Season 3, Episode 14: The Overlap of Disordered Eating, Eating Disorders & IBS

Welcome to The Gut Show, I'm your host Erin Judge, and I am excited to share this episode with you. Today we have a special guest, Beth Rosen, a non-diet registered dietitian specializing in GI nutrition and disordered eating. In today's episode, we'll talk about the complex relationship between disordered eating, eating disorders, and digestive disorders, particularly IBS.

Beth will share why we need to have these conversations in the GI space and what to really be cautious of as providers and as patients who are navigating care in this space to prevent disordered eating patterns and harm that can be done from those including eating disorders. This is a really fascinating episode if you've struggled with disordered eating in the past, maybe you have a history of an eating disorder or an active eating disorder, and you're dealing with digestive symptoms.

This episode will highlight a few things that you could do that aren't diet-related to get the care you need. You can always connect with Beth afterward through our show notes and all of the links there if you want to ask more questions. Enjoy today's episode and let us know what you think at The Gut Community on Facebook after the episode is complete.

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Erin Judge: Beth, thank you so much for joining me, I'm really excited to jump in! Before we do though, I want to hear a little bit more about you and how you became a dietitian. I know what you do now but I don't think I actually know the whole story and kind of what got you to where you are now.

Beth Rosen: It started a long, long time ago back in the 90s. I actually didn't start going to school for dietetics; I started as an advertising design student; I wanted to be an artist. That quickly changed once I got to school and realized you got graded on your art when I just wanted to do art. After a couple of changes, I ended up landing in dietetics, which was something I knew a lot about from my own dieting history. I got my degree from the University of Maryland and then went on to do my internship as dietitians have to do at Columbia University and did my masters concurrently there. When I got out of school, or actually, when I got my RD, before I got out of school, I didn't want to go the typical route of the dietician at the time, which was to be a clinical dietitian, or work in a hospital, so I decided to go in a different direction, which is now called corporate wellness, at the time, it was called health education. I worked for a company and I wrote courses, and I went around all over the state of New York and taught these courses to people in their places of business, and it was a lot of fun! I never wanted to do anything in quote unquote weight management because I didn't feel like I had the answer for how to make people smaller and keep them that way. I'm very much a truth seeker, I like to be authentic in my work, so knowing that I couldn't do that, I didn't even want to be a part of it. So going into private practice or counseling for me was something that I stayed away from for a little while. But eventually, I was made an offer to open a practice in a doctor's office where there was a GI and PCP, and they wanted to create this integrative sort of healthcare where you could see everybody there. It was a nice start, but it never really took off, but my practice did. I love the GI part of it so I built that piece. But while I was doing that I also had come into some knowledge about the health of every size movement, and intuitive eating, which I read back in grad school. And I knew that if I was going to do private practice, there would be no diet component for the work I was doing at that point. And that worked really well for people with GI issues, which is what I was working with because, as you know, being on a restricted diet causes more problems for people with gut health issues. So it was an easy foray into private practice without having to do the weight management. Years later, here we are today, and that's the main piece that brings me the most passion is working with clients and helping them feel better.

Erin Judge: Yeah, that's awesome. I didn't realize that private practice is kind of an accident for you, I had no idea that that's how you got into it. And just from what I do know about how you speak and some of what you share, you have a personal interest in GI as well correct? Were you already interested in GI or did that kind of come up from being exposed to the knowledge and everything that you were learning as you were caring for the GI population?

Beth Rosen: So they sort of came up around the same time. I was doing mindfulness workshops, intuitive eating work and focusing more just on getting off the diet cycle, that was where my practice really started. Then I ended up getting C. diff, which is a terrible infection that just wreaks havoc on your gut and your microbiome and everything going on in there. And for people who have C diff, about 12% of them end up having post infectious IBS that sticks around and just becomes IBS and I am one of the lucky 12%, so I have IBS with diarrhea. It took me a while to find the right practitioners, to get the help, to have people believe me that what I was feeling I was actually feeling. I found low FODMAP diet way early on, not early on how I was feeling but early on in the diet itself, maybe I found it in 2012 and I had been dealing with it for a little bit longer than that. Once I found that and I tried that I thought, oh my goodness, that actually works and it wasn't about, you know, losing weight or pulling out every food group. You know, I found that and that was just, that was such a great find and that really helped me even solidify my practice more to know that, okay, if people come to me with IBS, I have a tool. This is one tool, and it works for so many people. I was so excited about that so it just got me excited for me and for my clients. And I think that's been helpful also that I can relate to the pain, the discomfort, the bloating, the flares, the fatigue, all of that, because I've experienced it myself.

Erin Judge: Yeah, absolutely. We hear that a lot, I think with dietitians who get into specialty practice, especially in the GI world, so many have that experience themselves. So even in disordered eating and eating disorder world, a lot of dietitians have gone through that and that's what gained their own interest to study that more, but also create that empathy that is so important and valuable, and I think is like the superpower of dietitians because we have the ability to do that is the empathy that we're able to have when we've had certain experiences. Not just giving our own experience to our clients, we have the knowledge and the tools and education and you know, all the resources, and we just have the empathy from our own, which is so important.

One thing that you mentioned earlier, so in your specialties, you work with patients with eating disorders and disordered eating as well, correct?

Beth Rosen: I do. So that came a little bit further into my private practice, I really didn't want to work with people with eating disorders. If you know about RD training, there's not a lot of information about eating disorders in our training and unless you seek it out, how are you to know what it's all about? And I haven't sought it out, it wasn't something I was looking to do, and it was one of those things that I feared I would never, and you should probably never say I would never, but I would never work with people who had eating disorders and I would never work in TPN or tube feedings because I'm terrible at math, and I would kill somebody because I wouldn't be able to give them the right nutrition formula. And that was that piece and the other piece was, I'm worried I'm going to somebody will die on me because I won't have the right information. But as it turns out, I started to see a connection between GI disorders, namely functional GI disorders, things like IBS, gastroparesis, where your gut motility slowed, reflux, and seeing some of those things happening in my who are coming to me, and then realizing they have maladaptive eating behaviors, and wondering which came first. In the majority of cases, the eating disorder comes first, and that's from research. And so I went through some trainings, I got some supervision, I really started to learn and I found that I learned more as I worked with clients, but also becoming part of some dietician communities there’s just so much learning to be had. And then making the connection between GI disorders and disordered eating just made sense in my practice, because, you know, if I was going to be a dork and make a Venn diagram of people who have just IBS or just GI disorders, and those that have just eating disorders, that most two circles cross.

Erin Judge: Let's talk about that overlap, and a lot of people don't, I think we can live it and you can be in it and see it, but it's also hard to really understand because it seems like these are two completely different things, right? So let's talk first of about identifying what you mentioned with maladaptive eating behaviors. So we know that the gamut of disordered eating to eating disorders, the spectrum, what are some of these actual behaviors that you're referring to whenever you mentioned, like maladaptive eating or disordered eating behavior?

Beth Rosen: So they could be anything from cutting out a food because you think it's quote unquote, not good for you. And it can be then cutting a food group, like carbohydrates that have been vilified by diet culture. And incidentally, that switches all the time depending on where diet culture takes off, right? So back in the day when I was in school, it was the high carb, low fat diet, bagels were the best thing to get, everybody's eating pasta and added sugar to all their recipes and everything. And then slowly as time went on, Atkins found their way in and, you know, and then we got to paleo for a while, so carbohydrates are out, but protein was in and now it's keto so now, proteins sort of out but fats in, and then you have, you know, intermittent fasting, which is like, everything's out. Right, so you have all those kinds of diets, and they change over time, but maladaptive eating behaviors or disordered eating behaviors can be the behaviors themselves, like restricting, not eating enough for your body. It could also be thoughts about food, foods are bad for you, or change your body size. And that's scary too, you know, other behaviors that we don't want to mention, because they could trigger some folks who might have an eating disorder. But it does run the gamut and I think it's important to have that diagnosis, whether it's maladaptive eating behaviors because of food, fear established from having a GI disorder, and not knowing what food might be causing it. Because we think like everything that we put in our body is impacting our gut, sometimes that's the case. I mean, sometimes it is the food, but sometimes it's not the food. And then you know, those people with eating disorders who have minimized what they're eating, and now maybe their gut microbiome is not as diversified as it once was. And our microbiome contains all these organisms that play a lot of different roles in our health, one being our immunity, but so many others. We know from the research that when we have a diversified microbiome, we have a healthy gut, right? And we get that through a variety food.

Erin Judge: Yeah. what diet culture says might not be the same, because I think we hear it is usually about right, a healthy gut is usually linked to super foods, like eat these specific, like bone broth or whatever. You know, it's like these specific things are going to give you a healthy gut, or it's usually around restriction, around well, these things will give you an unhealthy gut when the truth is research supports diversity. And carbohydrates are really at the source of that, which is interesting.

Beth Rosen: Certainly, that's what feeds our microbiome is, I mean, our microbiome craves fiber, and where do you get fiber from? Carbohydrate sources! If you look at our food system, the majority of our food has carbohydrate in it…our grains, our nuts, our seeds, our beans, our legumes, our fruits,. our vegetables, even dairy. They all have carbohydrates in them because our body needs that to function, especially our gut.

Erin Judge: Yeah, absolutely. So we know that some maladaptive behaviors throughout the spectrum, right, through early on disordered behaviors to eating disorders can maybe contribute to a less diverse microbiome. What are some of the other changes that can happen and what are some of the other ways that some of the behaviors may actually impact the gut function and maybe present them as a digestive disorder?

Beth Rosen: Yeah, so restrictive eating and not eating enough or not eating frequently can make your system slower. If you don't have enough food, you're not going to create enough waste, so that might lead to constipation. It can also lead to slowed motility if your body's doing its best to maintain its equilibrium, it's going to slow your metabolism so that it doesn't burn off all the energy you're taking in, and that slows the motility of your gut which can lead to something called gastroparesis. It's sort of a cycle, right? They connect to each other, like you think, oh, this person has constipation, maybe it's because they're not eating enough fiber, but it could also be that they're just not eating enough.

Erin Judge: Yeah, absolutely. And we see that time and time again, even in our practice, where it's like, you look at the history of somebody who's dealing with digestive issues, whether that be constipation, diarrhea, bloating, you know, the most often is bloating and gas production, and you start to dig into the history and the symptoms were maybe minimal, right? They were there, they were frustrating, a little bit annoying and then a food gets taken away. And then more food gets taken away. And then we skip a meal, and then we reduce the intake during the day, then, you know, it's like you kind of see these histories coming on where it's like things slowly minimize and that could present with overall food goes down to a minimum or what I see fairly often is the under eating during the day, and then eating, you know, the majority of calories at the end of the day when you're home, you know, because you wanted to keep symptoms down and, you know, then by the end of all of that symptoms are so much worse, which leaves someone, you know, living with that saying, what did I do wrong? Like, you know, I'm frustrated, I'm worse off than I began, like, what else do I need to cut out? Like, I hear this, right? They just come to me, they say, what else do I need to cut out? What food is causing this? Why do you feel like that happens? Like, I'd love to hear your thoughts on that, I'm sure you see that too, and, and why is that happening?

Beth Rosen: I think people cut out foods, and they get to the point where they're eating really next to nothing because we assume that what we put in our bodies is causing that impact on our gut. And sometimes that's the case and sometimes it's not. But if you're removing food from your diet, and you still have the symptoms, it wasn't that food that caused it and yet that food doesn't get added back in. And I think that's the problem that we hold, maybe it's gluten and we pull out everything, including, oh, that's even worse, so we pull out dairy. So now we're not left with that much when I think gluten and dairy and yet we still don't feel well, right? And so the cycle continues, where now we pull out this vegetable or that fruit or this, things get pulled out and that sort of happens. But what we know about the gut, especially with bloat is that our gut is basically a long, long tube of muscles and it needs to be worked all the time. Right. And so eating regularly, and if you were to listen to your body, if you eat intuitively, if you're a competent eater, it's probably every couple of hours that you're going to feel hunger. If you honor that hunger and you eat, your body will do what it's supposed to do, the muscles move and things move down. The next time you eat, all your wastes will move down, make room for the new food and then eventually your gut will be filled enough that you'll get a signal and you'll go right and that's how it goes. But if you're sort of doing it, willy nilly without having food at a regular time, you're not going to move your bowels regularly then food can sit in your gut and ferment. And that fermentation is what causes that bloating feeling of the gas produced by the microbes feeding off of what's just hanging around.

Erin Judge: Absolutely. And then you feel, that's that “well, I didn't even eat anything and I’m having symptoms” conversations like, yeah, you know, there could be something else happening there. So if someone is dealing with that, let's say, you know, they've cut down food, and they're feeling frustrated. A lot of the recommendations around digestive disorders still is around food. I mean, you mentioned the low FODMAP diet, it's highly recommended, eat more fiber is recommended, even drink more water is recommended, but there is such a focus on food. What would you do with someone who is presenting that way? And like what other tools and resources do they have available? And like I know a little bit, too, but I love your opinion on this and just kind of if someone's sitting there thinking, well, if it's not about food, like what am I supposed to do?

Beth Rosen: Right, so I think there's two sides to that. One is, if you get a client that comes in that truly has a GI disorder, and their maladaptive eating is based on the fact they were trying to heal their gut on their own without, you know, without it being a true eating disorder or disordered eating behavior or caused by dieting, you might start with a dietary intervention, that might be the low FODMAP diet, or it might just be adding back some of those foods that were taken out to see if having a well rounded diet improves their gut health. But if you do that, and it doesn't work, there are some things you can try.

First, one of the tools that I might use is and I'm going to share some of these tools, but this is not, I'm not providing medical nutrition therapy for anyone who's listening or watching, this is just, these are some of the tools that are out there, work with your dietitian, you have to know what's best for your body. It's not appropriate for everybody. Right? So dealing with GI health is very individualized. That said, one of the tools I do use is a prebiotic fiber supplement, because if fiber sources have been out of the diet a long time, then the gut microbes are starving, and they need to be refed and they need to proliferate and grow and all those things, and prebiotic fiber has shown to be helpful, there was even a study that showed that it was as effective as a low FODMAP diet when used regularly. The study needs to be replicated, you need to see more of that, but it's still a tool that I find works very well for my clients.

And then there are some other tools like gut directed hypnotherapy. And again, you have to go to a specialist to have that done, there are some apps that do it but working with a specialist is really helpful because with functional GI issues, so functional means that the function isn't working well, but the structure is well, so if you were to take a camera and go into the GI system, you wouldn't see anything wrong, there'd be no holes, no scarring, no bleeding, no nothing but it's still not working right. So that would be a functional, right? So with functional GI issues, there is a miscommunication often between the way the brain and the gut communicate to each other. And so gut directed hypnotherapy helps the gut and brain to get along a little better. And also, I like to tell my clients sometimes that an IBS belly is a drama queen

Erin Judge: Yes, I always say it’s a Kardashian!

Beth Rosen: Yes! So when you know when a stimulus is put into the gut, whether it's food or drink or something, an IBS belly may react in a really big way to this little bit of food, where you and a friend might eat the same things and they're not feeling anything, although there's gas in them, but they don't feel it. If somebody with IBS has gas, they feel like they're blowing up, they feel uncomfortable, they might, you know, just be exhausted at that point. So many different symptoms come from that experience. So with gut directive hypnotherapy, it sort of changes that reaction, it calms down that drama queen a little bit, maybe it’s a drama princess but the drama queen is gone. So that's what the gut directed hypnotherapy helps with.

So those are the two big ones, certainly, and there are others, there's some connection with gentle yoga that may help some discomfort, some poses that may help to relieve gas, which is always fun to teach people. I know that you're a big proponent of the squatty potty, so proper positioning during you know, toileting is a good thing. And so these are just some of the tools, but it depends on the person what I would use, and there's some supplements also, that I might recommend that could be helpful. There's a lot of tools out there, so that's why it's so great to work with a registered dietitian who has expertise in the GI system, because we know what all these tools are and we can decide which ones to try first and it doesn't feel so hopeless.

Erin Judge: Yeah, absolutely. I agree with you, there's never a one size fits all answer, a single first step or a best, it's not about best options, even it's about each person and how things are interacting and what steps we take, and you know what to expect and how to support the body as you take those steps, it can be complex. And some of these cases, it can be almost more complex, and I want you to talk about this, because this is something I see a lot come up and something that I think patients or, you know, those of us with IBS, we're both patients, right, I’ve experienced this myself, and I know that a lot of the people I work with do as well, but whenever the gut has been slowed, right, whenever those muscles haven't been working, and whenever you've had C. diff or an infection, the gut has been extremely disrupted, so it's off, right?

Whenever the gut microbiome has been starved and those beneficial microbes just aren't flourishing like they are meant to, as you introduce foods, it's not always going to be sunshine and rainbows right away, right? It's if we know that, okay, well, some of these maladaptive behaviors likely are contributing not at fault of the person, I think there's a lot to that right diet culture, communication, not getting proper resources from providers, not being listened to enough to really understand that symptoms were actually fairly severe and needed some extra help. like, there's a lot of reasons why those behaviors happen. But when those bad behaviors are identified, and we know that okay, you know, eating more regularly, balancing out the diet, building up your diversity is likely going to help, the first time you incorporate those foods or the first time maybe you do incorporate eating more regularly, the muscles don't just magically come back and start functioning right away. The microbes don't just come out and say I'm ready, you know, I'm going to process all this food well, so let's talk about that, because that's something that a lot of people will experience. It can be almost disheartening to start eating more or start incorporating foods that they haven't in a while and now they are having these real reactions. So talk a little bit about that.

Beth Rosen: Okay, so, first off, it is possible that you'll eat a food and be fine. So not all foods may cause that, you know, lack of rainbows and butterflies or sunshine. But there might be some symptoms. I think what's important to note is that they're temporary. Right? You're adding back one food at a time, so if you have symptoms, you know it was that so then you can take it back out. It's temporary. It's not the same fear as oh, no, I've been diagnosed with IBS, what do I take out of my diet? What's causing this? I have no clue. Right? This is, let's add stuff back in, and again, working with a dietitian to come up with a plan on how to do that. Sometimes you might start small, small portions of it, maybe only once a day, build up to a full portion, right.

As far as the body getting used to eating again, if you've been restricting a lot, there is this dietitian, her name is Tammy Beasley, she works for an eating disorder company, and I heard her speak, a bunch of years ago, when you could be in public, and she gave a great analogy about a sponge. And she was talking about it from an eating disorders perspective for people with anorexia, who, you know, don't eat a lot and then have to start eating. And yes, that can be painful, because those muscles haven't been worked in a long time and they atrophy just like as if you didn't play a sport for a while, and then you go back and play, the muscles are gonna be sore. Same thing, right?

So the way she puts it is if you can think of I think most people can visualize this, a really old sponge, right? If you're looking at an old sponge, it’s just sort of crusty and hard and wrinkly and it's sort of perked up, right. And that's sort of how your insides are, because they've atrophied, they're just not working well. If you were to pour water on it, it wouldn't work so well, like it would splash off of it and wouldn't get absorbed. And that's the same way your gut works at the beginning, right, like, maybe absorption isn't happening, maybe you're gonna have some bloating and gas because things weren't absorbed. But eventually, the more water you pour on that old sponge, it ends up looking like a new sponge, it's pliable, it's absorbable, it's kind of all the things that a sponge should have, once you've soaked, right, so it might just take some time. There might be some hiccups in there but eventually, you'll be able to do all the absorption and get all the nutrients, and then your gut will feel itself. No need for tote bags full of supplements.

Erin Judge: Going on that same line, I like that you brought that up because sometimes I think the thought is to put a lot of supplements in and I've even seen this with some medications like medications can be so beneficial, but if the gut isn't working, putting even those things and like trying to simulate movement too much, you might not respond like you hope and they may not feel good. The best way which is comes back to that personalization, right of every single person will handle things differently. Your gut, you know, is not always just going to be able to jump in line like it needs care and support and some time and some self compassion and some grace, right? It needs all of those things. And having some support as you go through it can be helpful, because if you maybe have been restricting, and then you decide that you want to incorporate more food, like if you have a little GI upset, it doesn't mean that the food you added is off limits forever. It doesn't mean you did it wrong, I hear that often, like I did it wrong. Not necessarily, there may have been maybe a slower route but you know, it just takes time, so it's great that you brought that up.

Beth Rosen: Yeah. And the other piece about that is that, you know, if you try something and it doesn't sit well with you and you're not digesting it well, it doesn't feel good. You can take it back out of your diet and try it again in a month or two. Because by that time, maybe you guts done a little bit more healing. And you can do that with every food. And I use myself as an example all the time, when I did the low FODMAP diet back in 2012 I had so many trigger foods. And now I have two, you know, and there's one of them that I definitely won't go near. But you know, the other one if it happens, it happens, I know it's temporary. It depends on what your symptoms are and if they're constantly the same, like I say to my clients, like yes, you can be lactose intolerant. If you have milk, expect lots of gas, maybe diarrhea or constipation, it's temporary. You know there are things you can do not to do that, there are things you can do to take care of your body so you don't feel like that, but if it happens, you're not causing harm. It didn't do any damage. It's temporary.

Erin Judge: Which goes from the food fear to just knowledge right and understanding of your body and when you have that power of knowledge you get to make your choice of well I know if I eat dairy, this is what happens. Or if I eat lactose, this is what happens. And I can choose either not to have it because I don't have those symptoms, or I can choose to have it and take care of myself through the symptoms, you know, it's like having the power of choice versus being controlled by the fear and choosing well I can't have anything because who knows what will happen is so important, which you get through the process. And then it changes, the continual process with your body, which is so great. And I think that's one of the beauties of the intersection of like intuitive eating, and that approach with IBS and with digestive disorder management is that connection to the food and kind of keeping doors open, I’d love for you to talk about that because I know that's a tool that you use in your practice, and just how you kind of intercept that. And in particular, like, whenever you're using something like the low FODMAP diet, you know, how do you put all of these things together? Because there is restriction. So, you know, how does that fit together for this specific population?

Beth Rosen: Yeah, so just as a quick overview, what Intuitive Eating is, it's basically eating according to how your body signals you, it's how you ate as a newborn. And if you've ever watched a baby eat, when they're hungry, they cry, and that's their signal to tell you to feed them. And when they're full, they turn their heads, they fall asleep, right? If you've ever fed a toddler, and they're done eating, they will spit food at you, they'll throw food at you, like they’re listening to their bodies, right. And for many people diet culture comes in, right, whether it's family rules with clearing your plate, you know, cleaning your plate or not being allowed to eat certain things, because of diet rules in the house, that signal gets tamped down and we don't hear it anymore. Now we're listening to oh, eat at this time, don't eat at that time. Eat this, don't eat that, right, all these rules started getting away, we don't listen to it anymore. So Intuitive Eating is coming back to listening to those signals and the authors and I believe you've met one or two of them, what they say is that it's really about interoceptive awareness, it's about this congruency between what the body's telling you it needs and what you're giving it. Right.

So when you're talking about working with somebody with a low FODMAP diet and intuitive eating and allowing them to make choices about their bodies, I explain the diet to them, I show it to them, I show how they can have food from every single food category, including fun foods, including alcohol, safely without having fermentable carbohydrates, which is what FODMAPs are, and give their body a chance to heal and rest from fermentation that might have been causing unrest in their gut, right? So will somebody say oh, but I really love this? Yeah, so have it. But if you're still having symptoms, we won't know if the diet worked or didn't work if we can't get like two weeks of you're not doing this. I will only do this with folks that I know do not have an eating disorder or disordered eating, those folks, we need to treat the eating disorder and manage the GI symptoms. We cannot treat the GI symptoms at that time, certainly not with diet.

Erin Judge: Yeah, let's talk about that, because that's something that is a big one. We know right research is coming out, there's a lot of information coming out of the overlap of eating disorders and GI conditions, especially with IBS, we're seeing it too closely marry, and we probably know why, right? We just talked about a lot of the reasons why that can happen. But with someone who has a diagnosed eating disorder, and they're also dealing with these GI symptoms, why is it so important that they treat the eating disorder first? And what does that look like before they start addressing the GI component of it?

Beth Rosen: So there are a number of different eating disorders, a number of different diagnoses, and they all are treated differently depending on the diagnosis, it's important to have somebody get to what's called nutrition rehabilitation, where they've gotten to a point where they're eating enough for their bodies, where they're eating at a place where they're not participating in what are called compensatory behaviors, or eating disorder behaviors. Again, not going to name them because that could trigger someone but you could look that up if you want, but so you have to heal that part. In many of these cases, when the eating disorder is in recovery, the GI symptoms go away. Because eating disorders are causing the GI symptoms, right, whether it's restriction, whether it's purging, whether it's binge eating, these things can wreak havoc on the GI system. So once we remedy those, enough for people to heal, then we see if the GI issues go away.

There are instances where the eating disorders lived for a while and brought on the GI issue and then the eating disorder gets healed, but the GI issue lives independently of the eating disorder. And in that case, then we treat the GI issue, but we also need to respect the fact that this person who's coming to us has a history of eating disorder. So if they do, the low FODMAP diet is not the right tool to use for somebody who's been an eating disorder recovery or doing that work, because it can feel restrictive, because there is eat this not that in there. So in that case, that may not be the first tool you would use, there are other options within that tool. There's the FODMAP gentle diet, there's Patsy Catsos term which is cherry picking, right? So I'm just pulling out a couple of things without really letting the patient know that these are high FODMAP and just saying, let's see, if we were to you know, substitute your asparagus for broccoli, how you might feel right and not necessarily say asparagus is a quote unquote bad food and broccoli is a quote unquote, good food. Right. So that we don't want to get back into categorizing foods or vilifying any of that.

Erin Judge: Yeah, absolutely. I think, even without the presence of a diagnosed eating disorder, like we can't vilify foods, especially when we're using this therapeutic approach, right? I think the thought of diet because you mentioned the beginning, like you're anti diet, we use the low FODMAP diet, which probably should be called maybe, I think some people call it the low FODMAP Protocol.

Beth Rosen: I call it a dietary intervention, as dietitians we do dietary interventions, most of the things I do where I change people's food is not for thinness, it's not for weight loss pursuit. A diet is to make a body smaller, but a dietary intervention is to make the body well. Right. And wellness is not synonymous with weight. So you could be at a higher weight, or you could be at a lower weight, and you could still be not well, and even higher weight, lower weight and be well, right. So it's not based on weight. And I think that's the piece that comes in is that the low FODMAP is not meant to cause weight loss and if it does, then you shouldn't be on it, it’s not supposed to do that. There's plenty of food to eat on there that are totally safe in all the food groups and in the fun foods that you can go total variety from that diet.

Erin Judge: Yeah, absolutely.

Beth Rosen: I’m not saying it's a piece of cake, cuz it's not. I'm not saying it's easy, because there are some things that culturally when you pull them out, make cooking for some really difficult, but there are some substitutions. And you know, but I'm not gonna say that I would ever praise diet culture, but if there comes a time where diet culture co-ops a low FODMAP diet, our supermarket shelves will be filled with low FODMAP food, and restaurants will have menus and you know, we'll have more options. It's like when diet culture co-opted the gluten free diet and we have full aisles for people with celiac disease now.

Erin Judge: Yeah, that was a benefit! I don't know if they will come up to low FODMAP, maybe! I think the whole anti bloat movement is interesting, so we'll see. But it's not a sexy diet from that perspective, right? Because you're not cutting out full groups and whenever it's done correctly, there is variety. And I think something too, that people forget with low FODMAP and I call myself a FODMAP rebel, which is, I know that the creators of the diet would probably roll over and not be too happy about it, but you know, flexibility, like the low FODMAP diet is all about reducing load, right? It's reducing load, finding personal tolerance, and we do that through structure, which includes pretty strict elimination. And when you look at the research, it is scientific, where, you know, we look at how much FODMAPs are located, we bring them all down. But in reality, like when you're actually going into it, like there's flexibility. And if you were just handed a piece of paper that told you, okay, take out these foods, or maybe you downloaded an app, and you're like, all I can do is stick to these specific portions, like there's more flexibility than that for a lot of people and that's why the low FODMAP gentle, which is what Beth mentioned, you know, as the practitioner we might notice, like, oh, you're eating one thing that's very, very high, and you're eating it often, what if we swap that out, you might feel a lot better. And you could do that on your own, you know, if you're looking through the app or looking through a list, if you don't eat most of the foods on that list anyways, like, we can get so caught up in how we can't have it or it needs to be restricted, when in reality there is so much flexibility.

Beth Rosen: And that's why it's important to look at each client as an individual because if you do a food recall and you ask them what they've been eating, and they're not eating anything that you see is high FODMAP then foods probably not the issue. But if they're not eating enough food, that may be the issue. Right? So then it wouldn't be okay, let me bring restriction into this person's life. And they're already, it looks like they're afraid of food because they're not eating that much, right and let's see what we can add back. And maybe if we decided to add back up low FODMAP foods first, and they won't know that, but that's sort of where you start. So like I said, at the beginning, the low FODMAP diet is a tool and it's not for everyone and while the app is a great resource, it's not substitute for the education by a dietitian, because otherwise you're just looking at a bunch of traffic lights, and you don't know, you know, how to really implant it.

Erin Judge: Yeah, we need to change the traffic lights to teach that too much like red is not bad, right? Yeah, I think a lot of a lot of us feel that way, but it is such a valuable tool. And, you know, one thing that we see happen, and I'm kind of going a little bit of a rabbit trail here, because I think a lot of people listening probably experienced this where one, if you if you're coming in and you're listening, and you do have an eating disorder, or you'd have a past eating disorder, and now you're navigating this GI side, like get support from people who have those overlapping specialties like Beth, we have a member on our team, I personally do not work with eating disorders. It's not my specialty. it's not my train, I hired someone who does, because I knew better because it's so important, but also like the overlapping therapies, right? Of having an eating disorder trained therapist and making sure that your doctor, you know, your professionals are in line and also communicating to each other. If you bring on a GI like, you know, make sure that all of that is coordinated, because you deserve that quality of care. And I always like to say, you know, for those who are dealing with any chronic illness, but especially, you know, eating disorder on top of that, like, it can be a bit overwhelming alone and like it's not fair, and you know, all of those pieces, like, it might not be perfect all the time but having people on your team is worth it. You deserve it.

But for those who are coming in that are hearing this and maybe thinking, okay, well, I see myself now restricting, right? I see myself in this place where I fear food, and I am scared to eat, or I've noticed that I've cut a lot of foods out and I've no idea where to begin. Besides meeting with the dietician, just how they start challenging those thoughts, right? Because we know that there is some of a shifting, mindset might not be the right word here, but there's a belief that okay, food is causing my symptoms, the belief that, okay, low FODMAP diet has to be, you know, this perfect piece of paper that I was told, or, you know, if I don't feel well, I can't eat anything, I need to skip. So there's this frame of thought, because of experiences and even what we're told. So how do we go from this to having the belief that no, I can incorporate food? Or it is possible to build my diet up? You know, what I mean? Like, do you have any tools for that, or anything you would say if people are listening, and that's what they're experiencing?

Beth Rosen: I think support is the big piece there. I think it's it's knowledgeable support. So, you know, podcasts like this, blogs like Kate Scarlata’s blog, where you're going to get the real information, and you know, where you're going to get what's most up to date and not just a list of food from 2015, which is so out of date, because it's changed, right? I do think, unfortunately, that these folks do have to advocate for themselves to create that team. You talked about the dietician, the GI doc, the therapist, their PCP to really collaborate care. Unfortunately, our health care system does work in silos so it's up to the patient to create that. But you know, that's I think where the trouble lies is getting someone who starts with a little bit of food, fear, not to have them advanced to an eating disorder. And unfortunately, that happens because a lot of people feel shame, and they don't want to share they're having these thoughts as they're doing certain behaviors. And shame only lives in secret and once it's spoken, it can't live anymore. So tell somebody you trust who can help you navigate getting help, and finding the right practitioners help you.

Erin Judge: That's awesome And that's so true! And then what happens if you do share, let's say you share with your GI doctor and maybe they don't really hear it or you share with your dietitian, and they don't really hear it and they still are recommending restriction and it's feeling triggering. So you are talking about it and you're feeling triggered, how would you advocate in those situations? Step one, find a new person.

Beth Rosen: Yes, find a new person. Step two, when you're looking for someone to talk to about it, make sure that they have the GI experience and the eating disorder experience, make sure that they understand what Intuitive Eating is, what Health at Every Size is, what weight inclusive care is and that will diminish harm when you go for help. And if you're not sure, there are some directories there's a directory for Intuitive Eating dietitians, the bulk of them will be part of the Health at Every Size or HAES community, look there. For GI dietitians, I mentioned her before, but Kate's Scarlata has a blog that she's vetted the dieticians, if you have a GI doctor, they can become part of a new community called GI on demand, where there are dietitians there who have been vetted, and there are GI psychologists there.

There's a number of different places that you can find people who are safe. There's also, if you think you have an eating disorder, you can go to any of the eating disorder treatment centers to find outpatient dietitians, they'll give you information or places like the National Eating Disorder Association has lists. So there's there's lists everywhere of folks that can help. That said, not every eating disorder dietitian is going to know about how to treat the GI stuff, nor will they all be HAES aligned or weight inclusive. So it's important to ask the questions about their practice philosophy and what their expertise is.

Erin Judge: Yeah, absolutely. And you can call ahead and ask those questions. Even when we're thinking about Gi, it's okay to say, hey, you know, what kind of approach are you going to take? Am I going to start low FODMAP Day one? To me, that's a big red flag, or, you know, are you are you just gonna focus on my weight, you know, you can ask those questions ahead of time before scheduling and that can be helpful. And the communities that you build are so important. And I'm so glad that you brought up the shame piece, because I think we talked about that with GI, right, where if you're pooping your pants, like there's no shame in that, right? People make joke about it, you may decide to joke about it and laugh about it at some time, but at the end of the day, like there's no shame in the symptoms that you're having, the pain that you're having. And so when you bring it up, you know, you are able to get answers and a lot of times, that's all it takes is just sharing and being honest and open. The same thing is true with some of these behaviors. I think, you know, I've heard it from some of our clients whenever they learn what some of these maladaptive behaviors are, and when maybe the behaviors came after the symptoms, there's a lot of shame tied too, well, you're saying I brought this on myself. So in addition to there's no shame, what would you say to the person who might also feel like, oh, that does that mean it's my fault? Because that can feel really lonely, too.

Beth Rosen: Yeah. So you don't cause an eating disorder. You don't cause a GI disorder. Eating disorders are mental health issues and can they be triggered by a GI disorder? Definitely. But they can also be triggered by something somebody said two years ago, they could be triggered by a trauma, you could have the gene for it and it's a genetic predisposition and it gets expressed, we don't really know all the different ways that people get eating disorders, but we do know, you don't cause them yourself. We know one of the leading causes of getting an eating disorder is dieting. So if you've been working on weight loss, you're at risk for an eating disorder. Right? So that piece is there. And of course, you didn't cause it by dieting, because we're taught to do that, it's part of our culture to make people smaller, you know, until enough of us sort of rise up and say, body diversity exists so we can live in the bodies, we were given kind of thing, it's gonna still be here.

As far as GI issues, you didn’t give that to yourself. Either it's a genetic predisposition, so they asked the family about their history. You know, it's interesting that I have GI issues and my mom has a GI issue, my grandmother has a GI issue and yet, my grandmother and mother didn't talk to me about it until I told them about mine because there was shame about, you know, all that was going on. And now it's like, I talk about it all the time. It's normal. I mean, if you're watching this, you could see all the poop pictures behind me like it's, we just make light of it. It's you know, everybody poops, it's a book. So, but so with GI issues, you're not going to cause them and if you have one, something like IBS, there is no cure for it. The low FODMAP diet is a tool for managing but there's no cure right now. If anybody tells you they've been cured, they haven't and they're not telling you the truth. So we know that flares are par for the course, with IBS. And so they're going to be times when you don't feel good and that's not your fault, but you will have tools that can help you manage and maybe lessen the duration or the intensity of the flare at the time, right? So these are not our fault. And guilt will lead to stress and stress can lead to worse outcomes, so better not to feel guilty over it.

Erin Judge: Absolutely. Get your toolkit, your support system, get the resources and, you know, put yourself….that's putting yourself first too, like taking care of yourself and truly, which is health, right and wellness, like truly taking care of your body where you are, and not ignoring things or shaming things about yourself so thank you for bringing that up! And thank you for sharing everything because you have such a great tools. And if anyone's listening and you want to connect with Beth, like, I'll have all of her information in the show notes so you can connect, because you work with clients one to one, right?

Beth Rosen: I do, yes.

Erin Judge: Awesome. So if you really align and that's a great way to find good providers, honestly, as if you come across someone, through a podcast, on Instagram, wherever it is, and you really align and vibe with them, like, reach out to them. Maybe you work with them, maybe you work with someone that they're connected to, but likely they're connected to the people that also are like that. And so that's a great way to really build that community and build that system. So thank you so much for your time, anything lasting you want to share before we close down today's episode?

Beth Rosen: Maybe everybody should just stop dieting and causing harm to their bodies in search of thinness, which doesn't actually bring us health and that might solve a little bit of the disordered eating battle that goes on. It's not your fault and there are people who are looking to help you who believe you and if you come across somebody who doesn't move on and find someone else!