don't realize is that anorexia nervosa has a, the only psychiatric condition with a higher mortality rate is opiate use disorder. And so it has a very high mortality rate both related to medical complications of the restrictive eating pattern and then also related to suicidality. So it's really important that we are identifying this for our patients and helping them manage it. Because the longer someone is suffering, the harder it is to break that pattern. And so really being able to identify it and help that person as or as early in their life as possible is is really beneficial.

Kerry: 18:18

So what percent of the population do you think has disordered eating?

Rebecca: 18:22

Oh, disordering. So this one's so hard because I don't know that anyone has defined that well enough to really study it. Based on my anecdotal experience, I'd say like at least 75%,

Kerry: 18:35

Like from

Rebecca: 18:35

at least, at least.

Kerry: 18:37

sounds like that.

Rebecca: 18:38

It's because it's also so normalized, like a lot of these behaviors are very normalized and they're actually promoted, like intermittent fasting is like such a thing right now. And yeah, if you're intermittent fasting, that doesn't automatically mean that you have disordered eating, but it's, it is a pretty restrictive pattern to be following and if you're very strict about it, it can very quickly spiral. And

Kerry: 19:02

where the problem it becomes, right? The strictness with it. You can try something and see if it works for you, if it's fun or something, right? But if you're like not living your life because you're making it so risky. Then I think that's where it becomes more on that actual disordered eating. Would

Rebecca: 19:17

Yeah. Oh, absolutely. And because yeah, if you if you're wanting to follow an intermittent fasting window and you're like, oh yeah, I normally wake up at this time and I go to bed at this time and I normal, like it's not a huge deal. And then if, especially if you're like, oh, I had this wedding to go to. I'm gonna, I'm gonna, I'm not gonna do it that day'cause I'm gonna go to this wedding and enjoy the wedding. But if you're like, oh, I'm gonna skip the wedding because it's gonna mess up my fasting window, that is a very different interpretation of that behavior. And I think that's, it's that rigidity. But I, I've had patients who when they travel, they're like pre packing coolers full of food because they're afraid of not being able to get food. They can eat when they travel or just absolutely not eating when they get there. I remember when I was a med student, there was a med student on a rotation with me. We were on surgery, we were getting there at four in the morning and not leaving till six or 7:00 PM and they ate nothing but steamed green beans from the cafeteria that day because that was the only thing in the cafeteria that was acceptable enough for them to eat. And there's, of course we could all probably make improvements in our nutrition. There's a lot of food access issues and and nutrition, like food supply issues. I'm not saying that oh yeah, everything's fine to eat and we should just be, not worrying about it. There's clearly some degree of nutrition awareness that we need to have to be able to make sure we're adequately nourishing ourselves. But skipping meals entirely, especially when you're, gonna be working or if you're like, if you're traveling, like you can't just not eat. It is less healthy to not eat than it is to eat something that's quote unquote bad. And so I think that's it, that's where it can become more rigid and disordered when there's that degree of strictness around it.

Kerry: 20:52

How do you help, patients heal who are like showing these signs and symptoms?

Rebecca: 20:58

So I think the biggest piece is identifying the contributing factors. Like I said, there's often some psychological factors contributing, whether it's trauma or another comorbid psychiatric condition. Or just like a, socioeconomic pattern that was harmful to that patient that we are, that we need to intervene and address. And then I think the other thing is, breaking the shame and stigma of it. Just even having the conversation like, this is something that's happening and I don't like how it's affecting my life, and how can I change it? Because there's so much secrecy around this, like patients are so ashamed they often don't disclose it to their doctors. So connecting them with a therapist who is, versed in treating disordered eating and eating disorders is really helpful. And I think from a medical perspective, the biggest thing is looking again at the big picture and not making weight focused recommendations in particular, because so much of the driver behind these behaviors a lot of times is related to body image. Trying to change the size and shape of the body because that is a constant cultural message that we're receiving. And so if we continue to support from a medical perspective that goal and focus on that goal, it becomes really difficult to break those habits because they've been constantly used in service of that goal. And so focusing more on behaviors, what are some behaviors that we would like to implement? Like right now you're eating one meal a day and you're not sleeping well and you're not drinking very much water and you're drinking a ton of caffeine and energy drinks'cause you're so tired. Let's pick one behavior that we wanna change, make that change. Then gradually moving little by little towards a behavior pattern that we know is gonna be more beneficial for that patient. Getting better sleep, eating more consistent balanced meals drinking enough water and not too much caffeine or alcohol or other substances. And moving towards that sort of behavioral pattern that is a, that's healthy rather than let's try to get you to lose X number of pounds. Or let's try to have you lose X number of inches off your waist or get your body fat percentage to X number. Like when you make it so focused on that outcome that we actually don't have full control over, it causes the person to take those behaviors to an extreme rather than we make the focus the behavior. We can bring it always back to this is a balanced pattern and the weight will settle where it settles. If there's medical problems that we need to treat, we can treat them, but that doesn't mean that we need to be so focused on trying to get the body to do a certain thing for a certain cosmetic or aesthetic reason.

Kerry: 23:33

I think that's beautifully said. Focus on healing them in what, habits or things that they're not doing that it would be favorable in their health right now before saying, or even not at all saying, of course, you need to do this to make your pre-diabetes better, or something like that. I think that makes a lot of sense. How do you specifically manage like the metabolic problems that someone would come in that would benefit, we know clinically they might benefit from losing weight, but we don't wanna say the wrong things that they might end up with disordered eating.

Rebecca: 24:05

So I think the first thing I would challenge is like they may not need to lose weight to benefit clinically. Like a lot of times the behavior changes alone, whether or not it results in weight loss will improve the management of that condition. So if they're getting five hours of sleep, they're not eating balanced meals, they're drinking a ton of alcohol, like changing those behaviors. They will, you will see benefits in their metabolic health and it may or may not be accompanied by weight loss. And so I think there's we do, I think, very much have this assumption like, oh, if they lose weight, all these problems will go away. But that's actually not the case. Sometimes it's behavioral and if we change the behaviors, the problem may improve or be better or be, better controlled. And the weight may or may not change. There are definitely patients that I've seen, a lot of patients that I've seen who have been struggling with a metabolic health condition for as long as they can remember. They have been, they have tried every behavioral intervention. They are eating balanced meals, they're drinking lots of water. They don't drink alcohol. They're moving their body as much as they can feasibly in the modern world that we live in. And they're getting good sleep. They're really doing all these things and they're still struggling with their metabolic health. And we do have medicine for that. Like a really good example I would describe is like patients with PCOS. So I see a lot of patients with PCOS, that's another common comorbid condition that contributes to disordered eating and eating disorders. And a lot of these patients have been struggling with metabolic health issues since puberty. And they've really tried everything they really have. And adding a medication like metformin can be really beneficial for those patients. There are sometimes patients too who we might use a GLP one. I'm very cautious about the use of a GLP one for managing insulin resistance and metabolic health conditions just because the, there is a potential for, especially in a patient with an eating disorder history for a relapse. And for it to be misused or to contribute to relapse of the eating disorder. But I have had success with some patients who, you know, are doing well behaviorally and have recovered. And we're just really focusing on how can we address those metabolic health outcomes like the fatty liver, the diabetes or pre-diabetes. And we will use the GLP one in those cases, but it has to be done cautiously. And again, not with a focus on let's push the dose as high as we can and get you to. As much weight as possible, but let's use enough of this medicine to give you some benefit in your metabolic health problem and improve your risk factors without creating a new problem for you. And so yeah, there are times when medicines can be helpful but it should always be in a, in an integrative approach where we're looking at the big picture.

Kerry: 26:34

I'm glad you brought up the GLP one'cause I was interested in what your, perspective was on it. And what do you do with the patient who you know is walking in and really just wanting to lose weight and wants to go on a GLP one? This day and age they could get it anywhere.

Rebecca: 26:49

And there are, we are gonna be seeing, I'm sure in the coming years, so many cases reported of patients who have ended up very seriously ill with an eating disorder from misuse of a GLP one that wasn't properly prescribed or managed. So I'm very open and honest with patients about this. This is, serious medicine. This is not something that we use to lose some weight for a wedding. This is this is a medicine because there's a metabolic health condition that lifestyle alone is not managing. And we want to improve your risk your future cardiovascular risk, your risk of developing diabetes. We wanna try to address these metabolic health outcomes. This is not about weight loss. I'm very, I very much like start low, go slow. We are titrating to the effect of managing the metabolic health outcome, not trying to get the weight to a certain number. And the behavioral piece is so important'cause as as I'm sure you've talked about this on this podcast before, like when you use the GLP one. If you are under eating on a GLP one because of how much appetite suppression you're experiencing and you lose a lot of weight, you can lose lean mass too. So you're losing muscle, you're losing bone density. And we absolutely want to minimize that, that as much as possible. So I love to have patients working with a dietitian whenever possible when they're taking a GLP one to make sure we are not undereating, we're not missing out on enough protein. We're getting enough of all the major nutrient groups and and that we're engaging in some form of movement that's gonna keep the muscles active and reduce the risk of excessive muscle loss because so those behavioral pieces really have to be there. And if someone is still very deep in their eating disorder. That's not a great candidate for starting at GLP one, if they're very weight focused, if they're still engaging in a lot of disordered behaviors, they haven't done the psychological work to address that. It's gonna be a much riskier proposition. So it's always a case of discussing the risks and benefits and there's always patient autonomy, but it is very important for me to make sure that I am doing my due diligence to avoid causing harm to this patient. And I've had a lot of success with the patients that I've worked with using GLP ones, but I'm definitely doing it in a very cautious and slow and gentle manner and with a multidisciplinary approach where we are using a team with a dietitian and a therapist to make sure that we are addressing all the different components that are affecting that patient.

Kerry: 29:06

I have only very few with diagnosed eating disorder from someone other than myself. But the binge eating disorder the medicine works very well for that. So I don't know if you use it to treat that or you still, obviously maybe there'd be going, working with a therapist as well, I'm assuming. Right.

Rebecca: 29:23

Yeah. So I think with a, with binge eating disorder, it certainly, it suppresses your appetite, right? And you can only eat so much. So in that sense it works. I think it's I don't really see the eating disorder groups as very different from each other in the approach because the underlying issues are very similar. The difference in behaviors partially is genetic and then partially just depending on the various factors that impact the person's development. A lot of binge eating disorder comes from restriction. So there is other restriction happening that then results in the binging. I think what's maybe often missed is a lot of people can have actually anorexia and they have restricted and restricted. And the binging is actually in response to refeeding. That's, that can be a normal part of of recovering. So I think it's important to be able to assess like all of the behaviors, not just oh, they're binge eating we need to stop them eating. Like, why are they binge eating? Have they been restricting? Were they skipping meals? For days at a time, did they cut out an entire food group? What happened to result in the binging? Because the binging by, its, it's, it is rarely just by itself. It's, there's usually more to it. And so I would never just say oh, you're binging. Here's this medicine that'll stop you binging. Now you won't be able to that's not treating the problem. That's a bandaid. A lot of binge eating is associated with A DHD as well. It's addressing like, where is the binge eating coming from a stimulation or like a dopamine response that we're having to so are we addressing, that piece of it. Regardless of what the eating disorder behavior is that a person's engaging in, we have to look at the big picture and address that as a whole. And I don't see a GLP one as a treatment for binge eating disorder. I still would only use it if if there's metabolic dysfunction that increases cardiovascular risk of fatty liver disease and diabetes. Then we're using it for that purpose. We're not using it to address the behavior.

Kerry: 31:10

I agree with that. I don't know if the companies are going to agree with that.'cause I have a feeling that one will be down the pipeline as well for FDA approval, but we'll see. I agree with you though. So you've mentioned genetic component a couple times. I wanted to ask like what do you think parental food beliefs and behaviors, how do they trickle down into shape a kid's long-term relationship with food and body image?

Rebecca: 31:32

Yeah, so I think, there was certainly in the past and I still think to a degree there is this sort of idea of oh, it's the parents' fault we're gonna blame the parents. And it's like having blame the mom, but really like the parents have this, the genetics came from the parents, right? So the parents probably had some of these same genetic predispositions. And that is an environmental factor that influences the child's experience of food and understanding of food. But I would never say oh, it's the parent's fault that this happened. They caused this by the mom was dieting and that's why her kid has this eating. That's, that is an oversimplification. That's totally unfair. But there, there is a genetic component, so like the, what the parents experienced and then our modeling for their children is genetically influenced. And then of course, like that modeling is internalized by that child. It's certainly a factor. But the way I would see this is it's not the fault of the parent, but this is something that a parent can intentionally model healthy eating behaviors and f and beliefs around food for their children as a sort of preventive mechanism. If you know that you have a genetic predisposition in your family for disordered eating, it's something that other people in your family have struggled with, it's something that you've struggled with very intentionally modeling, Hey, you know what we eat regular meals throughout the day. We don't cut out food groups. We don't cut out carbs. We don't talk about our bodies in a way that is you know, deprecating or self-hating. We're focusing on what our bodies can do, not what they look like. We're focusing on nourishing our bodies, not trying to make them smaller. You can really model a healthier relationship with food for your children and that can overcome some degree of the predisposition that they may have. They're still gonna get those messages from the rest of the world. So you wanna be, you wanna have home be their safe space where they can have a healthier relationship model. But it's it is complicated. And I think it's important to be aware of as a parent.

Kerry: 33:20

No, I agree. I think that's really excellent advice, and it's always a difficult one I think, for parents to wanna improve their own health, but make sure that their, kids don't think that they're doing anything that is, too much. I don't know. I think it's great advice that you have there. You said one of your favorite tips was never skipping breakfast. Why is that so powerful?

Rebecca: 33:40

Yeah. So I think, breakfast, I think is so important for setting the tone for your day, like starting the day off with some energy. I think also just physiologically we're primed to wake up in the morning, eat, digest, poop, like it just gets the digestive system going. That's prime, that's that normal part of the circadian rhythm. So when you skip breakfast not only are you starting the day at a deficit of energy and possibly constipated but you are also, you're also, you're, you're pushing everything back in terms of the timing of when you eat. And so when you do, finally you're gonna be hungrier. You're more likely to overeat and you're more likely to reach the end of the day feeling oh, I did not get enough food today. I am starving. And then, 10:00 PM sitting in front of the tv, you're more likely to just like snack on a bunch of foods that you maybe didn't really intend to eat that day. And it's probably not gonna be as nutritionally balanced as if you had prepared yourself a balanced breakfast meal that contains all of the major macronutrients and, protein fat, carbs, and fiber. If you prepare yourself a balanced meal, you're starting your day off meeting more of your needs, you're less likely to have to try to compensate at the end of the day with whatever's available when you're exhausted because you actually have everything that you needed throughout the day.

Kerry: 34:57

Yeah, and usually I think that. But I think people who, you mentioned this before, like when they're practicing, like the intermittent fasting and things like that, that you're gonna make up, your body gets, is gonna want you to make up for it later in the day. So those hunger signals are usually, gonna be crazier. So that's definitely good advice. What else? I feel like we could talk about things forever. You have such good information. But I guess if someone thinks that they're having like an unhealthy relationship with their food, what do you think is the first like gentle step that, that you would recommend?

Rebecca: 35:27

So yeah, I think if where is it coming from? Is it becoming from a concern around your health? Because if you have a health concern oh, we have this condition in my family, I wanna make sure I don't get this. Or if it's coming, if it's coming from a health related concern, sometimes I think people are worried about something and they're afraid to go get the information and confirm it so they'll just skip to go to the doctor. So if you have a health concern, go to the doctor, get your labs done. Understand where your health is now, get your blood pressure checked, all those things, and then at least be starting with some concrete information rather than worries that you don't actually know what's going on. So I think, go go get your physical, go get checked out see where you are. If it's coming from a place of body image or just like discomfort with yourself, I think starting with a therapist is really helpful be to explore where that is coming from. And there are a lot of therapists that specialize in working with patients who struggle with disordered eating disorders, body image issues. And I think it's really helpful to, to go and explore where that's coming from. And then I think for a lot of people, just the way that we, the messaging that we receive from childhood on around nutrition and diet is so confusing that I think people get into this place of I don't even know what I should be doing anymore. It's you think, but then you're like, I'm getting this information from social media. I'm getting this information from people who are selling me supplements and other things. What do I actually need to be doing? And so if it's a concern of, I don't know what I should be doing. A dietitian is a great place to start because again, there's a lot of dietitians that specifically work with helping patients manage their relationship with food better, understanding their nutritional needs, making sure they're meeting their nutritional needs and uncomplicating all of the things that society has made very complicated. So I think, again, it's with everything. I always think that we need a team where there's never gonna be that one person that's gonna fix it, but I think to start from, I would start with where do you feel like this is coming from? And start with that and then and then go from there as you move forward,

Kerry: 37:23

That's super helpful. Obviously seek help and, find your team, I think would be the message there. So you've given us so much great advice and information. Where can people find you or work with you if they want to, hear more?

Rebecca: 37:37

Yeah my practice in the Houston suburbs, so in Sugarland, Texas and it's called Vida Family Medicine. Our website is vida family med.com, and then I am on social media on Instagram and TikTok at Rebecca Berens md.

Kerry: 37:49

Awesome. Thank you so much for joining us today and I feel like we could have talked forever, so I think we've got a lot of good information here. And any, if you, anytime you're welcome back, that's cool too. But yeah, everybody thank you Dr. Berens, and stay tuned for next week's episode.

Rebecca: 38:04

Yeah. Thanks so much for having me.

Kerry: 38:06

Thank you.