Dr. Sarah Roer Bendheim discusses her work with eating disorder patients. In this episode, Dr. Bendheim explains her path to studying psychology, treating eating disorders, counseling parents of children with eating disorders, and more.
“Eating Disorders” – with Dr. Sarah Roer Bendheim
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right, I’m here with Dr. Sarah Roer Bendheim to talk about eating disorders. Sarah, you’re a Ph.D. in psychology, that I know. Welcome, so happy to have you.
Dr. Bendheim: Thank you on much. Thanks for having me.
Dr. Fox: This has been great we’ve been circling this for a while. I know that you are, as you said to me, a “Healthful Woman” podcast pusher.
Dr. Bendheim: Yes, everybody who happens to run into me is like, “Oh, god, she’s gonna tell us some new “Healthful Woman” podcast fun fact and then send us the link.
Dr. Fox: Listen, I really appreciate that. I think it’s awesome. And, you know, we’ve been back and forth on so many things over the years and so many interesting topics and we’ve had a lot of great discussions. And I thought, you know, like, let’s talk about your specialty and what you do, and you know, and if it veers off to other stuff, great. So I’m really happy you’re on. Thanks for taking the time out of your busy schedule to talk to me and to our listeners. So thank you.
Dr. Bendheim: Thank you. Let’s do it.
Dr. Fox: Let’s do it. So first, just so everyone knows who you are, tell us a little bit about your background, sort of where you’re from, your education, how you came into doing what you’re doing today.
Dr. Bendheim: I’m originally from Seattle, Washington, not a native New Yorker.
Dr. Fox: That’s why we get along, by the way.
Dr. Bendheim: Exactly. It’s the out of towners, you know, don’t tell anybody.
Dr. Fox: Right, don’t tell anyone except who’s listening to this podcast.
Dr. Bendheim: Exactly, except anybody who’s listening to this podcast. We love you, New Yorkers. We’re not judging you. And I actually…the first time I ever came to New York was for college. But I always had an inkling that I wanted to do psychology. I had the opportunity to work for a summer at the Fred Hutchinson Cancer Research Center, which is a big cancer research center in Seattle. And they had a Ronald McDonald House where basically, parents, and families who have come from out of the world and the area to get cancer treatment, basically had a school for siblings. And they used to run a summer camp where we provided different types of regular camp activities, and also therapeutic support.
And that just kind of sent me into a really specific direction. Originally, I wanted to do pediatric oncology psychology in terms of providing families with support. And then when I started a Ph.D. in health psychology, which was at [inaudible 00:02:28], which was one of the few schools at the time that had a health program, they didn’t have oncology, they only had asthma and a few other health-related things. And so I kind of fell into the world of eating disorders when I met a lot of great mentors. So it veered track, but it’s been a very rewarding experience since I started.
Dr. Fox: And now you’re in private practice and you see patients in your office, correct?
Dr. Bendheim: Typically not, you know, COVID office is very loose. My office is a roaming office, depends who’s giving me their office. And my house, I do mostly private practice now. I work for a little bit in a school as well. But now I really just focus on private practice. And probably different times in my practice, sometimes it’s 100% eating disorders, but sometimes it could be 60% eating disorders and 40% just other related life circumstance stressors that people could use support with.
Dr. Fox: And when you entered your Ph.D. program thinking you’re going to go into psychology related to health and to cancer, how surprised were you to make that, sort of, turn into the world of eating disorders, because they’re very, very different, obviously?
Dr. Bendheim: Totally different. But I think the one thing that runs through them which is similar is the ability to hold the anxiety of life and death and a sense of urgency. And I think that that’s one of the things that stands out for eating disorders, which is the ability to engage with the reality that what we’re dealing with is really dangerous, but not be so paralyzed by it that we can’t help the people we’re working with. And I think in that sense, there was an intersection with pediatric oncology in that we were dealing with very intense things. You know, all mental health is intense, but these felt very weighty and intense and being able to engage with them like a deep, empathic, and sympathetic way. But also be able to see past it and not get overly bogged down in the fear of it.
Dr. Fox: I’m gonna jump to something pretty deep right now only because it just came to me. I mean, I prepare for these podcasts and, you know, we spoke before and I’ve been thinking about it. But it never really struck me until you just said that right now. That parallel between cancer which people think of as your, sort of, prototype medical-surgical illness that hits you, you know, like lightning from the sky, totally locked in horror. And, you know, one of the problems in society is that we treat people with mental health illness differently because there’s this idea of, well, maybe they’re somehow to blame, or maybe their parents are to blame, or maybe…you know, there’s all this, you know, that gets woven into it.
And so people who themselves are struggling with mental health conditions, or they have children who are struggling with it, one of the refrains that you frequently hear from them is, “Why don’t they just treat me like a cancer?” Or, “It’s not my fault, and just, you know, give me some sympathy, give me some empathy, give me some help, as opposed to judging me.” And that you shifted from one to the other so seamlessly, I think, speaks to the idea of how serious and how real these mental health conditions are.
Dr. Bendheim: I think it’s so true. You know, I actually have never had anybody ask me about the pivot from pediatric oncology, which I was so determined to do, to eating disorders in that framework. But I think it’s true. And oftentimes, you know, I tell parents or my clients who I’m working with, would you ever tell somebody, “Just work harder,” when they had a medical illness like cancer or diabetes? And it’s such a quick reframe that we just, kind of, throw around with mental illness, “Well, if you just engage, or you tried harder, or you thought about it differently.” And all those things are true, real coping skills that we can engage. But it doesn’t necessarily really validate the depth and intensity of an eating disorder or any mental illness in particular. And I think that that’s really true. And it kind of makes people feel bad.
I always tell parents when I’m working with parents…a lot of times I work with parents, sometimes doing parenting and sometimes when you have any type of children, teenagers, young adults with eating disorders, there’s a lot of parenting work. And I think one piece I always try to remind parents is you’re doing a really good job even when you feel like you’re not. Because I think that there’s a lot of blame. And I think it’s easy to blame and sound like you have all the answers when you’re sitting in the chair of knowledge, you know. But like, when you’re actually in the weeds then I think it’s much harder. I probably wouldn’t have had that level of humility when I first started out because I didn’t have kids. And I think I appreciate the depth of parenting much more today than I ever did as a young psychologist.
Dr. Fox: Yeah, the depth and also the real scary part that there is so much that’s out of our control with our children. You know, we like to think that we can, you know, sort of, if we just do what we need to do, we’re gonna direct them into the right place in life and hopefully, that’s the case. But there’s so much that we don’t have control over and so much you just, you know, hope and pray that they turn out to be the healthy, adjusted, content, happy beings in this world. And it’s just amazing when it happens but when it doesn’t happen, it doesn’t mean the parents are to blame.
Dr. Bendheim: I think it’s really particularly difficult, especially in the world of psychology. And I know just, you know, specifically with eating disorders where we talk so much about modeling. You know, that kids pick up on everything that parents do but it’s just parenting psychology in general. And I think that it just…on the one hand, it’s important words to live by as people and parents that what we do is taken in by the people around us. But I also think it has the power to be very debilitating, very guilt-ridden. And reminding ourselves also that, like, there is a model of, like, good enough, good enough parenting, good enough feeding, good enough that, you know, kind of lets us take a deep breath and realize, like, everything that we’re doing is not going to make or break people, children, and ourselves. And I think that, like, that’s an important message which we probably don’t hear enough and probably don’t tell the people around us enough.
Dr. Fox: Yeah, I mean, there’s the overt problem, which is the actual blame where someone thinks that they are to blame for their mental illness or that of their children. Or someone thinks this person, you know, a different person is to blame for their, you know, troubles. That’s, sort of, the overt problem. But there’s also even just the subconscious, this idea…I remember reading an article once where the woman who wrote it…I think it was titled, like, “Where’s My Casserole?” where basically, it was this idea that if you’re a parent, and you have a kid who’s sick with some major illnesses, whether it’s diabetes, or it’s cancer, or they have severe Crohn’s disease, your friends are gonna flock to you, hopefully, and they’re gonna, “What can I do?” And they’re gonna bring over food, and they’re gonna bring over, you know, games for the kid, they’re gonna really, sort of, engage. But if you have a child who’s home struggling from depression, or anxiety, or an eating disorder, no one’s coming to your door with gifts and food, they’re basically just, like, avoiding. And that’s…
Dr. Bendheim: Yeah, they’re tiptoeing around you.
Dr. Fox: Yeah, it’s not overt, right, they would never say you’re to blame. But that’s the message you hear that you’re on your own, this is your problem, you know, too bad. And that’s a very difficult message for parents or people themselves who are suffering to feel.
Dr. Bendheim: And I think it goes to the heart of so many issues that everybody is dealing with now, which is trying to get things out from underneath the secrecy curtains, whatever we wanna call it. Like, just allowing people to realize like, “Oh, yeah, I had this,” or, “I was struggling with that.” Or, “This is what I did, this is who I spoke to, this is where I got help.” I mean, I think we’re getting there but I don’t necessarily think that we’re there yet. And I think that one of the things that’s interesting about eating disorders is that it’s not typically something you can hide, not always. You know, we know that some people are able to hide it but because it’s something that you wear on the outside, it’s something that people can see.
And so it begs an interesting question of people who have eating disorders, they want people to know because more often than not, they want help. But it makes people uncomfortable and so they tiptoe around it and people are whispering around it. Instead of, you know, asking, “How can I help you? What’s the best way that I can help you? What’s the best way that I can support you?” And I think part of it is that they also think that nobody notices. And so that just validates for them that they can keep engaging in the world the way that they are, and that people are approving of them instead of encouraging them to use a different mechanism and a different medium to be heard and see the world. And when they do that, they’ll still be heard and seen and given approval of.
Dr. Fox: Wow, that’s super insightful. So I wanna go into specifics of eating disorders, but also I was trying to think, when did we meet? I mean, you must have known my wife, you know Mithal [SP] before…
Dr. Bendheim: So I know Mithal…
Dr. Fox: …before me.
Dr. Bendheim: …Mithal and I worked together.
Dr. Fox: Right because of the whole…
Dr. Bendheim: Yes, Mithal and I worked together.
Dr. Fox: …psychology thing. And obviously, I mean, I know, you know, you’re from Seattle, but you married into a family from here. And you know, I know all your husband’s, you know, siblings and cousins, and second cousins…
Dr. Bendheim: Cousins and the whole…
Dr. Fox: …and everybody. Yeah…
Dr. Bendheim: …[crosstalk 00:11:28.671].
Dr. Fox: …there’s 1000 of them so I that I know. And so when did you meet Mithal, when did you meet my wife?
Dr. Bendheim: Mithal and I started working together when we were…she was in [inaudible 00:11:39] as a psychologist for many, many years. I popped in there and she was already working in the lowest core, so her and I got to work together. She was just really fun. She was just awesome, just gets kids and smart and insightful. I was in high school and she was in the preschool so our intersection wasn’t so much. But every now and then we tried to have these, like, collaborative psychologists meetings, and we’d probably, you know, kind of have meeting of minds on lots of various issues and personalities.
Dr. Fox: Yeah, because she would tell me about you. I mean, my wife, she’s been working with, you know, the school-age and preschool, you know, forever. And she’s always said that high school, she’s like, “Oh, my God, I would not wanna do that, that is like a totally different world.” I mean, because then you’re talking about eating disorders and, you know, depression, anxiety, so much, you know, and sex, body image, all these things that come up. And she’s like, “Oh, my god,” she’s like, “I’m with the little kids.” So she had a ton of respect for you and, obviously, you know, for Jerry and everyone who works in the high school there and all your colleagues. So okay, yeah.
Dr. Bendheim: She is fun. I got to work…I actually came into the high school teaching a Jewish sexual ethics class to the senior girls. And then it kind of expanded into, like, body image and healthy sexuality. And it was probably, like, one of the most interesting and fun thing that I got to do there. Because it was really just like, I enjoy teaching and I was able to get to really know the students in that class. And everybody had a lot to say and it was a great opportunity. So that’s how I actually ended up getting in the door at [inaudible 00:13:10] and then, kind of, took on more psychology-based hours.
But that was how I started there, kind of in the trenches and thinking…because one of the things that I always think about was that eating disorder programs are kind of awful. I mean, I hate to say that, but like, you know, schools love to like…you know how the schools do, like, “Oh, today, we had drug awareness day. And today, we had, you know, this awareness day.” And it’s all great and really important, but they do it with eating disorders and it’s like a disaster. But schools feel the need to do it.
I tell school counselors all the time and school psychologists all the time, this isn’t the way to go. But they feel like they have to in order to be responsible. But in reality, the best thing to be doing is to be working with high school students on positive self-esteem, positive self-image, positive body image. So like this was an opportunity for me to really be able to do that with high school kids over the course of a whole semester. From my end, it was really much more important and much more impactful.
Dr. Fox: Right, because you’re working on, sort of, some of the roots of it as opposed to the manifestations of it.
Dr. Bendheim: Yeah, you know, it’s kind of an interesting thing. High school psychologists will have done…for a while, it was very popular, and they had all these eating disorder programs. And then they’d call one of us psychologists and be like, “Our program was so successful. And you know how we know? Eight weeks later, we have a bunch of kids who we’ve identified as eating disorders.” I was like, “You weren’t successful, you just gave them a bunch of ideas.” Like, this actually didn’t work the way you thought this was going to work.
And so really just like encouraging people to think about it a little bit differently and just think about self-esteem, and self-awareness, and body awareness, and body image in, like, a really positive, healthy way. And to get kids talking about it, less about eating disorders and more about their identity and selves on a regular basis. Enabling and encouraging teachers and parents to weave it into the conversations on more of a daily basis instead of a one-off program.
Dr. Fox: Yeah, that’s tough stuff though. I mean, those teens, they’re…I mean, they’re wonderful but it’s a tough age group. No, it’s a tough age group.
Dr. Bendheim: It’s so hard.
Dr. Fox: They’re all going through so much. I mean, there’s, you know, hormonal changes, physical changes, emotional changes. They’re growing up, they’re in high school, which is gruesome. I mean, everybody hates high school…
Dr. Bendheim: Totally.
Dr. Fox: …you know, to some degree…
Dr. Bendheim: Exactly.
Dr. Fox: …and it’s just horrifying. And now on top of that, it’s like, now I gotta deal with my body image. Oh, God, I just…
Dr. Bendheim: It’s horrible.
Dr. Fx: …it’s very hard. Oh, my God. I have such pity for everyone in high school and those who have to, you know, work with them. Yeah, I have kids in that age and it’s very hard.
Dr. Bendheim: It’s so challenging. You know, the other thing I always tell parents, sometimes…like, particularly to parents with high school-age kids. They’ll call me, they’ll be like, “My kids said, you know, the worst thing, like, ‘Oh, I look awful,’ and I just kind of smiled at them and was like, ‘Okay.’” And they’re like, “What was I supposed to say in that moment?” And like, it happens all the time they’re like, I totally dropped the ball. Like, I should have had, like, some insightful response. You know, it’s like…
Dr. Dox: A poem to read.
Dr. Bendheim: Exactly, right? I was like, you know. And like, parents feel like it all the time. And teachers feel like that all the time. They’re like, “Some kid just said something to me and I just looked at them blankly and smiled and was like, ‘It’ll get better.’ And they’re like, ‘What’s wrong with you?’”
Dr. Fox: I’m an adult, that’s what’s wrong with me, we’re all mutated.
Dr. Bendheim: Exactly. So I always tell parents and teachers when they say that I was like, you know, you can always go back to them. Go back to them and say, “You know, you said this to me and I was thinking about it and I realized I gave like, kind of, a weird response. Like, here’s what I would have liked to have said.” And it kind of validates them and gives you, like, a day to think about it in a more thoughtful way when you’re not thrown off. Because I feel like it happens all the time. it happens when kids ask about sex, it happens when kids ask about bodies, like, it happens all the time. Parents do this weird thing and they’re like, “Okay, great question. What do you want for dinner?” Like, “Okay, next [inaudible 00:16:53] next.”
Dr. Fox: It’s like a press conference, “Next question.”
Dr. Bendheim: “Next question. Great point, next question.”
Dr. Fox: You’re out of order, yeah.
Dr. Bendheim: Exactly.
Dr. Fox: We do not recognize the delegate from France, you’re out of order.
Dr. Bendheim: Exactly. You know you had asked me how we first met.
Dr. Fox: Oh, yeah, it wasn’t through my wife?
Dr. Bendheim: No, it was through your wife, absolutely. Because, you know, one thing that I have recently talked very openly about is the fact that, you know, I’d had four kids super easily, and then I had a series of miscarriages. And I was going through a complicated miscarriage and my doctor’s practice had fallen apart. You know, little did I realize that probably, to some degree, what I was going through was somewhat normal. But you know, in retrospect, everything that you haven’t experienced before feels scary and overwhelming. And I was kind of…I found myself in a mess of a miscarriage that nobody could tell me what was happening with. And, you know, I said, “Wait a second, I think…” Somebody mentioned, “Try to get in touch with Dr. Fox.” So I said, “Okay, maybe I’m gonna, you know, go out on a limb and text Mithal. And you were on a plane to Bermuda. I remember this like this was yesterday.
Dr. Fox: Yes.
Dr. Bendheim: And you’re like…
Dr. Fox: Yes, I remember, on a plane, yes.
Dr. Bendheim: Yes, on a plane. I was standing outside Lazy Bean Cafe in Teaneck and I was like, okay, I’m gonna…I can’t believe I’m doing this. And within about three hours, you had gotten me an appointment at your office. And it was like the most kind, generous moment. And I did go on to have a miscarriage, but when we then went on to have twins, we went to Bermuda on your advice and that was my connection. It was all about Bermuda, it’s where we had those twins.
Dr. Fox: Well, I mean, because…
Dr. Bendheim: We went to Bermuda.
Dr. Fox: Yeah, I provide sound prenatal care as well as travel advisory. So I think that was Zika time, right?
Dr. Bendheim: It was Zika time.
Dr. Fox: I think that’s why we said Bermuda because Bermuda was Zika-free.
Dr. Bendheim: Yeah, that’s why you said Bermuda. Nevermind the fact that my husband was traveling back and forth to South America. But Zika seems so pale in comparison to COVID.
Dr. Fox: Yeah, Zika is so three years ago, yeah.
Dr. Bendheim: So three years ago, nobody is worried about Zika anymore. We just have COVID. Anyway, yeah.
Dr. Fox: And then we became fast friends, which was amazing.
Dr. Bendheim: Exactly.
Dr. Fox: So it’s awesome. So can you help me understand, what is an eating disorder? How would you either define it or explain it to me or to our listeners?
Dr. Bendheim: I would say that an eating disorder on any range. In other words, whether we’re talking about anorexia, or whether we’re talking about bulimia, or whether we’re talking about binge eating disorder. But anorexia is when you have restricted your food intake to the degree that it reduces your body weight significantly, and it’s in a dangerously medically low place. And as a result of that, you have other medical implications. And bulimia is not necessarily dependent on your weight category, but more about the fact that you engage in dangerous behaviors to compensate for eating and oftentimes for large binge eating episodes.
Binge eating is when you engage in eating copious amounts of food in one setting. And oftentimes, as a result of that, you know, your weight is on the other extreme with also medical complications ranging from, you know, overweight to obese. And so kind of looking at it on the continuum, I think it’s really about engaging in using food as a coping mechanism for life. You know, without going through all the nitty-gritty clinical details, which there are many, the way that I think about it is using food as a coping mechanism for life in the way that it debilitates you ultimately. It impacts your ability to function, it impacts your ability to engage in the world in a normal, healthy way. Like any type of mental illness, the degree to which something completely takes over your life and it doesn’t allow you to engage in life in a meaningful way, right?
We all have anxiety, the world is filled with disordered eating. But what crosses from disordered eating to eating disorder is when it so takes over your life in a way that doesn’t allow you to engage in the world in a healthy way and puts you medically at risk [inaudible 00:21:06] of an eating disorder.
Dr. Fox: Yeah, I think that’s a really important point because when a lot of people hear about eating disorders…and again, since there are different, sort of, subtypes and there are so many ways it can manifest itself and people hear some of the descriptions and somebody’s like, “Well, yeah, I occasionally at 11:00 will eat a whole babka, and that’s not a great idea, and I feel pretty sick the next day because of it.” Or someone else will say, “Well, yeah, you know, I’ve done that where I had to really crash diet for a week and it was probably not a good idea, but I did it.” And they’re like, “Well, do I have an eating disorder,” or why is that different from the other person? I think that line that you cross where it takes you from just like an odd thing you do periodically, you know, for a reason as opposed to taking over your life and putting you at risk, meaning you can’t live your life normally, you’re not well, that’s really where you have the disorder, so to speak.
Dr. Bendheim: Yeah. And you disengage from reality, right, like there’s a piece of that also. You know, if you talk to people who have severe anorexia, they don’t have an accurate perception of themselves, their body. And some of that has to do with the fact that they’ve actually engaged in malnutrition of their brain. Some of it has to do with the fact that you lose real perspective. So I think there’s also a piece of it disengaging from reality. I think the same thing is true with binge eating as well and the same thing with bulimia. And I think there’s also an ability in terms of length of time, right? So you know, not always, but I think there is a degree of it which has to do with the time.
It’s interesting, I see with my clients who are ballet dancers which is also a whole other can of worms, right, because the ballet industry is dependent on them being at a certain weight. And so, you know, you’re playing a different type of balancing act. So I think every person’s own perspective on where they’re coming from, taking into consideration what their weight historically has always been and what it’s supposed to be, and what their eating habits look like, I think that’s an important piece also. And the degree to which they have a healthy relationship with food. And their ability to navigate the fact that sometimes we eat more and sometimes we eat less, and sometimes we exercise more, and sometimes we exercise less. And these are just aspects and components and part of our daily activity and routine. But we can work with them, we can travel with them, we can adjust to what we need to given our life circumstances. I think there’s a huge piece as well, like the flexibility is a huge piece, thinking about it that way.
Dr. Fox: When you mentioned before about this idea that many people specifically with anorexia have, like, this break from reality, is there an overlap between these diagnoses and other psychological or psychiatric diagnoses? Like, is there a high correlation between having an eating disorder and having, let’s say, you know, OCD, or having depression, or having some sort of, you know, schizophrenia?
Dr. Bendheim: Anxiety and depression are always typically related to eating disorders, mostly because there’s such an emotional component to eating disorders. So especially we know when it comes to binge eating, any type of binge eating, whether you engage in compensatory behaviors to make up for the fact that you just had a binge eating episode, which would be more akin to bulimia, or you just had a standard binge eating episode. So we know that there’s a high correlation between the emotional experiences that they’re having in that moment and their binge episodes. In other words, they’re actually stressed out, they’re actually overwhelmed, they’re actually anxious about what is happening and that is how they compensate for it. That’s how they cope, that is their coping mechanism.
The same thing happens to be true with anorexia as well that there is a degree to it. And even though I try to stay clear of it because I think there’s a component of it that’s a little cliché, but I think it has more to it, which is that, you know, there is more often than not a perfectionistic component. You wanna get something right, you’re trying to engage in the world in the most perfect way that you can and so I think there’s a high degree of anxiety that comes from that. People who have anorexia tend to not eat when they’re stressed out, that’s their coping mechanism. So it’s the same anxiety, depression story, but the reaction to it is different. The OCD is 100% there, but then what is it, the chicken or the egg? In other words, did a person’s tendency toward OCD cause their eating disorder? Or was it that the eating disorder created an environment for a pre-existing OCD tendency to become active?
So I think that some of the clinical work involved is teasing out, you know, what are we actually looking at? So if we treat the OCD as a primary focus, will the eating disorder go away on its own? Or is the eating disorder too severe that it has to be treated really intensely focused on as an eating disorder? So I think those are just, kind of, some of the pieces that we think of that and circle around when it comes to eating disorders. But it’s not always a one size fits all model but those are…you know, anxiety and depression are big ones.
Dr. Fox: Right. And then in terms of just understanding the three that you mentioned, anorexia, bulimia, and binge eating disorder, I think anorexia you described most people, sort of, understand. Does bulimia always involve vomiting, or is it only sometimes involves? If you look at the definition of it, it never mentions the word “induced vomiting,” although that is frequently what people do.
Dr. Bendheim: Yeah, so the word that I used, which is, I guess, the clinical word, like, compensatory behaviors. In other words, so it could be laxative use, it could be inducing throwing up, it could be engaging in such severely high-intensity exercise as a way to obliterate any type of caloric intake. So it’s doing anything as a way of compensatory for the food that was consumed.
Dr. Fox: Got it.
Dr. Bendheim: So it doesn’t have to be vomiting.
Dr. Fox: Right. Because people think of, you know, bulimia as just vomiting but it doesn’t have to be. It could be other unhealthy behaviors to compensate.
Dr. Bendheim: Yeah, I think part of the reason why more often than not we see it as bulimia has to do with the fact that binge eating is very intense. When you talk to people who’ve engaged in binge eating episodes, there’s like a real intensity to it, and they then feel a real depth of horror about what they did. And so the violence of causing themselves to throw up feels very powerful, and important, and feels very good to them. And so I think that’s why you often see people engaging in vomiting, there’s like a real relief of the binge eating that they thought was going to soothe them, but ultimately, then only ramps up their anxiety more. And so the actual act of vomiting is so intense that it actually serves as an anxiety reducer. And so…
Dr. Fox: Like masochistic, in a way.
Dr. Bendheim: It’s totally masochistic. There is a correlation between people who get tattoos and binge eaters, some of it has to do with this desire to like feel things and see things in a very intense, painful way. There is something about feeling pain. And people will describe the fact…and this is why there’s an aspect of bulimia that’s tricky, which is that in terms of like recovery that there is nothing as powerful and that feels as good as throwing up after they’ve had a binge episode. Which to most people sounds horrific because people will go to great lengths to avoid throwing up because it’s such an awful experience.
And people who have bulimia can identify with that fact but it also feels very good. There’s a lot of shame in it, right? They feel shameful about the fact that this is happening. They don’t necessarily want people to know. But in terms of a physiological response, it’s very powerful. That’s hard for people to relate to. But I think when people do relate to it, they can engage in higher levels of sympathy. To be like, yeah, it’s gonna be really challenging to overeat and not throw up. And finding a coping replacement is probably never gonna feel exactly the same. That’s hard.
Dr. Fox: And then how do you define a binge eating disorder where frequently people are overweight or obese from the very common form of obesity and being overweight?
Dr. Bendheim: I think the thing that I usually think about…and I think this is just like for people to recognize. I hear this a lot when I do parenting class and someone is like, “What about my child who just loves food?” And we do see that people who enjoy food more than other people. And I always think it’s important to remind everybody that we all came into this world really different, we look different, our behaviors are different. I even like marvel at my own twins who shared the same house for, sadly, only about seven-and-a-half months instead of the allotted nine. But, you know, even when we got to the NICU and looked at them, the nurses were like “This one is like, totally like this, and this one’s totally a different being.”
And to this day, like, they kind of live their lives alongside each other, they couldn’t be more different. And I think it’s important to remind ourselves of the same way we expect people to behave different, we shouldn’t expect people to look the same. To recognize that everybody has a different body shape and a body type. And, you know, we probably don’t tell people enough, you know, you could starve yourself compared to tomorrow but the reality is our body types are going to be different. And so we actually need to learn how to be part of a world that embraces different body types.
We’re not there yet, society hasn’t done that. And so I think, you know, as a result of that, one of the things that we have done is, kind of, made the suggestion that anybody who’s not a size, fill in the blank, whatever that looks like for men or for women must have an eating disorder, they must be bingeing. And I think that’s a really important misnomer to say no, that’s not true. Like, there are going to be people who are naturally smaller, and some people who are naturally bigger. And so not everybody who’s overweight has an eating disorder. And I think that that’s really important to put out there.
I think the difference is when it crosses the line is when, first of all, they actually are engaging in poor eating habits, they feel out of control. The difference with a binging episode is they feel out of control. They know that they’re eating copious amounts of food not when they’re hungry, but because they’re upset, or they’re fat, or they’re anxious, or they’re happy. And as a result of that, they’re eating so much more food than they would otherwise because they’re eating it in a really maladaptive way. And that tends to lead to real obesity, which is what we’re talking about when we’re talking about binge eating disorder. And that’s just like an important thing to put out there.
Dr. Fox: How common are these? Are they increasing, decreasing, or have they been steady for a while?
Dr. Bendheim: You know, I don’t know the current prevalence rate numbers, despite the fact that I just did a talk on this. I was actually talking about, like, cross-comparison. I think overall, they’re mostly to some degree staying the same. The one thing that I will say that we do know is that we know that eating disorders amongst middle school kids is growing, anecdotally. This has to do with this debate about does social media negatively impact teenagers…
Dr. Fox: Yes.
Dr. Bendheim: …middle schoolers?
Dr. Fox: Yes, everything.
Dr. Bendheim: The answer to that yes, yes, yes.
Dr. Fox: Social media negatively impacts teenagers. True.
Dr. Bendheim: True, check. You know, all these classic studies that when, you know, social media or television wasn’t introduced in a place like Fiji, the famous Fiji study, that once they introduced, the eating disorder rates, like, shot up through the sky. Interestingly, I was just listening to a podcast where they were talking about a Harris Poll study. Anyways, it’s very fascinating because one of the things they were talking about is that teenagers who have healthy relationships in person tend to have healthier relationships with social media, and the contrast also being true. But that notwithstanding, I think that people take in social media standards in a really negative way. So I think it’s totally impacting middle school kids.
Clothing actually might be a huge contributor to eating disorder development in younger kids. Because clothing is made today with the expectation that people’s bodies are X, Y, and Z, particularly amongst middle schoolers and teenagers. You know, teenagers like to think they’re very unique. But here’s the thing, if I walk into a high school, I notice right away that all the teenagers, for the most part, are dressed the same. They’re all wearing the same whatever the item of clothing is that’s trendy, that’s what they’re wearing. But it’s not actually necessarily fitting everybody the best way that it could.
But because we’re forcing kids, or kids feel forced, to wear certain “cool dress code,” as a result of that, I think it actually increases eating disorders because everybody’s trying to fit into one size. And so we know also that kids who actually feel like they can’t fit into a certain size of clothing, and then they start dieting, and they start restricting, more often than not, that then leads to binge episodes because they’re so hungry and starving. So then they actually ended bingeing on whatever they haven’t allowed themselves. And it just starts them off on, at the best-case scenario, a lifetime of yo-yo dieting, and the worst-case scenario, setting them up for an eating disorder. So you know, those I think are really complicated pieces.
I also think we’re seeing an increase in eating disorders amongst mothers and people heading into their 30s and 40s who have had kids. And the expectation that…you know, it used to be I think that moms were okay looking like they had had a lot of kids. Not a bad sense, just like their bodies weren’t like they were when they were 20. And I think in today’s day and age, there’s a lot of pressure put on women to create themselves into the way that they were pre-having kids when they’re done having kids. I think there’s a lot of pressure.
Dr. Fox: Yeah. And I think that you brought up a lot of really interesting points and important points. And since this particular podcast is geared towards women’s health, I wanted to ask you, in terms of risk factors, I was gonna just say, you know, what are the risk factors? But one of the things I was always curious about is why do you think these are so much more common in women than in men? Is it purely environmental that there’s different social pressures on women than men? Or is it something biologic, perhaps, or just because this has sort of been modeling from mothers to daughters for generations? Like, what’s your thoughts on that?
Dr. Bendheim: I think science and research would probably show all of the above. We know there’s a biological component. We know that people who have eating disorders when they restrict, the pleasure principle in their brains light up. So we know there’s a biological component and that should not be, you know, minimized on any level. But we also know there’s a huge environmental component, we know that modeling is high. And I think that the reality is, for the last hundred years, the dieting model has been strong, and prevalent, and it’s out there and people are talking about it. Goes all the way back even to the way in which religion talks about anorexia. Like, holy anorexia, you saw it typically only amongst nuns, which is fascinating, you know. Even back then it was only women, you know, the first anorexia cases are all women. So it’s not to say that it’s only women, but I do think that it’s prevalently more women.
And I think it somewhat has to do with the fact that women, for good and for bad, are more preoccupied with their bodies than men, probably. I would hazard a guess that just like in a healthy way, and I think it causes some unhealthiness also, okay. Like, we’re nervous when we’re trying to get pregnant, we’re nervous when we’re not pregnant. You know, like, there’s all this, we’re highly monitoring our bodies for different changes. If we were trying to get pregnant. If someone’s not trying to get pregnant. Even as young…you talk to young girls, how old were they when they got their period? And people encouraging women to track their periods, or track how they’re feeling about premenstrual symptoms. I think we are attending to bodies in a much more intense way than men are.
Dr. Fox: And so what would you advise people in terms of either for themselves or for perhaps their children, what is the best way to watch out for this and potentially prevent this from happening or lowering the chance it can happen in terms of whether it’s modeling or education, or lifestyle changes, what would you recommend to people?
Dr. Bendheim: You know, I think the thing that, you know, I tend to live by, both my practice but in my own home life, is engaging in moderation. You know, really having a home that is full of lots of different food habits. And really trying to allow ourselves as women to go through the different stages of life, and to really remind ourselves that it’s going to be okay. And I think that it’s hard to do that when you’ve never done something before.
Like, I was thinking about your podcast that you were talking a couple of weeks ago about birth plans, and I was secretly having a good laugh. Because I think birth plans are more anxiety-ridden when it’s your first kid. And then once you’ve done it before, you’re like, “Okay, I’m not as worried about what’s gonna happen,” you feel like you can do this. And I think sometimes reminding ourselves, as women, that women for generations have gained weight and lost weight through pregnancies, through nursing, through all sorts of different life events and life circles. And we have to be kinder to ourselves and kinder to our expectations.
And that our goal in life, to the best of our ability, is to be able to maintain a weight that works for us, which is usually based on maintaining a mindset of moderation. Moderate exercise, moderate activity, which is good for our minds, and our brains, and our mental health, and our physical health, moderate eating. And really trying to allow ourselves without judgment to engage in the world. And I think stopping to pause to think about…you know, I always say to some clients, like, “Is it worth it? You know, do you really think that the torture that you’re engaging in for yourself…?” and sometimes they can’t control it. But I think sometimes they’re able to take a step back and say, “No, you know what, I would rather, you know, not be torturing myself for 5 pounds being able to fully engage in life.
You know, something a mentor once said to me that was so powerful is we look in the mirror and we see how we feel, not what we are. That if we’re attending and anxious about our weight, and our bodies and how we’re presenting ourselves to the world, maybe it’s a clue that it’s actually not about our bodies but how we’re feeling about ourselves. And I think if we work on that, we’d be presenting ourselves to our children and the world in a much more thoughtful way.
Dr. Fox: Yeah, our children, they see us, right, they know what’s going on. And I think that so many…And we were talking before the podcast about this idea of modeling for our kids and what they see in our home. And these ideas about, you know, foods that are allowed to them or not allowed to them. And you seem to have…even though this is what you do for a living, you seem to be a little more almost laid back in a sense about foods for our kids.
Dr. Bendheim: I am more laid back. I had actually a very funny exchange in my house where I’ve literally had to eat my words. I for years have had a rule in my own home that I never make one food dependent on another. In other words, it’s not that you have to eat this in order to get this. Like, typically, it’s like you have to eat dinner in order to get dessert. Because then we’re elevating one food over the other instead of teaching our kids that all food is wonderful. And it’s about having it in moderation. And really not necessarily like, you know, that’s a good food but that’s a bad food. We don’t talk like that at my house at all.
But recently, some kids have been throwing…for the first time in my parenting years have been throwing some dinner rejection at me. And so I said, “Guys, you have to eat dinner in order to have an after-dinner snack.” That was like my new thing. And so one of my kids said to me, “Why is that new?” And I was like, “Well, I never used to do that but you guys aren’t eating dinner.” And he very quickly clips back at me. “Well, thankfully, now the dinners are better.” And I was like, “Thank you.” So that was code for, “You took out the mandatory fish night, Mom, and you replaced it with, like, meat sauce. We much appreciate it.” Like, “Thank you.”
But I think it’s actually…it really is important. In my house, like there’s nothing that’s, like, reserved for a special day. And so I oftentimes will tell my kids, you know, like, if you want something and you’re worried somebody else is gonna take it, that’s sometimes a lot of fear for kids at home. Like, they feel like they have to binge on it because it’s gonna be gone the next day, maybe another kid is gonna take it. You know, there may be somebody…maybe it’s gonna run out. Sometimes I’ll like literally put it in a bag and be like, “Okay, this is yours.” I used to give like, dessert and dinner to my kids at the same time when they were little. So like, if they had the cookie first, fine. More often than not they always gravitated back towards the chicken. And so I really believe in it.
And I practice what I preach on this one. I think that, like, the most important thing that we can encourage is for our children to see us eating cake. Most children recognize that their parents eat “the healthy food.” But when we send the message that we also eat the desserts, we’re sending a really bad message to our kids that like that’s something that’s off-limits, and it’s better to control yourself around. Instead yeah, everybody has dessert the same way that everybody has dinner. And I think it’s like a really important message.
Dr. Fox: That is great. Tell me your philosophy on sugar cereals. I love this.
Dr. Bendheim: Oh, God, okay. I do not believe…some families have this thing where it’s like only sugar cereals on the weekend. And so as a result of that…
Dr. Fox: Right, when all the kids are off their Adderall, give them more sugar.
Dr. Bendheim: Exactly. When all the kids have nowhere to go, there’s absolutely no structure, let’s just put out an array of, like, Froot Loops and Fruity Pebbles and see what happens. And then we wonder why they’ve lost their marbles by the end of the weekend. Okay, brilliant. And then we also give them technology so that’s like a perfect combination. So I think that one of the things that I always say is there’s no such thing as, like, only sugar cereal day, it makes me crazy. And when I say this I usually get like loud audible gasp like, “Oh my god, you let your children eat Frosted Flakes on a random Tuesday?” I’m like “Yes, it’s true, in my house you could have Frosted Flakes on a random Tuesday. “
Dr. Fox: We’re big believers in that. We’ve always had like 30 cereals, like, all the time. We’re a big cereal family so all the choices, it’s wonderful.
Dr. Bendheim: [inaudible 00:43:35] for me when my kids are like, “Oh, we don’t like Trix.” I’m like, “What’s wrong with you people?” And the truth of the matter is, is that that is how we have lived our household and the kids can have cereal anytime they…any cereal they want. And interestingly enough, the other day, one of my kids was like, “Mom, have you heard of Honey Nut Cheerios?” I was like, “Yes.” Like, “We’d never had it, could you buy it for us?” I was like, “Okay.” And like, you know, it’s just funny because I think like, that’s what people assume is, like, a healthy cereal. And I think it just goes to show that, like, if we leave children alone they will, most of the time, make good, healthy choices for themselves because they want to feel full. It’s only when parents, like, start getting into the weeds of it because of our own anxieties that we actually mess kids up when it comes to food and feeding, which I think is powerful.
Dr. Fox: Yeah, I think it’s so funny because I mean, everyone has these stories because every family…You know, all of us are weird in our own special ways. Because we’ll have that and we’ll be saying…and one of my kids will have a friend over and we’re like, “Oh, they love to come over because it’s the only place they’re allowed to get doughnuts,” or something. We’re like their crack house and so…
Dr. Bendheim: We are the crack house. totally.
Dr. Fox: They come over, “We get this here at the Fox’s.” “You let them eat this?” “Yeah, whatever.”
Dr. Bendheim: I used to have kids that would make like a beeline. We lived in an apartment, which is basically like living on a small kibbutz where everybody just kind of goes in and out of each other’s homes. We had one good friend of ours, their kids would come and make a beeline for my candy cabinet. And she would look at me and she’s like, “I know, I know I should really let them have candy.” I’m like, “I’m just telling you, like, they’re bingeing on mine here.” Like, “I know” Like, “It’s fine, you know, they’re welcome to come, you know, have their candy here at any point in time, but they’d be much better off if they didn’t have it.”
Yeah, so you know, I really…I don’t know, I believe it. I believe it so firmly and it doesn’t mean to say that, like, we should let our kids sit down and eat, or ourselves, you know, a whole box of cookies. I think, like, we should be able to try to…and some kids need more help learning how to moderate than others. But most of the time, it has to do with our own anxieties or like, you know, someone said to me, “Well, I can’t have it in the house because I’ll eat it.” I was like, “Okay, so you have your own eating schtick. Why do you need to put it on your kids? Let your kids do better.” Seriously, why are you torturing your child?
Dr. Fox: Right, don’t give them your problems. But I think it’s also…
Dr. Bendheim: Exactly.
Dr. Fox: …it’s about, like you said, it’s moderation. It’s also like big-picture healthy lifestyle. So you know, if someone’s like, “Oh, we went out to eat and I had more.” It’s like, tomorrow, walk a little more than you normally would, or, you know, just sort of, you know, try to balance your life out in the sense that it doesn’t mean that you have to be so strict with everything every day. But as long as your overall view is healthy, and you wanna feel well, you know, you wanna have energy, and you wanna have the right nutrients. Okay, like, whatever, like these things are not the biggest issues in the world if a kid has a cookie or not.
Dr. Bendheim: Yeah. You know, something I think my pediatrician said once when I first…with one of my kids just like one good meal a week. Well, great, words to live by, you know, like…
Dr. Fox: It’s a low bar.
Dr. Bendheim: It’s a low bar. I’m like, done, check, I got that. You know, I think it just reminds us, like, not every…and I think it goes back to this idea of perfection and the standards we hold ourselves to and the standards we’re setting up for our kids. Like, not every day is going to be a perfect day. But I think that actually one of the pitfalls just going back to, you know, women and mothers, one of the pitfalls I actually hear so much of is like…and you talk about this a lot on some of your podcasts when you’re, you know, encouraging, like, exercise and healthy eating for pregnant women.
But I think one of the pitfalls that happens is that more often than not when women aren’t pregnant, a lot of times, they fall into this habit of feeling the need to be so rigid in their food and diet. And then they become pregnant, and they’re like, well, I’m gonna gain weight anyways so like, let me eat everything that I would never normally eat in my life. And then as a result of that, they actually end up not gaining pregnancy weight, which everyone is gonna gain, but actually gaining so much more weight, which actually then sets them up for postpartum to feel so uncomfortable, and then have to go back and engage in this, like, rigid dieting because they’re feeling so overwhelmed in their body.
And so they’re really just, like, staying the course of, like, a moderate eating habit that was before, during, and after that has all different types of foods and moderate exercise. I think that actually ultimately makes people feel much healthier and is much better for them. And they can actually then, you know, model and engage and I think probably be more present postpartum also because they’re not feeling so overwhelmed and exhausted beyond what they already are postpartum.
Dr. Fox: Yes, it’s so interesting that you mentioned that because there’s so much focus on pregnancy and prenatal care and in the textbooks on weight gain, right? What is the right weight gain? There’s a normal amount, there’s too much, there’s too little, it’s based on your starting BMI, there’s all these things. But the interesting thing about it is…well, there’s two interesting things.
Number one, all of that data is what we call observational, meaning they say we took a population of 10,000 women and this was the typical weight gain in the 25th to the 75th percentile. But just because that’s what most people have, it doesn’t mean it’s necessarily the best, or that the people who are the outliers are doing something wrong, or there’s something wrong with their pregnancy. There’s always gonna be…like, if that’s your standard, then 25% of people on one end and 25% on the other end are gonna be abnormal, which means half the people are abnormal, just from the get-go. So that’s like, really weird.
And the second thing is, I always tell them, you don’t have control over your weight gain, you have control over what you do, right. So I say, all I’m interested in is are you eating like a good, well-balanced, healthy diet for the most part, and are you active? And if the answer to those questions are yes, I don’t care what your weight gain is, right? Like, it doesn’t matter to me because if you eat healthy and you’re, you know, exercising the right amount, and you gain 75 pounds in a pregnancy, well, yeah, that’s annoying, but you’re not doing anything wrong.
Dr. Bendheim: That’s your body. Exactly.
Dr. Fox: Yeah, that’s it, and most of its water, and it’s gonna come off, and if you have that lifestyle, you’ll lose it. And on the flip side, if you gain “too little,” I’m not gonna beat you up. Yeah, maybe…listen, if we think the baby is not growing, we’ll check, we’ll do this. And so I feel like, “How much weight did I gain? I said, “I don’t really care. Like, it doesn’t matter to me as long as you’re, sort of, doing what you should be doing from a healthy perspective.”
The only exception sometimes with twin pregnancies it’s better to gain more weight. But that’s unique to twins because that’s a whole separate discussion. But again, you know, most people, you know, 97% of people are not carrying twins and so that’s a conversation I have. And then even with twins, it’s the same thing, it’s like, you know, do all those things, but maybe eat more healthy food. You know, sort of like, intentionally eat some more because it’s hard to do it you know, as you said. As you know, with twins, it’s not easy.
Dr. Bendheim: Twin pregnancies, yeah, [crosstalk 00:50:27.594].
Dr. Fox: We’re gonna have you talk about that, that’s gonna be something else.
Dr. Bendheim: I love them but…
Dr. Fox: We’re gonna have a birth stories series, and you’re gonna talk about your birth.
Dr. Bendheim: Oh, my God.
Dr. Fox: That was a fun one.
Dr. Bendheim: That was a fun one, I know. Oh, God, twin pregnancy.
Dr. Fox: Just briefly, how would you treat these? Right, so someone comes in and they have a significant eating disorder, and they’re coming for therapy, they’re coming for treatment, how is it? Is it a lifelong thing? Is it something that takes years and years and they never get there, or some people are “cured?” How does that work?
Dr. Bendheim: I took this on from the get-go, I believe in people being cured. Some people are like, “Pople are never cured, they just manage it through their life.” Maybe that’s true for some people but I also really believe in people’s ability to be cured. I think sometimes there are gonna be more vulnerable periods in a person’s life like transitions or like a big eating disorder, like, flare-up time. I think it depends on where people are too in terms of the severity of eating disorders, right. So we always know that there are people who require inpatient treatment, and I think that actually just has to do with the fact that they need refeeding, right, more than anything else.
Like the reason that inpatient treatment is driven is because we need to refeed them in a way that’s fast and safe and so we need monitoring. And they’re not able to feed themselves. When it comes to…hopefully, we know that there are better outcomes for long-term recovery in an outpatient setting. In other words, the less inpatient treatments that a person has or needs, their ability for long-term success is better. So we always like to treat people in an outpatient setting.
Usually, you know, we approach it from bringing in lots of different people. Sometimes we have nutritionists on board who can help create a meal plan to give people a sense of structure. And to, you know, do weekly weight checks to make sure that people are gaining or losing what they want to be gaining or losing, or what we want them to be gaining or losing. You know, I’ve done twice a week therapy or weekly therapy, there could be psychiatrists involved, it could be pediatricians involved, medical team involved.
For me, it’s like a multi-pronged approach. I think it’s a balancing act, which is really trying to engage and changing a person’s behavior around food. But at the same time, spending time thinking about themselves and how they engage in the world. And when they start to do that, they’re able to actually put food on the backburner and engage in life in a much more healthy, meaningful way without having to use food as a thing that navigates them. So ultimately, probably doing both at the same time is always the best-case scenario. Working with nutritionists are the best because then they can do the food and I can do the therapy, and that usually…everybody stays in their lane.
Dr. Fox: This is such an important topic. And the work you do is really crucial for so many people both who come to you, you know, acutely or chronically for their own concerns or their own eating disorders. But also just the educational piece, you know, talking to people about this, bringing this out in the open to women, to their families, to men, to everybody to just understand what this is. And try for all of us to develop, you know, a healthy lifestyle in terms of our eating, in terms of our exercise, and how we view each other. And I really thank you for doing this and spending, you know, your time helping me understand, and our listeners also.
Dr. Bendheim: Thanks for having me and letting me share. And for everybody who, you know, helps us talk about these things a little bit more, we’re all learning and we all can get better at it. So it’s all based on our conversations that we have with each other and being able to think about things in new ways every day.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com, that’s healthfulwoman.com. If you have any questions about this podcast or any other topics you would like us to address, please feel free to email us at firstname.lastname@example.org. Have a great day.
The information discussed in “Healthful Woman” is intended for educational uses only, it does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.