166 | Think You Can Spot an Eating Disorder?

The person with a spoon in their throat is telling me they don't have an eating disorder anymore because no one told them they were underweight.

Welcome back to the Exam Room Nutrition Podcast. I'm your host, Colleen Sloan. I'm a PA and dietitian, and I have a question for you. But I need you to be totally honest with your answer. When you picture a patient with an eating disorder, who comes to mind? If it's a frail, underweight teenage girl, you're definitely not alone. Because honestly, that's the picture many of us were taught in medical training. But that stereotype can cause us to completely miss the patient sitting right in front of us who might be struggling. Today I'm talking with Jessica Setnik, a dietitian, writer, speaker, and eating disorder expert who you may know from the Eating Disorders Clinical Pocket Guide or her Eating Disorders Boot Camp Training for Healthcare Professionals. And Jessica shares a totally different way to think about sweets and treats. And one of my favorite takeaways was that if we want kids to have a healthy relationship with food, sometimes the adults in the room need to manage our own food anxiety first. This episode is honestly gold. I'm going to be re-listening to it because it challenged me, gave me language I can use with my patients, and I think it's going to make you look at eating disorders and honestly pediatric nutrition a whole lot differently. So grab your coffee or drive safe and enjoy my conversation with Jessica. All right. Well, Jessica, I'm so excited to have this conversation with you. Thank you for the gift of your time. Welcome to the podcast.

Thank you. Glad to be here.

So I remember when I was in school and we learned about eating disorders, and I'm sure my listeners can totally connect with this. The picture was painted of an adolescent, uh frail, malnourished, usually a gymnast or ballerina. And like that is the picture we have stamped in our head. So I'm curious from your perspective, can someone living in a larger body who appears to be eating normally or have stable lab results still be experiencing an eating disorder?

Yes, 100%. And that stereotype is so bad that it actually has a name. It's the swag stereotype, the skinny white adolescent girl. And it has been completely disproven. But unfortunately, it's what the eating disorder field is totally based on. And so those stereotypes really persist. But actually, it turns out that's less than 10% of people with eating disorders. And yet that's the avatar, that's the image in our mind that we have. But lab values don't get abnormal until someone is extremely unwell thanks to homeostasis. And weight tells you nothing about an eating disorder except for weight change. Weight loss can be very hard on the body, right? And actually, the research shows that individuals who are in larger bodies are more at risk of eating disorders because they're more bombarded with the message to restrict their eating and their cardiac complications are just as bad or worse as someone who is underweight. And so we really have to change our entire mindset about what we think eating disorders are. So I actually prefer the word dysfunctional or disruptive eating because it just takes the conversation off that sort of tunnel vision that people get when we say eating disorders, you think of this very specific image.

And it it stems from training. I'm I'm on PA faculty and I actually asked a lot of my students, can someone in a larger body have an eating disorder? And it it wasn't even like a 50-50. Like majority of them were like, no, because they're in a larger body. So they have this misunderstanding like right from the start. I feel like we're a family feud and I want to go, eh. I know. I know. That's why I wanted to start with that topic to make sure like we are all on the same page. That body size does not equate, like you had said, dysfunctional eating. I really like that terminology. Okay, I want to talk a little bit about early feeding experiences. And you've talked about this a lot and how it can influence our relationship with food for our entire lives. So I'm curious what messages or feeding dynamics tend to stay with people into adulthood.

So there's two major categories, and they both deal with parent kind of feeding practices. And I want to just clarify that we are not, I am not ever blaming parents. I think that most parents, many parents, caregivers who aren't parents intend to help their child, are trying to raise a child with love, are trying to protect a child with things that they weren't able to have in their own life and sometimes intergenerational trauma. But the things that parents do that I think can be the most harmful that stick with people for their whole life is either restricting food, saying that you can't have that, punishing someone because they ate something, telling them they ate too much, or forcing someone to sit at the table until they eat. So it's kind of the two sides of the coin, but it's the feeling that people remember, even if they don't remember exactly what happened. They remember being coerced or shamed related to food, and that feeling sticks longer even than the memory. The other thing that sticks through adulthood is food insecurity, which is no one's fault. Well, it's it's sort of shocking to say that it's 2026 and there are still children in this country who don't have enough to eat. So there's a system-wide fault. But the idea of not having enough as a child creates a drama inside that causes someone to have that feeling, that fear of not having enough to eat lifelong, even if they are, you know, as financially successful as a CEO and could get whatever they want. They're still eating sometimes from that point of, I didn't have enough. And that's how their sort of relationship with food was formed. And you can't just undo that without some conscious work.

I feel like this is such a tricky tension to navigate, especially if we are working with a child in a larger body who we do want to encourage and promote and support, quote, healthier eating, while at the same time preventing them from having any of those disordered eating habits. You know, like you had said, if they're restricting them from certain foods, it's that perfect balance. And I hear parents tell me all the time, I just want my child to eat or to be healthy. And I firmly believe that no one wants their child to develop an eating disorder. No clinician wants that either. So let's dig into a little bit more about what are some of those like well-intended efforts to raise a healthy eater. Like we are all trying our best out here, but maybe they do create that anxiety, shame, or that preoccupation around food.

Well, so the first piece of this whole conversation has to be is there an issue with the eating? You are saying you see a child in a larger body, you want to help them with their eating. We have to interrupt that thought process right off the bat and say, I see a child in a larger body. How do you even know they're not eating healthy? Maybe they're eating perfectly healthy and this is their normal body type. Someone has to be the biggest kid in fourth grade. If this is the biggest kid in fourth grade, let's make sure they're a healthy, happy, confident biggest kid in fourth grade. So we we I have to draw your attention to the unconscious bias that's already in there. I see a larger child and I need to help them eat healthier. They may be eating fine. And that's where I think dietitians come in. And unfortunately, there is so much misconception out there that eating healthy is a DIY project. So I think that we don't think enough to refer to a dietitian and say, oh, we need to actually investigate is there an eating issue here or not. Instead, it's like bigger kid must not be eating right. Bigger kid must not be eating healthy. So that's the first step as far as well-intended efforts, is to try to determine based on someone's size that they are or are not a healthy eater because those things are independent. Weight is not a proxy for how someone is eating, even though it's so ingrained. And let me say that again because there's probably people who are like record scratch, right? But weight is not a proxy for how someone is eating. Weight is an unconscious bodily process like your heart rate, how much you breathe, how long your hair grows every month. Your weight is part of your normal growth and development until it's not. And so we need to err on the side of assuming that a child is eating appropriately until we have evidence that they're not. And the evidence cannot be their size. Their evidence has to be a change in the growth chart percentile. The evidence has to be a conversation about what they're eating, when they're eating, how they're eating, if they're using compensatory measures, if they're doing dysfunctional things with their food. So I just want my child to eat healthy is a really good goal. The goal then becomes how are they going to learn to eat healthy? By watching the people around them eat healthy. And so if a parent is restricting, if a parent is on a diet, if a parent is leaving the table to immediately go to the bathroom, let's say we won't assume what they're doing in the bathroom. If a parent is weighing themselves every day, these are the ways that a child learns to eat, not by the what is put in front of them, not by osmosis, but by observing. And so when we say negative things about our bodies, our children hear those things and interpret those things as something that either they will believe now or believe when they grow up or be worrying about all the time in between. So the well-intended efforts, I think, are a lot of our own distress and anxiety and fears about food. And so the very best thing that we adults could do to help kids is actually manage our own distress about our own eating, about weights and bodies and the distress that we feel in wanting our kids to be healthy. That health anxiety is on us. Kids aren't born with health anxiety. We put it on them. And so the solution is actually not in the kids or anything we do to the kids. The solution is actually in us.

So well said. And I actually support and agree with everything that you had said. Now, I frequently have will have parents mention to me that uh the patient is sneaking food or she's getting up in the middle of the night to bring in food, or parents are finding like candy wrappers and chip wrap wrappers hidden in their rooms. So I'm curious, how do we as the provider provide support? What can we do in the room with that patient and family?

So the first thing to say is do you notice this behavior in other situations? So do they also take toys and hide them under the bed? Do they also, do you also find empty wrappers of, I don't know what else, Pokemon cards? Like, is there a, is there a theme here that is more global than food? Right. If your child is anxious at meals, are they also anxious when they go to school? Are they also anxious around new friends? Right? Those are the kind of questions we want to first ask to find out if if it's only occurring with food or if that's just the only part of it that someone is bringing to the table. Because if it's more of a global issue, we may handle it in different ways than if it's just about food. The second thing is to say, is this a change? Has this been going on the child's entire life? Is this something where we might do an assessment for Praetor Willie, which would be a genetic test? Or is this something that has changed? And if it's changed, what else has changed in the environment when you noticed or before you noticed the change in the child's behavior? So those are the two most important things. Is it only related to food? And is it is it a change? Is it something new that you've noticed? And a lot of times what you'll find out is that something did change, whether it's someone in the family having a health event or going on a new kind of eating plan, um, whether it's the parents noticing that the child was bigger and starting to restrict their eating. Um, those are the kind of things that we want to turn around right away and make sure that a child is not feeling restricted in any way, because that always, always leads to overeating somewhere in their life. Um, then we want to look and find out if there's something that could be going on, like an anxiety issue, a depression issue, a problem with friends, depends on what the what the age is, but always looking at the environmental issues. In other words, thinking of the child as sort of, this is gonna sound silly maybe, but like a perfect being that there's nothing wrong with the child, but the child is responding to their environment. So what has gone on in the environment that could be causing this change? And to me, those are the most significant aspects to start with. I could keep going on and on, but those are the basics. Is it something that's global in other areas or just with food? Is it something that's new and what has changed in the environment since the time that it's been happening?

Along the same line, I'm curious how do you handle the topic of treats or like sweets with families? Cause I find this is always a big concern in families is like, do they have dessert? Do we offer it every night? And if we don't, now it's put up on a pedestal and then there can become obsession because there's restrictions. So how do you coach parents who are kind of navigating the sweets and the treats that should be part of life and celebration? Right.

Again, it's our food anxiety that we're putting onto our kids the idea that if we don't monitor their eating, they will automatically do the wrong thing. And I know that that's really important when you're talking about like crossing the street, right? We need to hold someone's hand. We don't want kids crossing the street because they don't have discernment. But when you think about who is bringing the food into the home or let's say even an outside event, it's the parents. Kids don't have a credit card, kids don't have a car. So, in other words, once you've chosen these foods are okay for my child to eat, I feel like it's then the child's choice what to eat and which order to eat it. So if a child's eating a rusty nail, at that point you intervene, right? But if something is food and you have already determined that this is an appropriate food, the idea that these foods only belong at this time is an issue. And it's very interesting because I was at a big family picnic and one of the children walked with me through the line. So I'm the aunt. So we got um, you know, chicken nuggets, corn. I was asking the child as we went through, do you want this? Do you want this? Do you want this? And because it's just funny to think about this, but I only I could reach all the food in the chafing dishes. We then get to the dessert portion, and the the dessert portion is right at child eye level. So I actually got another plate so we could put the desserts on there. I know some people would say, we'll take the food and we'll go eat it, and then we can go back for dessert. I'm lazy. I didn't want to have to go wait in the buffet line again just to get the desserts. So I got another paper plate. I let the child put the desserts on the plate. We carried them to the table. We're sitting and eating. And the first thing the child ate was a cupcake. And this is the kind of cupcake with blue frosting that, like, it's almost like that dye they put if you shoplift clothes or something and it'll get bursts all over you. Like, there's no hiding that this child is eating a blue cupcake because it's all over their fingers, all over their face. And another adult looked at me and said, Why do they get to eat their cupcake first? And the first thing that popped out of my mouth is they're sitting with a dietitian. We're just not that picky about it. We don't have that many rules. Yeah. You know, and I thought it's interesting that through another person's eyes, this is weird that the child's eating the cupcake first. But if I've already, let's say I'm using finger quotes, if I've already okayed all the food on the plates, why would I say you can't have this food? I was just like super calm. I just said they're with a dietitian and we just don't have that many rules, right? So that's what I'm talking about. Once you've already decided that this is a food that your child can eat, you really, I think it's really a problem to say that food is for this time, or this food is for this time, or this food is only after you eat this other thing. It makes it more alluring. It makes the other food seem less appealing. And those are the kind of value judgments that even nonverbal cues can give.

I want to play parent advocate, if that's a word, and tell you what I hear. And I'm sure you hear this all the time when I kind of give that type of food freedom of choice and their order in which that they eat something that you've already pre-approved. And I let them know, like, hey, if they want to eat the dessert, they can have the dessert first. Their pushback, a mom will always say to me, but then I'm concerned he or she is gonna get full on the dessert and not eat the meal. And I know what they're getting at. They're concerned they're not gonna get the nutrients found in the rest of the chicken, rice, and beans or whatever the meal actually was. So, how do you address that concern? Right.

So I have never seen a child become malnourished in that way. What I have observed instead is that a child will, let's say, I've seen this in my niece. She would reach over a brownie to get an apple when an apple is what appeals to her, right? And that's what we're trying to do. We're not trying to say, give your child a full plate of desserts and let them eat it. We're trying to say, give your child all the foods and don't put value judgments on them so that they are equally drawn to all of them or all of the ones that at least they like the taste of. If you restrict sweets and then you put out sweets, yes, the sweets are always what the child will go to first, if they even believe that they're allowed to eat them, because there's a lot of that that has to be kind of undone. The goal is that the child feels so free to eat what they're comfortable with that they do eat the dessert first because they're not worried about what you're saying or the look that you're going to give them. And then they go on and eat whatever else it is that they want. But the thing to me is a child that eats the dessert first is actually already showing you that they have been somewhat restrictive.

Yeah. Well, we could talk about this the whole time, but I have a lot of other topics I want to get to. In the top of the hour, you had mentioned that um other things, you know, might show up before weight changes and especially before abnormal abnormal lab values that we see. So, what are those some of those signs that might show up early? Right.

So it's it is uh developmentally stage appropriate, sort of different for different stages. Um, for a teen, it might be something like, I've decided that I want to eat a healthy lunch. A lot of times for teens, it's a very voluntary, conscious choice. I want to become vegetarian. And a lot of times, if the choice that a teen makes is something we consider healthy, we get excited and we say, Oh, this is great. Okay, let's go to the store and we'll buy all the vegan options or whatever. And we forget to say, oh, what brought this on? Because a lot of times a teen has the mistaken impression, although it's certainly out there in the world and you can see where they got it, that changing their eating, changing their exercise, changing their body, changing their weight, that those are things that will make their life better. They'll have more friends, the person they're attracted to will be attracted to them, et cetera, et cetera. So anytime a teen or even a younger child makes a conscious decision to change their eating, that is a sign right there. We have to look and say, what is going on? Oh, tell me more. Tell me more about wanting to be vegetarian. Let's find out. Was there a movie shown in health class? Is there a mistaken belief that is behind that? For a younger child, it might be less conscious. It might be a child eating less, it might be a child eating more, hiding food, those kind of things. We want to look for that behavior long before it shows up as a weight change or an abnormal lab value, because it may be something that has happened, an event, whether it's a community-wide tragedy or natural disaster that's caused stress. But in children and adults, some people respond to stress by eating more, some people respond to stress by eating less. But it's interesting when you see something like a natural disaster, or unfortunately, there are things that are very unnatural happening in the world. When you see on the news, they'll say, like, monitor your children for these things. Are they having trouble sleeping? Do they not want to leave your side when it's time to go to school? They mention all these things that could be a result of distress. Very rarely do I ever see is your child eating more or less? But a change in eating, even if it's unconscious, is a very specific sign that a child is under stress that even they may not have the words to describe. So any change in eating, conscious, unconscious, is the number one thing that we can look for. Now, there are things that we can look for before that, which is stressful events even before they impact a child's eating. But that's something that I don't think our culture is kind of ready to accept that when something stressful happens to a kid, we should already be alert for their essentially their pre-eating disorder. We should already be alert for their problem that hasn't even happened yet. But I wish we were. I wish we could say something stressful happened. I'm watching my kid for any signs of distress, for not wanting to do the things they enjoy for isolation, for sleeping problems, for bed wedding, for eating issues, but to even get further earlier in the situation where we're really looking at mental health, because once the eating symptoms have set in, that's a sign that the distress has been going on for quite some time.

Yeah, I want to linger here a little bit and provide some practical maybe scripts for a clinician, general pediatrician, PA, even a dietitian, but someone who is just talking about nutrition, we're doing a uh a well check. Yeah. What are good, maybe two or three screening questions that we can ask to maybe tease this out? Because this can be uncomfortable. You sometimes don't really know what to say or what to ask. So, what are some great questions for us? Okay.

So the the goal is to try to figure out what it is that the person might be secretive or embarrassed or shy about talking about. Because if you're not asking, people aren't telling. We know that. People only ask the questions they're directly asked. So again, a little bit age dependent, but the number one question you can ask is. Is I would sort of open the conversation and say something like, um, do you like to eat? Are you comfortable with your eating? Or do you have a favorite food depending on the age? Like for a little kid, you might say, Do you have a favorite food or do you have a favorite meal or something like that that just sort of opens the conversation? Like, now we're talking about food and eating. And then the next question would be, is there anything you eat when nobody else is around? Because that's when you're trying to find out, is there something secret that the child feels ashamed about eating or not eating? Um, in the case of depression, someone might say, Well, when no one else is around, I just don't, I don't feel motivated to eat. Um, on the other hand, it might be, well, you know, I do like to sneak sugar packets from Starbucks when we stop at Starbucks. You know, that's the kind of thing you're trying to ask is like, is there anything that's kind that you're sneaky about with food? I'm so curious. And if it's an older kid, you might even say, you know, say this during the time when a parent is not present in the room. If you take a few minutes with a patient without a parent present to say, is there anything about your eating you don't like to talk about with your parent present? Because you're really trying to get at the part that, and I I hate to say this because I wish my whole dream for the future is that no one is ever ashamed to talk about their eating, but you're really trying to not, you're trying to avoid that I know the right answer, and I'm trying to impress the person who is asking the question. And so that one question, what what's different about your eating when no one else is around, is really a way of finding out what someone is ashamed about. Now, it may be totally benign, whatever it is that they say. They may say, well, when no one else is around, I like to eat really stinky cheese that no one else in my family likes, and they all like complain about the smell, so I only eat it when no one else is around. And you're like, okay, no problem here, right? So I'm not saying there won't be a false positive, let's say. But if it's something like, well, I only eat blank when I'm blank, you want to find out more. Okay, so you only eat ice cream when you're at a friend's house. Tell me more about that. Well, at my house, they don't let me eat ice cream. Is there a reason? I mean, if you're lactose intolerant, we can solve it with lactate or, you know, lactose-free ice cream. But if it's more, you know, my parents say that's bad for me, then there's a different way you would address it. So it's it's that idea of what's different at different times, or when you're letting yourself be totally free about food, what's different about your eating?

Yeah. So if a if through that conversation we are realizing something might be going on, or maybe this patient, you know, we've got a good relationship with them and they do finally admit that they're struggling with food, their body image. What do we say in response? And then on the flip side, what reactions are like the worst that immediately shut that conversation down?

Well, okay, let's go with the right thing to say first, right? We'll end her with that. The right thing to say is, I'm so glad you shared that with me. Or thank you for telling me. That seems really important. And I find that a lot of providers will say when I'm doing a training, I don't ask these questions on purpose because I don't know what I will say if I get a positive response. Yes. And my answer is always the same. You ask about a ton of things that you don't know what you'll do. You say, How are you sleeping? And if someone says, Well, I hang upside down from the ceiling like a bat, what are you gonna say? Like you can't possibly think, premeditate all of the responses and all of your responses to those responses. It's not how it works. In the real world, saying, I'm really glad you told me that. You know, I'm not really sure what is the right solution to that, but I'm going to talk with my doctor colleague and I'm gonna call you back, or I'm gonna call your mom back, or right, or let's bring your mom in to talk about that a little bit, or you know, those are all okay. Like we're so used to the standardized test where if you're supposed to answer a question, you're like, I don't know the answer. Let me Google that, or you know, and and I'll report back next time I see you. Like, that is not an okay answer on a test, but it's totally a legitimate answer. So you have to ask the question, even if you don't know what someone's gonna say. Someone says, Well, every time I eat, I throw up. That's not the end of the interview, right? You just say, like, tell me more. Does it come up automatically, or is it something that you're forcing? Right? We we we have to trust in our ability to take something unexpected and ask supportive questions about it, or say, you know, this is a first for me. I haven't heard about this before. I think I need to gather some more information. Let me think. What other questions could I ask? Or what else can you tell me about this? So, really, it's just information gathering. So validating, making sure that you do not act like the person has done something wrong. Like, okay, so I just read this thing that said the biggest trauma in after a trauma is when you tell someone about the trauma and they dismiss you, disregard you, whatever, that you get traumatized again because now you're never gonna tell anyone else about it. And so it becomes really a problem. So if someone says to you, well, you know, sometimes after I eat, I go to the bathroom and I make myself throw up, and you say, Oh gosh, I'm really sorry that's happening. Can you tell me anything more about it? Is there a difference between the times you do throw up and you don't throw up and you treat it literally like any other symptom, as opposed to, ooh, that's bad, you really shouldn't do that. Just treat it like a symptom and just ask more questions, just like you would with any other symptom. So, as far as what the wrong things to say are, the wrong things to say are that's bad, don't do that, you're killing yourself, la la la la la. Anything where you think you can scare someone into not having a problem, that's never worked in the history of mankind, right? So anything that is unsupportive or makes it sound like this is someone making bad choices, those would be the things I would stay away from.

Now, how do we bridge the conversation? Uh, let's say if the child needs help telling their parents or bringing their parents into this. And I've had uh parents who are in disbelief and kind of also um discredited the patient's lived experience or what they're telling us is going on. So how do we as the clinician kind of act as the mediator and bridge that so the child can get support?

You are like I have to take a deep breath because I feel it in my chest. Like, what an uncomfortable situation, right? But the good news is you are the authority in the room. Period. Whether you feel competent to have this conversation or not, I am giving you the badge of authority. You are competent to have this conversation because what you're trying to do is is sort of like you don't ask a two-year-old, like, what do you want to wear? You say, Do you want this pants or this dress? Right. It's the same thing. You can say to a child something like, oh, that's really important for your mom and dad to know, or for your dad and dad to know, or for your grandparents to know. Do you want me to be present while you tell them, or would you prefer if I tell them while you're here? Those are the only two options, right? Is either you tell them and I'll be here to support you, or I'll tell them and you'll be here to pipe in if I say anything not quite right. And then if in the case you mentioned the parent is in disbelief, we have to really help the parent manage their distress so that it doesn't fling onto the child. So, in other words, we are, you know, that saying of like be the adult that the younger you needed you to be? It's sort of like that. You have to be the adult that this child needs you to be because they aren't able to have this kind of relationship with their parent. They are the parent is the authority in that relationship. So you have to come in as the ally for the child and say, you know, your child has let me know that um sometimes when they eat, they feel compelled to go to the bathroom and throw up. And I am hearing myself say that and thinking, wow, as a parent, my first instinct would be, why would you do that? And I wanted to validate that for you and also say this is a symptom of a different kind of issue. And so I'd like to see, have you ever noticed this? Is it something you've been worried about or is this new information to you? What questions do you have for me? And unfortunately, sometimes this is gonna take a little longer than maybe what we had budgeted for this appointment. So we may have to say, I'd like you to come back for another appointment as soon as possible, or I'm gonna have to leave, but I'm gonna bring in a nurse or social worker who can continue this conversation with you and your child so we can figure out next steps, right? Because you can't just leave right when you just opened that can of worms.

Really like how you don't just slap on a diagnosis, like this is what your child is experiencing, they have an eating disorder, and here's a referral. I really like how you actually pause and ask the parent their observations because it feels much less like I'm now accusing you of like you did this to your child, they're experiencing this, versus, hey, what have you noticed? You know, is this if this is new for you, like I'm also here to support you? I love that you use the word ally for the patient, but also this is usually big news for a parent. Like I said in the beginning, no parent wants this for their child. So I really like that approach that you take. Now, this is difficult too. Who or where do we refer this patient to? Let's say everyone is on board and we really want to get treatment. What are our next steps?

So, my suggestion is always, always, always look to a pediatric eating disorder dietitian because even if you're not sure if it's an eating disorder, that's what we eating disorder dietitians do. And you can explain that to a parent. This is a person who's really good at sifting apart. What is an emotional issue that needs to go to a therapist? What is a medical issue that needs to go to the PA or the doctor or a nurse practitioner? What is the nutrition issue that the dietitian can handle? We're excellent sifters of those things. And so that's always my first step. I know some people will say, I think you should go to a therapist first. My problem there is not that therapists aren't really good at what they do. They, unless they are specifically, and I mean very highly specifically trained in eating disorders, they do not have the medical knowledge to say, this is a malnutrition problem. This is not safe to be seen as an outpatient. Whereas a dietitian is trained in the medical aspects and knows what to look for, how to assess for dehydration, those kinds of things that could be a bigger issue. So to me, it's always an eating disorder dietitian. And I actually started an organization to make it easier to find eating disorder dietitians. And it's called the International Federation of Eating Disorder Dieticians. And we can put the website in the show notes, but you can always email and say, I have a patient in this area, this is what we need, or you can give that information to the family member so that they can contact and find out who is a good eating disorder dietitian in their area, either for in-person or for telehealth. But to me, that's always the number one. With that said, I will caveat that when you have a child who is showing signs of dehydration, you have someone who is actually fainting, having heart palpitations, someone who whose heart rate is lower than 40, someone whose blood glucose is low. Those are indications that this has been going on for a long time. Because remember, homeostasis. So by the time you're seeing those changes, that is an urgent care situation. And I would not take the time to refer someone to a dietitian that might happen in a week or two. That is a situation where you, as the medical provider, need to evaluate is this something you can handle in office? Is this something that needs an emergency department run? Or is this something where you are literally contacting eating disorder treatment centers to see if they have an open bed?

Yeah, that's really, really helpful. Now, my final question is actually kind of reflecting on what some of your patients have told you if they've reflected on some of the care they received and what they wished a provider had recognized or maybe asked sooner. And before you even answer this, one of my favorite episodes that I've done on the podcast, I've done 160 episodes. I interviewed a young, I think she was like 20-something, young woman for her perspective of her eating disorder journey. She's now been in recovery for a couple of years. And that's episode 41 called Silent Battles: The Secret Struggle of Eating Disorders. So after this episode, go check out that episode to really get a personalized look at kind of the care on the other side of the exam room and what it looks like to be a patient. But Jessica, I would love to hear what if some of your patients told you when they reflect on their story that maybe could have changed their outcome.

Gosh, I would say almost everything is weight related. Well, they say my weight is fine, so I must not have a problem. And I am specifically thinking about a patient who had a spoon lodged in her esophagus. She was using, yeah, she was using a spoon, a baby feeding spoon to throw up. And she said, I think I have a spoon lodged in my esophagus. And I said, What do you mean you think? And she said, Well, it fell down there while I was purging, and now I can feel it when it comes back up. And I said, You have to go to the emergency room right now. And she said, Oh, I've already been. And I said, And what happened? She said, Well, the doctor said, kids swallow marbles all the time. It will probably pass. I said, Does this person know what a spoon is? And she said, Yeah, I always carry an extra one in my purse. And she held it up and she showed me and she said, I showed the doctor. And the doctor said, Well, I don't see it on the x-ray. And I said, Okay, well, we have to figure out what to do about this. And I'm dialing the phone number for the primary care doctor in session. And me, while I'm doing that, the patient says, And by the way, I don't think I have an eating disorder anymore because they weighed me at the emergency room and they didn't say anything. And I thought, this is like the strongest cognitive dissonance I've ever experienced in my life. The person with a spoon in their throat is telling me they don't have an eating disorder anymore because no one told them they were underweight. It is so strong in our culture that if your weight is okay, you are okay. We have got to stop doing that. So that would be the number one thing. I think I've heard that from patients of every size, every shape. They've said, I know it's because my weight is finger quotes fine or finger quotes overweight. Nobody ever suspected I had an eating disorder. And people have suffered for years, sometimes decades because of it.

And I love that you shared that story. And thank you for sharing that. That was so eye-opening. I mean, you saw my face when you told me she's a spoon in her esophagus. But that's why I started the beginning of this conversation really unpacking body size and its relation to disordered eating and eating habits, because we are, it is so ingrained in our culture, our thinking, our medical training that if someone is of normal body weight or higher body weight, they cannot possibly have an eating disorder. So I'm so grateful that you shared that and that that I'm sad that that's been the experience of a lot of your patients because, like you had said, unfortunately, they've missed out on care probably for years. All right, Jessica, this has been an incredible conversation. Thank you so much for helping us navigate such a sensitive topic. I think it needs to be navigated, but it needs to be done with compassion, with humility, and just with understanding and, you know, and hope for the future because we can provide that for our patients. So I agree. People want to connect with you online, where can they find you?

Jessicasentnik.com is my umbrella website. That's where you can find out about my professional training courses, invite me to come speak at your event. Everything is there at jessicassetnick.com.

Awesome. I will definitely link down to that below. She would be an excellent speaker for any of our medical conferences. But thank you so much, Jessica, for your time today. I appreciate you being here. It's been great.

Thanks for bringing more light onto this.

And thank you guys for carving out some time for nutrition today. I will see you next week.