In this podcast, Dr Jennifer Gaudiani talks about your bones, and what the effects of malnutrition caused by a restrictive eating disorder such as anorexia, can be on your bone health. We talk about:

  • How malnutrition affects your bones
  • Bone density
  • Osteoporosis
  • Osteopenia
  • The various treatment options

Podcast transcript courtesy of Elaine

Ask Dr. G: Anorexia, Malnutrition and your Bones


Tabitha: Hello! Welcome to this week’s podcast. This week, I am talking to one of my favorites, Dr. Jennifer Gaudiani, who is just close to me in Denver which is wonderful, because I can go and see those guys every now and then and they are a fabulous, fabulous team of women who are changing the way that we treat eating disorders mentally, I think. Anyway, so I feel very honored that I get to speak to Dr. Jennifer Gaudiani, on a regular basis, and today we are going to talk about bones! So let’s get right into it! The first thing that I asked Dr. Jennifer Gaudiani was actually on the topic of bones, where the heck are we going to start? Here’s Dr. Gaudiani.


Dr. Gaudiani: Ooh there’s so many good places to start with bones. Hmmm, let’s talk a little bit about how bone density gets established, and when. And then let’s talk about the impact that malnutrition can have on bone development and bone health.


So, in our adolescence, between the ages of about ten and twenty, we put down the majority of the mineralization of our skeleton. That’s when our bones get hard and gain all of the strength that they need to take us through the rest of our lives. Subsequent to age 20, in the majority of people, bone continues to do what is called remodeling, over time. So it forms a little bone, it resorbs a little bone, it forms a little bone, it resorbs a little bone. But the majority of actually getting that skeleton strong to go the distance happens during adolescence. If, during one’s adolescence, one is not eating enough and one does not have sex hormones, that process can get disrupted. And normally, as you know, I talk about eating disorders across the entire spectrum of body shape, and size, and type of eating disorder. When we’re talking about bone density problems, for the most part we are talking about classic Anorexia Nervosa, which comes with a significantly lower weight. So I just want to make that clear, and there are scientific reasons, of course, why this is true. So for the most part, in this talk, I am going to be talking about Anorexia Nervosa-related bone density problems.


Okay, so, let’s say that we have an adolescent who is 16 years old. We’ve got a teenager. And let’s say it’s a young woman who started her period at age 13 and her periods have been pretty regular and now she’s started to restrict calories, her weight started to fall, and her periods disappeared. We know what happens in the brain is that, my favorite concept – the “caveperson brain” says, “let’s turn all the sex hormones off, because we are trying to conserve calories to save our mammal. Let’s make sure that there is very little sex drive, there is very little menstrual blood loss as a body resource, and there’s no ability or reduced ability to get pregnant because this body is not safe to sustain a pregnancy.” Well, it turns out that a few things happen as a result of this starvation and sex hormone loss, and we’re going to talk about males, as well, here. 


We’ll pause for a moment and think about what happens when people expect to start losing bone density, when they’re in their 60’s, and, you know, if it’s a woman, she’s post-menopausal. Because she has no estrogen anymore, her bones resorb more of the calcium. That is, they take the density out of the bone and sort of bring it into the blood. So there’s a leaching process going on. However, she’s a well-nourished postmenopausal woman and so her bone can still form. It’s just that there is a slow process of leaching of the bone-density over time, so very slowly she begins to develop a higher risk for fracture. In malnutrition, we have no estrogen (we’re talking about a female) and so just like with the postmenopausal woman, that leaching process happens, and the bone density starts to be absorbed out. But in addition, she’s starved, she’s stressed, her cortisol levels are high, and there are a number of other hormonal factors that kick in, and she doesn’t make bone. So, not only is she not making bone; she’s resorbing it, and therefore the bone density loss in Anorexia Nervosa can be catastrophically fast. And if we’re talking about a 16 year old, she is in the heartland of when her body wants to be putting down the skeleton that’s going to take her the rest of her life! She may never have the chance to mineralize her skeleton properly. And even if she’s recovered by age 20, or 21, or 22, she may never have a chance to mineralize her skeleton, and then she just has to go with what she’s got for the rest of her life. If it’s a person who has developed their eating disorder, say, at age 25, or 30, then they may have fortunately mineralized their skeleton during those key years, but they can still have the “bones of a 75 year old” within a year or two of their illness. It happens fast.


Tabitha: Wow. Malnutrition is a big deal!


Dr. Gaudiani: Turns out! It’s not good for ya, in so many ways!


So, when we think about young men, or men in general with Anorexia Nervosa, because of course, we musn’t leave them out, there’s a similar process whereby testosterone gets turned off by the caveperson brain and they too have no sex hormones. If a male gets Anorexia Nervosa while he is in his adolescent years, he too will fail to mineralize his skeleton, and if it’s later on, that lack of testosterone, plus malnutrition and stressors, can once again make him lose bone really fast, only he is at a further disadvantage, because he doesn’t have a period to trigger his doctor to think that there might be something wrong with his bones. 


Tabitha: Oh wow, yeah yeah.


Dr. Gaudiani:  In young men, my experience is that they’re often missed. The doctors don’t think that because it’s not a female and because there’s not a period being missed, to check that bone density. And as a result, I’ve seen guys who have gone 10, 15 years with significant malnutrition before they came to treatment and had this suggested, and then they may really have 80 year old bones. 


The question then is, what’s wrong with bone density loss? What’s the big deal? Why do we care? And the answer is that people have a significantly higher fracture risk with bone density loss. And a lot of my younger patients have a bit of a “ho hum” feeling about that. Like “okay, Dr. G, so I won’t trip over the cat and break my hip. Fine. No problem.” And what I remind my patients is that our spine is a set of little building blocks stacked on top of each other. When we’re standing or sitting, anything but lying, those are opposing gravity. That is, those nice building blocks stand sturdily upon each other. But if you start to get bone density loss, just the act of living, just the act of being a column in gravity can start to compress those weakened bones down. And they don’t compress universally and equally; they tend to compress forward, so that a person can develop a permanently kyphotic or hunched forward upper-back. And no amount of yoga poses fixes that.


Tabitha: Yeah, yes. I would know.


Dr. Gaudiani: Is that right?


Tabitha: Yeah, I do have that, especially in my low back I have… what did my chiropractor say? For my age it shouldn’t be that compressed. But, it also could have been a lot worse, so, I count myself as very lucky. And I know what you’re saying there as well about the younger patients, and I know that when I was in my early twenties my doctor could have said that to me, “I’m worried about your bone density,” and I would have been like “meh.” The other thing that you probably get told and the thing that I used to say to my doctor was “well fine, I’ll just take a calcium supplement and I’ll be alright.” 


Dr. Gaudiani:  Hmmm. Yeah, that’s right. It’s so easy for the eating disorder to try to minimize the severity of medical problems, isn’t it?


Tabitha: Oh yeah. 


Dr. Gaudiani:  Let’s turn, in fact, to management, because your point is really well made. Because calcium supplements ain’t gonna cut it. Maybe before we go there, let’s define what we mean by different grades of bone density loss. Because that can be really confusing, and unfortunately, the radiology system that establishes what defines what degree of bone density loss can be profoundly invalidating and misleading if you’re just holding a report of your bone density scan in your hands and seeing the word “normal” at the bottom. So let’s take a second and define degrees of bone density loss and let’s really dig in to treatment options, because there is a lot out there. And we’re also going to talk about exercise, and the role of exercise in bone density loss. 


When somebody under 50 years old gets a bone density scan, and let’s say that we are not talking about children, let’s say that we are talking about, you know, 20-50 year olds, for the most part, the report should always be read as a “Z-Score.” And I know this gets into the weeds, and you’re like “why do I care,” and it’s because there are patients and families out there right now holding a DEXA scan and saying, “nobody else was an expert for me; I’m gonna need to use Tabitha here.” So that’s why we’re gonna give this level of expertise. 


Tabitha: I hope they’ll use you!


Dr. Gaudiani:  By our powers combined, yes. So the Z-Score is the appropriate score to read if somebody is between 20 and 50. In such a young person, a Z-score of less than -2 (awkward scoring system) defines “low bone density for age.” That’s all they’ll say. “Low bone density for age.” If a young person has another cause for bone density loss, which in my mind includes Anorexia Nervosa, or they have a fracture that is what’s called “non-traumatic” that is, it’s not that you had a terrible ski accident, it’s that you fell off the curb, landed wrong, and broke your foot. Then that together with a bone density of less than -2 equals osteoporosis in a young person. In a young person between 20 and 50 officially, there’s no such thing as Osteopenia, which is the sort-of interim bone density loss that is diagnosed in people over 50. And I got this wrong for years. All the years I was at Acute, I was diagnosing Osteopenia when it’s not officially a diagnosis in somebody younger than 50. I know! It’s surprising. And it’s a tool that we lose, unfortunately. But that leaves every single young person from 20 to 50 years old who has a bone density scan that comes back at, you know, -1.5, reading “normal” on their report, even if that bone density may reflect a significant skeletal mass loss directly as a cause of the Anorexia. So what I like to say is that a bone density score in a young person 20 to 50 that’s better than -1 might not need treatment. That’s -1; that’s not -2. However, if it’s a really serious athlete, then anything in the negative column at all is abnormal, because an athlete uses their bones, and when bones are exposed to what’s called “weight-loading exercise” they get the message: “ooh, we’ve got to get stronger!” And they actually get denser and thicker. A pitcher’s arm in baseball has a much thicker bone density than his non-pitching arm, for instance. So in an athlete, (and I’m not talking about an Olympian; I’m talking about a kid who plays sports or a young person who is engaged in sport) they should have a positive number bone density. And anything in the negative column says that you have lost bone as a result of an imbalance between your energy intake and your energy expenditure. But the problem is everyone reads that report and goes “I’m normal; knew it! Ha ha. Knew it.” You’ve got to be able to interpret it in a right patient context. Now let’s take somebody who is over 50, because we know that people over 50 deal with eating disorders as well. In that case we use a T-score, for people over 50, and that’s the more familiar scoring system, where anything above -1 is normal. Anything between -1 and -2.5 is called Osteopenia, and anything lower than -2.5 is Osteoporosis.


So now we’ve sort of set the scene, basically. And I’ll say that studies have shown that in adolescent girls, even before the bone density scan shows any abnormality, their fracture risk increases substantially, even just one year into their Anorexia Nervosa. And again, you’re young you think “eh… a fracture, whatever.” But if you’re an athlete, that could sideline you for a whole season. You know, much less, if you want to just not be in pain and not have to deal with the recovery process. 


Okay, so treatment. First of all, getting adequate calcium and vitamin D is reasonable. There aren’t specific levels set out that clearly are going to help bone density loss in an eating disorder though; it’s just a reasonable building block to have around. The official levels for vitamin D OH that you check in the blood should be between 20 and 30. Some people like them higher than that, that’s fine. If they get higher than 70 or 80, one runs the risk of liver toxicity. And so, you know, as long as my patients are above 20 I’m okay with it. I have seen patients with toxicity though. And probably the vitamin D OH level could be checked once a year. And vitamin D tablets are a great source of supplement; it’s not unreasonable to take one or two thousand IU a day, especially in the winter, when you aren’t getting sunshine. As far as calcium, my theory is always that dietary sources are best. Dairy and other natural sources of calcium are terrific. If for some reason one cannot get that in, then, you know, 1,000 or 1,200 mg of calcium a day is reasonable. Again, it’s just a building block. Some people like calcium citrate the best. I clearly own no stock in any of these products, none of the products in fact that I am going to be discussing. And I don’t get taken out to any steak dinners by any drug reps. So anything I discuss here is going to be because I feel like it’s the best evidence-based thing to do. So calcium is reasonable. Taking too much calcium can contribute to kidney stones. Calcium also sometimes constipates people, so, you know, don’t take more supplemental calcium than you need. 


Then you sort of take the next step forward. And there is some really exciting research on this that is cutting-edge, both for athletes and for patients with Anorexia Nervosa. The cutting-edge research says that if you have a premenopausal woman whose caveperson brain has stopped telling her to make estrogen, and you measure that through an estradiol level, and the lack of a period on a regular basis is also a diagnosis, and she has bone density loss, we’ve got a new evidence-based treatment that looks really exciting, and that is patch estrogen at a very low dose. So why patch versus pill? First of all the pill does not protect your bones. If people take one thing away from this talk, the pill does not protect your bones. Unfortunately. I wish it did! But all of the studies have shown it didn’t and yet OBGYNs, who are very well-meaning, and doctors, continue to prescribe it inappropriately. However, patch estrogen seems to absorb in a certain way, and be metabolized in the body in a certain way, that it’s effective. What is it effective at? Well, studies of adolescent girls with Anorexia Nervosa have shown that when they use patch estrogen by comparison with a placebo, that is, something without medicine in it, when they have decreased bone density and no period, their bones do better at the end of the study time. They have lost less bone density than the people that had the placebo. And the idea behind this is that of course the gold standard for getting better in your bones, as better as you can get, is to fully restore weight until females’ periods come back and often, because as we have talked about with periods, periods can come back at any stage, but it is until full weight restoration, including many months after the first period comes back in someone who happens to get their period back at a very low body weight. The idea is you use patch estrogen to bridge the person to that recovery period. Because every single day that you are underweight, you are losing bone density. So how can we stem the loss? And the answer is patch estrogen. Vivelle is the one that I use. I use Vivelle 100; patients apply it twice a week, Sunday and Wednesday, and it’s always on. But you can’t just give someone pure estrogen and that’s it. Or their uterus lining will grow and grow and grow, and run the risk of turning cancerous. So 10 days out of the month, the way that this study was designed, you give Medroxyprogesterone, 10 mg, which is a pill (everyone makes progesterone naturally, this is something that is natural) and you take it in the evening because it can make you a little drowsy. And 10 days a month you take Medroxyprogesterone, sometimes it will give you a period, sometimes it won’t, depending on what else is going on, but it always protects the uterus from cancer. Patch estrogen is not birth control. It does not work to prevent pregnancy. So let’s imagine that somebody hasn’t had a period in 6 months, they think there’s no way that they could get pregnant, they can. As we like to say before, “eggs happen.” And so this patch estrogen is not birth control. But, not only is this validated in an adolescent population who has no periods and has bone density loss, it’s also getting validated in elite athletes. This is really exciting, because in an absence of an eating disorder, there is something called the “Relative Energy Deficiency of Sport” or RED-S, which replaces the old “female athlete triad” as being a much more 360 degree inclusive, scientifically accurate measure of all of the things that happen to someone in every organ system, physically and psychologically when they’re not getting in enough energy and they’re putting out too much energy with their body. And in athletes, it’s looking like Patch Estrogen plus Medroxyprogesterone helps their bones when they don’t have an eating disorder. Even more interesting perhaps, is that athletes who are on the patch have been found to have better cognitive testing than athletes who have lack of periods and bone density loss who aren’t on the patch. So somehow this little low dose of patch estrogen not only helps the bones, it sort of helps the whole body, because it is more naturally mimicking what somebody would have if their energy balance were proper. And it’s not for athletes, like you say, “oh great, you have the patch; that’s all you need.” No, still work to get into energy balance so that natural systems kick back in. 


So for any of my young female patients below 50 who have no period, low bone density, depending on the person that could be below -1 or it could just be negative anything, I start them on the Vivelle Patch and Medroxyprogesterone. There are other alternatives, but all of them have considerable side effects, and you just have to be aware of them. It’s a thoughtful decision. Unfortunately this is not a situation in which there is a great solution, it’s got no negatives and all positives; this is a pretty nuanced discussion. 


So for some people who have Osteoporosis, let’s say that their period is back. You know, let’s say that they have achieved their body weight and that their period’s back but they still have significantly low bone density, one option is to use a class of medicine called the “bisphosphonates.” Like, oftentimes postmenopausal women use Fosamax or Alendronate, Risedronate, it’s all the “-dronates.” And those are once-a-week medicines taken by mouth. In the moment, they have very few side effects, maybe a little reflux, maybe, you take it once a week on an empty stomach in the morning. Very rarely, if you’ve had a lot of dental work done it can cause necrosis of the bone in the jaw. I’ve seen a couple of patients with that. But it’s well-tolerated and it’s effective, and it’s an anti-resorptive. So it keeps the body from sucking back the bone density. The problem is, in women of child-bearing age, this whole class of medicines stays in your system a long time, far longer than when you are actually taking it. It crosses the placenta, and animal studies have shown fetal harm. 


Tabitha: Wow. Yeah. 


Dr. Gaudiani: Human observational studies (of course no one is doing randomized control trials) have looked promising. That is, where a woman has needed, for medical urgency reasons, to be on this class of medicines, even while pregnant, she and the baby, and then the baby turned into a child, all looked fine. 


Tabitha: Fabulous.


Dr. Gaudiani:  So that’s good news, good news. So if it has to be, it has to be. And you know, I think practitioners feel a different range of comfort in prescribing bisphosphonates for women of child-bearing age. And I think that it’s just a conversation. If I have a 27 year old nurse who is engaged and can’t wait to get pregnant and is really motivated in her treatment and is moving straightforward ahead, I’m not going to put her on a bisphosphonate. I’m just not. These days, because we didn’t have this option before, I’m going to put her on patch estrogen, if anything. If I’ve got an 18 year old who has never been sexually active, has been sick in her eating disorder a long time, and has truly dreadful bone density, in addition to patch estrogen, I might consider. 


Tabitha: Right. Case by case.


Dr. Gaudiani:  Case by case. There’s also a daily injectable called Forteo that builds bone. It’s showing that it’s probably 2-4 times better than the class of bisphosphonates, and that’s pretty fabulous, except that insurance, you just have to wrangle them to cover it. And a daily injection is burdensome and just incredibly expensive if insurance doesn’t cover it. And after 2 years of taking Forteo, you have to go on a bisphosphonate anyway, or you lose the benefit. So there’s that. And there’s also a black box warning on Forteo that they found that when they gave rats 60 times a human-like dose, some of the rats developed cancer because Forteo is a bone-building medicine. To date, the literature shows there are no human cases of bone cancer from Forteo, but it’s out there, and patients will see that information and they will want to know what the story is.


Tabitha: Yeah. 


Dr. Gaudiani: So that’s kind of state of the art at the moment for female treatment. There are some other things coming up. Prolia is one of them, there’s just a number of things that are sort of “on the horizon” but aren’t evidence-based yet. For males, the treatment is testosterone. And this is really really interesting because it turns out that testosterone, usually applied on the skin daily, acts in the same way as the class of bisphosphonates; it prevents bone resorption. So if I have a male who has Anorexia Nervosa, bone density loss, and he has low testosterone levels, defined as testosterone of less than typically 200 on two different occasions, two weeks apart in the morning, (thank you for giving us the hoops to jump through, insurance) then I will prescribe him topical testosterone. And the nicest, easiest version of that is a pretty little patch. Oftentimes it’s more expensive so insurance says, “no you have to use a gel and smear it into your skin,” and okay, if you must. That testosterone does a couple of things. One, it protects his bones. And it may take the edge off. Two, it may just give his brain the boost that is good because you’ve got a sex hormone going on. And three, it brings back sexual function. That’s not always welcome. So I have got to talk to my guys about whether return of sex drive and sexual function is acceptable. Is that scary? Is it safe? And make sure that I am clear about the consequences of treatment. As with estrogen treatment for females, in males you only treat until you expect their natural testosterone to be turned back on. So you know, you get them back into what seems like an appropriate weight range, maintain that for a bit, take them off the prescription hormone, and see if their natural body kicks in. You can’t use testosterone in guys who haven’t finished growing. And we have to remember that Anorexia, if acquired during adolescence, will stop linear growth, for the same reason that the caveperson brain wants to conserve calories in all of the other ways. A guy who is 18 years old might have a bone age of a 15 year old. And you can actually check that by just doing a simple X-ray of his hand. And you can see how close the mineralization has come to the end of the digit, and give him a bone age. Once a male’s growth plates are closed and he has finished linear growth, you can use testosterone for his bones.


Tabitha: Okay. Wow.


Dr. Gaudiani:  But before that, if you give him testosterone, you’re going to slam his growth plates shut and he’s never going to grow again. 


Tabitha: Wow. I actually just, this whole half hour I’ve been sitting here listening to this, and it’s just like, wow. This is so in-depth. And you just have all of this knowledge in your brain, at your fingertips, because this is what you do. You know this stuff. And it just strikes me as to how important that is, because there is so much and I just think that specialization, doctors who specialize in treating eating disorders, as you do, is so needed. Because how could just a doctor who spends probably 98% of their time treating people for non-eating disorder things have all of this information as well as all of the things that they…


Dr. Gaudiani:  Yes, I am grateful for the specialization and love my patients so much, and a lot of the information that other doctors have I no longer have in my brain. Because this is what I do day-in and day-out. Do we have time to finish with just a quick thing about exercise?


Tabitha: Yeah we’ve got plenty of time. Yeah!


Dr. Gaudiani: Brilliant. Okay, thank you so much. Many of my patients have come to me and said, “Dr. Gaudiani. The reason that I run ‘x’ number of miles a day or a week is because it is good for my bones.”


Tabitha: I would have said that. 


Dr. Gaudiani: Of course! Of course you would have. And the answer is that weight-loading exercise is great for my bones, and yours now, as beautifully nourished people. But a very helpful study out of Canada from 2011 showed that (and this was in young women, unfortunately males were excluded, so were older women) in young women, who were doing even moderate exercise while they remained underweight and amenorrheic (without periods), their bone density worsened faster than the ones who didn’t do that. And they included pacing in moderate exercise. Fortunately, for the once and future athlete heroes amongst us, once patients were fully weight restored, even intense exercise helped their bone density. We have to remember that bone density loss is one of the only medical problems of Anorexia Nervosa that may not fully normalize with eating disorder recovery. So it’s quite a significant thing. And I used to conclude, based on that study, in the hubris of being a young doctor, that exercise is a privilege of full recovery. And now I would like to think that I’m a little more humble and a little wiser maybe, because I now know that exercise, or movement, makes recovery sustainable. So in my outpatient practice, if I’ve got a patient who is an athlete who is very motivated, engaged with their therapist and their dietitian, able to not purge, to eat appropriately, I reintroduce movement as early as possible. And continue, within mindful bounds, to escalate it over the course of treatment, because it is joyful to experience your body in nature, if that is one of the things that your body does well.


Tabitha: What about if someone had compulsive movement problems? 


Dr. Gaudiani:  It’s case-by-case too. I try not to make absolutes.


Tabitha: Right. It’s difficult.


Dr. Gaudiani: Yeah! If somebody says to me, “in all honesty, Dr. G, there is no way that I can do any kind of movement right now without counting or wanting to escalate,” then I say, “okay, great, this is going to be a rest time.” But if somebody says, “it’s worth it to me to be allowed to take a 30 minute walk twice a week. It’s worth it to me.” Then I say, “okay, and process through how that felt with your therapist please, because I am a simple Internist, and let’s see how it feels.” And if they said, you know, 30 became 45, became a run, became whatever, then we say, “alright, you’re not ready yet and that’s okay.” But I try to reintroduce it because that’s the life they are going back to.


Tabitha: Absolutely! And you know, for someone who was a very compulsive exerciser, I always say that I had to stop in order to fully recover and rewire my brain and unlink food and exercise in my brain so that they were independent and I could eat without having done exercise. I had to stop and that’s true for a lot of people as well, but that doesn’t mean that I can’t exercise for the rest of my life. That’s not the point. Movement is joyful and I love to walk my dogs and ride my horses and do things like that so it’s like, that’s the whole point of getting that full recovery, is that you can start to do things that are healthy and that you really enjoy, because you enjoy them, not because you feel that you have to. 


Dr. Gaudiani: I think that’s exactly right and I think that, you know, it takes a trusting relationship with your team to be able to say, despite the demands of the eating disorder, “I need a break. I can’t do this safely.”


Tabitha: Yeah. Yeah, that’s the part that I think is the biggest struggle for people, to be able to say that. And also to even, just kind of like as you said, when they recognize, “you know what, I went for that 30 minute walk and I felt like I had to do it the next day and it just made my head busy,” and it’s really difficult to admit that stuff. I think that in admitting it you’re realizing, “okay, I have to stop right now. That doesn’t mean forever. And I’m stopping so that it can be just joyful, and not compulsive.”


Dr. Gaudiani: That’s right. The whole point of recovery is to be in the privileged position of being able to live your values. And if that means you’ve got to postpone some and pause some to get there, then that’s what you have to do. 


Tabitha: Well I think that the first thing that I need to say there, after this conversation, is that while ignorance is bliss, it really shouldn’t have been. From my personal experience, I knew, when I had Anorexia, I knew I was over-exercising. I knew that I was under-eating. I knew that if I went to the doctor too often that she would probably try and stop me. Or maybe I was scared of that, because frankly the doctor never did tell me to stop exercising and rarely even told me to eat more, even when I was presenting very underweight. So my perception was that if I went and talked to anybody about my health that they would tell me that there was something wrong with my health and that I had to change the things that I was doing and I was scared of that, so I didn’t go to the doctor very often. And that allowed me to muddle on for years in this blissful state of ignorance. And I really wish I hadn’t been able to do that actually; I wish that somebody had been able to tell me the things that Dr. Gaudiani has just told me now, about how malnutrition affects our bones (not just our bones, of course, so many other systems), but that was just the one that we were talking about today. So, if you’re listening to this, don’t sit in that place that I did, for so long, knowing this information. Change something. Sort this out. You only get one body, and the body that you’re in right now isn’t ーunless, I mean I could be completely wrong and with the medical science going the way it is, for all I know, in 20 years time you might be able to computer-generate another body, so I could be lyingー but, present-day truth is that you only get one body. And you have to look after this body. And you mustn’t, please don’t allow your fear of changing, your fear of recovery, your fear of weight gain, all of these fears fears fears fears fears, holding you in stagnancy, and keeping you in malnutrition. Because, as Dr. Gaudiani said just then, every day in malnutrition hurts your body. This stuff is important. Get the support that you need. Get the help that you need. And make changes right now. In the words of Elvis, “a little less conversation, a little more action.” You’re listening to podcasts on recovery, that’s great. “A little less conversation, a little more action.” Take the action that you need in order to get better. Thank you for listening folks, and you can contact me; my email is Or you can tweet at me; my Twitter handle is @love_fat_. I’m going to leave all of the contact information and website information for Dr. Gaudiani in the show-notes to this episode, so do look her up. You know, on her website, she’s got lots of really fabulous one-minute videos. So if you’re a bit like me, and you can’t watch any Youtube videos that are longer than 3 minutes, these 1 minute videos will be right up your street. Quick snippets of information in less than 60 seconds. Cheers, and until next time, cheerio! 

About The Gaudiani Clinic

The Gaudiani Clinic provides superb expert outpatient medical care to adolescents and adults of all sizes, shapes, and genders with eating disorders or disordered eating. The Gaudiani Clinic also offers comprehensive person-centered care to those who are recovered from an eating disorder. Through a collaborative, communicative, multi-disciplinary approach, the Clinic cares for the whole person, in the context of their values.

Under the care of Jennifer L. Gaudiani, MD, CEDS, FAED, patients receive expert medical care provided in a comfortable and highly discreet private practice setting. Dr. Gaudiani is one of the only outpatient internists in the United States who carries the Certified Eating Disorder Specialist designation and is internationally recognized as an expert in the eating disorder field. In her role as an expert outpatient medical doctor, Dr. Gaudiani can function as a patient’s primary care physician or as an expert adjunctive physician as part of a multidisciplinary team.

The Gaudiani Clinic is located in Denver, Colorado with both local and telemedicine treatment plans available.

Dr. Gaudiani also offers professional services including private and group consultation, professional webinars, and presentations.

For more information about the Gaudiani Clinic, please visit, call 720.515.2140.

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