Dr. Lisa Erlanger joins Opal’s Nutrition Director Julie Church, RDN to share the evidence and compassion that led her to evolve into a weight-inclusive physician. Lisa explains how the body is impacted by dieting (aka starvation) and emphasizes the importance of adequate nourishment as a strong focus of weight-inclusive health care practices within eating disorder treatment and beyond. She even gives some quick tips on how to help medical providers get out of their weight-centric trance and provide respectful medical care, regardless of body size. Wherever you are on your journey of weight-inclusivity, this is a must listen!
To find Lisa: Dr. Lisa Erlanger’s website
And to see what she is doing to advance education of medical practitioners go to:
Connect with Opal:
Thank you to our team…
Editing by David Bazzi
Music by Aaron Davidson: https://soundcloud.
Sound engineering by Ayesha Ubayatilaka at Jack Straw Studios
Transcription by Rev.com
Julie Church (00:07):
Hello and welcome to the Appetite, a podcast brought to you by Opal Food and Body Wisdom, an eating disorder treatment clinic in Seattle, Washington. This is a podcast about all things food, body movement and mental health. And I’m Julie Church Dietician and one of the co-founders of Opal as well as your host for today’s episode. And today I have a lovely guest with us that is much anticipated for me at least just straight up have a conversation with, I always love having conversations and learning from Lisa, and I anticipate you as listeners will want to listen to Lisa probably more than once to take in all of the things that she’ll share. So Lisa Erlanger, Dr. Lisa Erlanger is here with me and Lisa is trained as a family physician and currently still is a clinical professor at the University of Washington Medical School and is working as a physician for the Emily program here locally in the Puget Sound region.
(01:01):
Thanks for being here. Thank you for having me. I’m really excited. Yeah, so I would love for you to just start by sharing, I guess our path right to finding each other in the field was that Lisa was currently a physician at the University of Washington, like Hall Health, like student school health services and I was a local dietician and Lexi Giblin, one of the other co-founders was a therapist. And so the three of us shared some clients and was serving some of the local students and I think in our work together, trusted each other because of the health at size and weight inclusive lens. I know that in your practice that evolved over time even more so to be something that really you’re now known for and somebody that we lean into as an expert in that work. So can you share with our listeners how you got there and why it is that you practice as a doctor from a weight inclusive
Dr. Lisa Erlanger (01:58):
Lens? Yeah, I’ve been thinking a lot about that since I knew we were going to have this conversation. And I think it goes back to why I went into medicine in the first place. I grew up with a brother who was chronically ill and was cared for by family physicians at the university. And they were so important in our family’s life. And the reason they were is because they approached us holistically. They were my brother’s doctors, but they cared how I was doing and they cared how things were working for us in the family. They cared maybe the most important word. And I went into medicine because I wanted to make a difference in people’s lives by empowering them to live the life they want to live and they’re able to live within their current context. And empower, I think is a really important word.
(02:59):
And although I’ve worked in different places, I’ve always worked with people who are more marginalized within medicine and within society, and that can include being a woman or femme presenting in our society. But it also includes people with disabilities, immigrants, black and brown people living in redlined neighborhoods. And part of being the non-dominant person in our society is some disconnection from your body. You’re always being told your body is not right, it doesn’t fit the norm, it needs to change. And then when we encounter illness and disease, that trust is broken even more. I’ve always felt that my role as a doctor isn’t to be the expert over your body, over my patient’s body, but to advise you in working with your body and regaining whatever trust can be there and whatever control you can take away from society and to yourself. And I’ve not always done the best job of it, but it’s always been important to me not to take over control.
(04:14):
And in working with populations of people who lack control to some degree, even though I was still weight centric, both in my personal life and in my medical practice in that I still basically thought it was better to be dieting. I don’t even know if I thought it was better to be small, just like to be dieting and I was chronically dieting and I would offer advice about dieting to patients who asked. It was never a focus of my work because there’s so much else to get done in trying to live in this world in a body. And I already knew in the back of my mind that dieting is a chronic thing that never reaches its goal and there’s not time in a short medical visit, there’s not even time in a long medical visit to be spending a lot of time talking about something that is never really going to work. And
Julie Church (05:21):
I want to come back to why you believe that eventually because some listeners might be like, what do you mean? I think dieting could still work, but we’ll come back to that.
Dr. Lisa Erlanger (05:30):
So when I came to Hall Health, when we started working together, eating disorders were a bigger part of the practice, but also as emerging adults were living out in the world, they were coming to terms with traumas they may have experienced in the past. They were experiencing traumas in their current life or they were navigating big, even small health decisions on their own for the first time and dieting or trying to get smaller. It just never seemed like maybe where we should be spending our time. You’re making all these big decisions about how you’re going to approach your sexual relationships, how you’re going to take care of yourself, whether you’re going to use drugs and alcohol, talking with you about getting smaller just doesn’t seem like the place. But I think it was also where I first saw really the absurdity of helping some people learn to feed themselves adequately and nourish themselves the way they deserve to be nourished and telling other people not to nourish themselves. And it just began to seem so absurd and I enjoyed working with you all because reaching a societally accepted ideal body size was never on the table. It was always about nourishment and recovery no matter what. And so I began to teach myself about that and learn about that and learn that really was more important to eat regularly and satisfy oneself with nourishment than it was to conform to societal standards.
Julie Church (07:26):
And I love hearing how it woven your personal journey and how that then was working into the professional. As I know many of us can say that, right? We do seek probably some of our professional journeys to also continue to grow as people. So I can hear how that path has been true for you. And what, I guess I kind of referenced this when you mentioned dieting, but in the medical field it’s not as commonplace to have that attitude that weight isn’t the central part of a medical visit or the proxy for if somebody is healthy or unhealthy, that’s very different and countercultural. So how are you taking the data or the research or the more mainstream messaging around weight and health and how we hear from the main message that those things are connected and have what kind of main relationship together that’s very easy and simple. And how do you interpret the research or what even are you reading that would inform you to get to this place as a doctor?
Dr. Lisa Erlanger (08:34):
Those are lots of big questions.
Julie Church (08:37):
What are some of your favorite things to reference that kind of continue to help you feel like, yeah, I know not this in my own practice, my own life, in my own human relationships, but also from some of the data that backs up medical care. How do I continue to feel strong in this?
Dr. Lisa Erlanger (08:56):
Yeah. Well, I want to start with the experience that our patients and our acquaintances and our families and we have, there are certainly people who are able to manage their weight over long periods of time by watching what they eat and maybe holding themselves a few pounds below where they would naturally drift. But for those of us who have dieted to lose significant amounts of weight, it is commonly known that at some point we quote fall off the wagon and the weight comes back and we are taught to blame ourselves for that. And there are whole industries, I don’t know if I can mention any specifically.
Julie Church (09:48):
It’s fine
Dr. Lisa Erlanger (09:49):
For Weight Watchers for example, that are built on the idea that people will have to engage in this behavior over and over again. And so I think we all know at some level that if we are going to suppress our weight long term, we are going to have to repeatedly engage in this undernourishment and that it’s really hard and nobody can maintain it over a period of years.
Julie Church (10:24):
Would you say when I talk about that as like dieting fails, dieters don’t fail. The belief in there in the world is that the dieters are the people that fail. They need to just have better self-control and stick with it and that this is really something that’s can be accomplished versus when I look at the science and such, it’s like no, actually dieting fails dieters. We actually are succeeding in surviving as a species when we actually choose to nourish ourselves more than that particular diet’s telling us to do.
Dr. Lisa Erlanger (10:59):
Exactly. The body is brilliant. We aren’t failing. The body is brilliant. The body recognizes that there’s not enough nourishment coming in and that there’s still a lot of activity or perhaps increased activity. And it has a multitude of very brilliant intricate ways of making you more hungry, making fat and sugar more palatable, making it hard to stop eating once you start and generally encouraging you through a variety of metabolic and physiologic and psychological changes that happen because of hunger hormones to exert less energy. So then we feel lazy and out of control and we gain weight, which is exactly what the body wants us to do.
(11:52):
And so we won the diet lost, and it is really quite effective as a way to occupy people feeling that they have failed and that they need to continue not just to purchase products and purchase guidance, but work on themselves before they can succeed and go out in the world and live their lives. And it’s a way that we as women and black, indigenous and communities of color keep ourselves down, we’re hungry and cranky and think we failed. And it’s just not true. The science supports this. So the cycle of the body reclaiming nourishment and weight takes between two and 10 years. Most diet studies are shorter than two years for that reason. But when studies look out more than two years, we see that even when patients are able to maintain their diet intervention, they begin to regain the weight. And between five and 10 years, between 95 and 99% of people will regain at least the weight to where they started.
(13:17):
And as many as two thirds will overshoot that weight usually triggering another round of dieting. And we call that weight cycling. And the horrible part of it is that weight cycling and the metabolic physiologic and psychological harms from weight cycling actually account for most of the increased morbidity and mortality. So sickness and death that we usually blame on body size. If we look at long-term, huge population studies that have taught us perhaps that larger people are sicker and we reanalyze those for weight stability or whether people were weight cycling, the weight cycling or weight instability accounts for almost all of the increased morbidity and mortality that was attributed to BMI or body size in those studies controlled for body size. So at any particular body size, those studies show you’ll be healthier and live longer if your body weight stays roughly stable than if you lose and then regain weight. And this is really different from other medical conditions, for example, with cigarettes, which people often compare to body size
Julie Church (14:36):
In terms of it being a health risk, right?
Dr. Lisa Erlanger (14:38):
Yeah, a health risk and a behavior. And first of all, weight is not a behavior, but it’s often called one and treated like one. And food is not addictive, which is a whole another conversation we’ll have to
Julie Church (14:51):
Totally.
Dr. Lisa Erlanger (14:52):
But if you’re someone who smokes every cigarette less that you smoke improves your health, and if you stop smoking for a month and then start smoking again, you will still accrue some health benefit. That’s the same with blood pressure. It’s better to be on a blood pressure medicine for two years and then go off of it than to never have been on a blood pressure medicine. But weight doesn’t work that way because weight is a characteristic of a body that the body wants to protect. And so if we go on a diet under nourish ourselves, suppress our weight for a short period of time, and then regain the weight, we have actually caused metabolic and physiologic changes that harm health. It’s not like we’re temporarily healthier even though we might feel healthier, and we could certainly talk about why that might be.
Julie Church (15:45):
Or even getting a marker, you might get improvement in your blood pressure measures or some other biomarkers,
Dr. Lisa Erlanger (15:52):
Right? Absolutely. And that’s because we also have protective mechanisms for starvation, and if we are acutely starving, the body lowers blood pressure, so we’re not making as much effort there. It reduces inflammation, so we’re not wasting energy on our immune systems if we might starve to death before, we might get infected our insulin resistance and therefore our blood sugar drops, our cholesterol might drop. These are all short-term adaptations to under nourishment. We also get endorphins natural opioids that make us feel better because evolutionarily, if we’re going to starve to death, we might as well be numb to it. So it’s not uncommon for people to feel really good when they first start dieting, not to mention they’re doing something that’s very socially acceptable.
(16:43):
But over time, if a person remains undernourished, we actually see a reversal of some of those markers, whether they gain weight or not. So when patients admit to our programs with anorexia, for example, in a very suppressed weight, they often have a high cholesterol or insulin resistance and elevated markers of inflammation. And we certainly see that as people begin to regain weight after dieting, that blood pressure goes up, insulin resistance goes up, and that’s often blamed on the body size itself, but there’s better evidence that it’s the weight cycling as well as the stigma associated with regaining weight that has those effects.
Julie Church (17:29):
The weight cycling, that’s such a big component that it’s so easy to see how people be like, oh, well that’s somebody that’s in a larger size body, they’re always trying to lose weight. And so then of course the size of their body must be the problem, but it’s no, they’re just a chronic dieter that then that weight. And I like to simply say it puts a lot of stress on the body and stress that’s like a simple way. People are like, oh yeah, stress isn’t good for me, at least all the very complicated things that are going in all the various body systems. But it’s just think about that how much change the body is cycling through and all the different systems. It’s just stress
Dr. Lisa Erlanger (18:09):
And the body, once starved is making long-term adaptations to protect against future starvation and in a situation where the starvation is internal or external through food insecurity, once the body has been starved, it’s going to kick in mechanisms to protect against a future episode of starvation. And those don’t necessarily look like what we consider to be health, yet it’s very adaptive. And we know that most people who diet do diet again. And so again, it is rather elegant of the body to take that approach. It’s also completely understandable that people do diet repeatedly because being large in our society is considered bad. It’s considered unhealthy both in terms of associations with disease but also unhealthy in terms of how we think people should behave. We think people should be managing their weight and eating in a way that our society considers healthy and moving their bodies in ways, exercising in ways that people consider healthy. So simply walking around in a big body is seen by others as unhealthy. And one of the ways larger bodied people can engage care and approval from people around them, particularly healthcare providers, is by showing that they’re actively trying to reduce their body size. And I call that performative dieting,
(19:50):
And a lot of larger body people learn to do that the moment they walk into a healthcare provider’s office. I know I’m trying to lose the weight. This is my golden ticket so that you’ll give me the same kind of healthcare. You might give somebody smaller.
Julie Church (20:05):
Yeah, yeah. And some people stop going right too because they don’t have the energy to fake that or to have to bring in that kind of energy to then get the right that they should have and be deserved.
Dr. Lisa Erlanger (20:20):
Absolutely. It’s a huge problem and studies back up what we know anecdotally, which is that people often will try to lose weight before they see a healthcare provider or if they have gained weight, they don’t want to go back, or if the provider has told them to lose weight and they haven’t been able to, don’t want to go back or simply they’re just tired of everything focused on their weight, which is not safely or sustainably modifiable for most people. And one of the most rewarding, but also devastating parts of the practice I had doing primary care for people in larger bodies was meeting the people who hadn’t been to the doctor in years often after being given a diagnosis of an illness that might be considered weight related, and then they never went back for medical care
(21:25):
Even though there is no disease that occurs only in larger bodied people and not in smaller bodied people. So we know how to care for any illness in any body without weight loss. But what my patients would tell me is that once they were given a diagnosis or had a problem like knee pain that was blamed on their weight, the shame and the frustration and the stigma and sense of hopelessness of returning to the doctor kept them away until they heard that I was in a practice where I would see them regardless of whether they were actively trying to lose weight, and I wouldn’t ask them to change their weight. It’s just so devastating to have someone break into tears when I say, we don’t have to get your weight. I had like to just set weight aside. I don’t think it’s a measure of health or a good target for interventions that doesn’t feel like rocket science or breakthrough. It feels respectful and kind. And to be told right now, you’re the only doctor I know of who will say that. It doesn’t necessarily feel good. It makes me
Julie Church (22:57):
Sad. Yeah, I feel like too, your desire to be that for those patients, I’ve always felt that to be so authentic and true and you’re one human, so you can’t care for all the people or even reach all those people that are feeling that way or desiring that. And I know that you so deeply desire that, and the hope is that there’s going to be more trained up in the field of medicine to be able to care for clients and patients in that way.
Dr. Lisa Erlanger (23:27):
Well, that’s why I think the work you all do is so important because patients are demanding this change now. And more and more we’re learning that we’re entitled to see a healthcare provider and declined to be weighed and declined to be counseled about our weight and doctors are scrambling to catch up and to learn how to manage that.
Julie Church (23:59):
This is maybe in thinking about when somebody is actually getting care and they aren’t certain yet if their provider is going to treat them with the respect they deserve. Any tips or easy any tips or suggestions as to how they might get the care that they deserve though? I think just like things they could say to the physician or to the staff that then would allow for them if they have the energy to do so, to kind of come in there and be cared for respectfully.
Dr. Lisa Erlanger (24:32):
Yeah, that’s such a great question. And I really believe that most healthcare providers go into these professions because they want to truly help people. So mostly we’re trying to get people who want to help us to see how they can help us better than they were planning to. So it helps me to go in thinking of this person as a potential ally who doesn’t know yet that they can be my ally. And one of the things that I think makes a big difference is declining to be weighed. And I encourage people of all sizes to do this because it’s hard as a larger person who might feel self-conscious already walking into the office to be the first one to raise this at a particular clinic, but declining to be weighed makes a statement that you don’t consider weight to be a key part of your health.
(25:39):
And it also keeps that number from being front and center at the beginning of the visit. In my personal practice, I never weigh people on their way to the exam room because I think it sends a message that weight is the most important thing to know about you, and then it populates all these fields in the medical record and sometimes it’s in red showing on the screen and we can all see it. And I like to just set it aside. And then if I need a weight, I like to explain why and decide with the patient if it makes sense, but by declining to be weighed or at least declining to see the number that tells the group that you’re asking for something different. Other tricks I think that can be helpful is declining to change into a gown. If there’s not the right size asking to wait to have your blood pressure taken later in the visit, you’re feeling anxious about experiencing stigma, which can raise your blood pressure.
(26:48):
And because blood pressure is so commonly associated in our minds with body size, there’s a identity threat that goes with this idea that I might have high blood pressure today and that might be blamed on my body size. And so I think waiting on the blood pressure can make a big difference until if you’re comfortable with the provider, and again, all of this is hard, but if you’re able to say something like, I’m aware of the associations between body size and X, Y, and Z, and I’m really not here for body size or weight loss counseling, what would you do for someone who was in a smaller body who had this same condition or this same concern? And I think that can wake somebody up out of their weight centric trance say, oh, I do know how to do this, right? Well, if you were in a smaller body, I’d prescribe this medicine. Or if you were in a smaller body, I’d actually examine your knee and can help get that, and that’s great. Anyone who’s uncomfortable in the medical setting, I think bringing an advocate is really helpful and that person can be the one who says those things.
Julie Church (28:04):
Yeah, that’s great. One of the wonderings I have is the intersection of eating disorder treatment and then weight inclusive care. And I’m wondering if you would to try to speak into that because there is a time and a place, at least this is how we have handled it at Opal, is that there is a place where we will increase somebody’s weight intentionally, and there is never a time where we would restrict their food or eating or give some sort of prescription for them to lose weight. So there are times where a client sometimes might, especially a newer client that feels like, wait, is this weight inclusive care if you’re telling some people and leading some people to gain weight, but then never telling other people to lose weight. So just wonder how you would answer some of that or how that plays into the weight inclusive care in the eating disorder realm when there’s a variety of different shapes, body sizes.
Dr. Lisa Erlanger (29:05):
What a fascinating question. Well, I think we have to take a step back and ask what is weight inclusive care?
(29:13):
And you might hear this described with other phrases sometimes, for example, health at every size or weight neutral care, I’ve heard weight affirming care. I call it weight inclusive care because weight inclusive care does not mean that anybody can be healthy in any size body. It means that everybody has a right to access healthcare services and to pursue wellness regardless of their body size. It also recognizes that bodies come in a variety of shapes and sizes and levels of health. And that weight is not a modifiable aspect of a person, at least in safe, sustainable ways and should never be the target of health interventions or a measure of whether those interventions are being successful. I call it weight inclusive because it also acknowledges the stigma and bias and overt discrimination that people experience the larger their body is. And it attends to that stigma, it acknowledges it and recognizes the effect stigma has on health as well.
(30:43):
But we know that regardless of how big a person is, if they believe themselves to be too big, they experience stigma in a weight centric world. And so we can never know by looking at someone whether they feel they are the target of weight stigma, and often we’re the target of our own internalized stigma. So to me, that’s what weight inclusive means. And as I’ve practiced weight inclusive medicine, I’ve recognized that undernourishment is a real threat to the health of people across the weight spectrum. It’s extremely common in people the larger they get because dieting is so common, and as we diet more, our body can use less food. And so attention to nourishment becomes a big part of weight inclusive care and the understanding that the evidence shows that we can’t safely or sustainably suppress body weight long-term without developing, in most cases disordered eating or eating disorders. So while weight is not a measure of health in terms of having a graph that shows what the perfect BMI is, and I just plug your weight in and I can tell you what your, I’m sorry, plug your height in. I can tell you what your weight should be.
(32:13):
I can guess and really know that whatever you have weighed is at least what you need to weigh because bodies can’t undernourished for prolonged periods of time. I think the question of whether we should be weighing people regularly in eating disorder care is a really fascinating one. And I don’t know the answer because basically we, way, way, way, way, way, while we’re saying, don’t worry about your weight, what we’re really, we’re using it as a proxy for nourishment, but we know that weight in general is not a good proxy for anything. Totally. So setting that aside
Julie Church (32:58):
And the big asterisk that insurance companies always ask, and that’s the way that people access care. Most people access care, which is like a big cycle that we’re all a part of that we really don’t love being a part of, but
Dr. Lisa Erlanger (33:07):
Okay, exactly. And we know that people at the very least need to renourish themselves back to whatever baseline of nourishment they were, which may have been chronically undernourished.
(33:19):
And so weighing them, it is a reasonable proxy in this situation. But I think what the bigger question is is that so much of what drives eating disorders is not just a beauty ideal, it’s also a health ideal. And as medical professionals, we are responsible for a lot of the stigma linking weight and health and using health as a reason for people to get smaller. So it can really be a barrier to nourishing fully in eating disorder treatment. The fear of getting bigger, not just because I won’t meet beauty ideals, but because I either will be sick or I will be perceived as sick. And I don’t think we can help people do that while we are literally telling other people they need to be smaller because they look like someone who would be unwell. And that’s why that’s we’re not making bigger people smaller, and we’re not trying to make small people bigger. We’re just trying to get everybody to eat enough so they can go live their lives and be well in the way they want to be. Well,
Julie Church (34:43):
Yeah, I like that. And I think one of the things that I have usually said this, and correct me if you think this is any problems with this, but I think also is there is a point where the body could have, if lack of body mass on the frame, the human frame could potentially have consequences. So if the heart as a muscle does not have enough mass to pump blood through the system of the body, then there’s a concern there that then, oh, we have seen evidence to say increased body mass for the body and some of these organs and other parts of the body will lead to just sustainable health, just functioning like basic, vital functioning. And that’s evidence to say there’s ethics behind the weight gain process in somebody that is showing those kinds of signs of malnourishment or their body needs that, and there just isn’t the ethics on the other side of the spectrum of going, oh, okay, well this person is in this large size of body and there is a direct correlation to if I were to have them lose weight, then x, Y, or Z would actually improve.
Dr. Lisa Erlanger (35:53):
I think there’s so much in what you just said. So much so. Yes, exactly. So the correlations between high body weight and health at the extremes of both high and low body weight, we see increased morbidity and
Julie Church (36:13):
Mortality. Okay. Yeah. At that extreme. And what is extreme I think is always good to talk about too.
Dr. Lisa Erlanger (36:18):
Well, there’s a lot of misunderstanding about what is and isn’t unhealthy. And interestingly, I always assumed that what is considered a normal BMI is the BMI that has been research shown to have people live the longest or have the fewest diseases. That’s actually not even true. So for the average population, the lowest mortality occurs in what would be considered the overweight BMI and even higher for many populations. So for women, for black people, for older people, and for people living with chronic diseases like heart disease, diabetes, cancer, all of those people have lower mortality in actually higher BMI classes, at least into the lower range of what’s considered obese.
(37:16):
Then we have the question of above that is the body size or the fat cells causing disease? And research suggests that weight cycling and weight stigma account for the increased burden of disease that we do see at those higher BMIs better than the body size itself. But then the other question is, does intentionally making those people smaller improve their health? And if we look out five to 10 years in those studies, intentional weight loss does not predictably improve morbidity or mortality or disease status once you have a disease. So there’s that. Exactly. We have not shown that having people even at the highest end of the BMI spectrum, make their body smaller, makes them healthier. In fact, having them lose weight typically will cause weight cycling, which will make them less healthy. But there’s another piece too about what you were talking about the mass of vital organs and body size, because we often assume that only people in very small bodies have lost mass in their hearts or their kidneys or their brains. And it is true just like at the high end of the spectrum, that people at the very low end of the weight spectrum have markedly increased morbidity and mortality. In fact, below the normal BMI mortality and morbidity rise much faster than they do at the higher end of the spectrum.
(39:00):
But how much weight you’ve lost or the percentage of body weight lost predicts change in size of organs and physiologic signs of starvation better than actual BMI.
(39:19):
So we often look at very small people who are really struggling with eating adequately, and we think that they are the sickest people with eating disorders, but we can have a very large person who has lost a very large percent of their body weight, which we sometimes see after major weight loss interventions that then take on a life of their own, and they can have equal, if not worse, changes in their hearts and their brains and their physiological functions. So while it’s very, very important for very small people to regain weight so their brains and their hearts function, it can often be missed how important it is for a larger person to nutritionally rehabilitate, even if it means gaining weight or gaining more weight.
Julie Church (40:14):
Yes. Yeah. And that oftentimes it’s at least thank you. I mean, in eating disorder treatment, it feels like those individuals have a harder time believing that they truly are malnourished just because of all the societal beliefs of like, well, my body is this still this size, and according to the BMI still, and in this particular category that’s above the quote normal or above the obese or whatever. So how is that possible? And it is hard to then show those markers. I know there’s some ways to be able to show those the same medical chemical lab tests that could show that for somebody in a smaller size body can show malnourishment in a larger size body. Those don’t discriminate in that way. Are there specific lab values that you would be speaking to?
Dr. Lisa Erlanger (40:55):
Yeah, that’s a great question. And as you said, I think it can be really hard and really confusing for someone who is starving in a larger size body because they might be getting messages from the insurance company that you’re not starving, you’re too big, or from their various physicians or healthcare providers or family members, I don’t know, your eating disorder providers really off their rocker. You need to be eating less, not more. So it can be even harder because I think there is a collective understanding that when someone gets too small, they need to gain weight. But in that way, I think it’s even more synchronous to be approaching everybody this way, which is that we’re not making small people bigger until they reach the point that we have to make them smaller,
Julie Church (41:43):
Right? Yes.
Dr. Lisa Erlanger (41:44):
Everybody needs to be nourishing themselves adequately.
(41:50):
One of the insidious things about Undernourishment profound weight loss is that we can’t always measure something measurable to tell us that there’s something wrong, but we know that bodies do show the same things in people of all sizes when they’re starving, and that in larger bodied people, those findings can be misinterpreted as weight related illness. So I’m thinking of a few things that you’re probably thinking of as well. So we might see electrolyte abnormalities, blood salt abnormalities, so low potassium, low phosphorus, low magnesium or nutrient deficiencies like low zinc. When we see those in a small person who we know is actively dieting, we say, that’s because you’re not eating enough. Happens the same in larger body people who aren’t eating enough. But you’ll often see under a list of reasons people might get low phosphorus obesity as a cause without any research looking at how often larger people are actually dieting. And that chronic dieting that goes too far causes low phosphorus.
(43:02):
The other thing we see is people losing periods, and I often see larger body people come into treatment carrying a diagnosis, say of PCOS because they were larger and they weren’t menstruating or having irregular periods. And the association is made that they have PCOS, and then that is often treated with weight loss and weight centric healthcare, which worsens the undernourishment. But if we actually do the hormonal tests and we test their estrogen and we test the stimulatory hormones for their ovaries, we see that actually everything is shut down, almost like they’re in menopause. And that’s actually what
Julie Church (43:42):
Restoration response,
Dr. Lisa Erlanger (43:42):
Right? Hypothalamic amenorrhea starvation. But if we look at a smaller person and we see they’re not menstruating, we immediately think, oh, I wonder if they’re exercising too much or eating too little.
Julie Church (43:55):
Yeah. Yeah. Man, I am so aware that there’s several research articles and graphs I can envision that come from these that we’ll definitely put in the show notes so that you all can reference those. Most of them are publications that are pretty complicated, and you can still get tons of great information and support for what Dr. Erlanger is speaking about here. And I guess when we started by saying, okay, what brought you to this? How do you practice? Or why do you practice this way? I think hopefully you as listeners can hear so much of the mind, the smarts and the intellect that Lisa’s using in combination to the heart and that piece. And sadly, in the world of this, we have to prove it with the intellect and some of the backing of the research to have people believe it. And sometimes those are people that are victim to this discrimination and some that are just so weight focused practitioners that don’t believe in this. But I hope that you could hear that both of the things that help the doubters, and also I hope too, to hear that heart of just this care that drove you from being a sister to your sibling and to care for people, and how you desire to do that now in a way that will truly reach and care for all people in all bodies. Lisa,
Dr. Lisa Erlanger (45:32):
Well, thank you. And I’m glad that that comes through. And I also like that you raised this question of evidence because I’m ambivalent sometimes about talking about the evidence because what if a paper came out that showed,
(45:53):
What if, it was established that fat cells do cause disease, and that if you’re able to lose weight, it makes you healthier? That would not change that people of all sizes deserve compassionate, ethical evidence-based care that they have control over, and we would still have a right to go to the doctor and not be weighed and to go to the doctor and asked to not be lectured about our body size. Totally. Right. And fundamentally, that right is inherent to a person regardless of their body size. And it just so happens that I believe the research a hundred percent supports this approach over a weight centric approach. And I know we’re going to get to talking about weight loss drugs, but the reason those are so exciting to people is that there’s become a general idea that dieting doesn’t work. All these companies that were trying to sell us dieting all those years and then telling us it was our fault when it didn’t work, now they’re saying dieting doesn’t work and trying to sell us something else. So I think it is important to look at the evidence while holding that bodies come in different sizes, and every single person deserves compassionate care.
Julie Church (47:19):
Yeah. Thank you. Totally. Well, Lisa gave you a little teaser there, and I do hope to have another episode with Dr. Lisa Erlanger talking about weight loss medications in this current era. But for now, thank you for being with us and for hopefully stimulating all of our hearts and minds in this time. If you as a listener want to learn more about Opal Food Body Wisdom, check out our website or follow us on Instagram. And thank you to David Bazzi for editing Jack Straw Cultural Center for Sound Engineering. And Aaron Davidson for the Appetite’s Original Music. See you next time.
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