Have you struggled to find the right treatment to help you treat your eating disorder? Are you struggling to find medical support for yourself or your loved ones? How can you tell if a treatment strategy is genuine? In this podcast episode, Dr. Cristina Castagnini speaks about overcoming barriers to receiving quality care with Rebecca Eyre.


Rebecca Eyre is the CEO of Project HEAL, the leading national nonprofit focused on equitable access to eating disorder support. Project HEAL offers direct services to people who are unable to access treatment, providing free treatment, assessments, cash assistance, insurance navigation support, and community education. Rebecca is a licensed mental health therapist who has been treating individuals with eating disorders for over a decade, and she's a vocal advocate at the intersection of eating disorders and social justice. Visit Project HEAL and connect with them on FacebookInstagram, and Twitter. Connect with Rebecca on LinkedIn.


  • Barriers to care
  • Systemic healthcare barriers
  • Be mindful of size-reduction strategies

Barriers to care

  • Systemic
  • Cultural
[Cultural barriers include] Social stigma, the glorification of thinness, and a lot of representation issues in the media. (Rebecca Eyre)
  • Lack of providers
  • Personal
There [are] internal barriers. We think about resistance, shame, and denial a lot as clinicians because they’re still there when a person is in treatment. (Rebecca Eyre)

Systemic healthcare barriers

The biggest systemic barriers are access to healthcare and affordability. They do blend because often people who struggle with financial capacity cannot afford insurance. Insurance does not cover every level of care. Most healthcare plans don’t delineate eating disorder specialists on their provider finders.
What that means is that people who can’t pay out of pocket, between $50 and $200 a session, are not getting access to those outpatient providers. (Rebecca Eyre)
Another systemic issue about getting people to access medical treatment for eating disorders is getting them deemed “medically necessary”. Sometimes a person’s labs and blood work may look “normal” even when they are terribly sick, and this can stop them from being admitted.

Be mindful of size reduction strategies

Sometimes misinformed doctors or practitioners may first recommend size reduction strategies before looking at any other solutions when it comes to eating disorder treatment or health-related issues. This strategy is not based on real care. If any health care strategies are geared towards the ultimate goal is weight-loss, over and above recovery, then they are not real treatment plans.
Changes in input and output that are aimed at the ultimate health goal of weight loss are so destructive. (Rebecca Eyre)
Remember: steer clear of diets, because they are never the answer!



I am a licensed Psychologist and Certified Eating Disorder Specialist. While I may have over 20 years of clinical experience, what I also have is the experience of having been a patient who had an eating disorder as well. One thing that I never had during all of my treatment was someone who could look me in the eye and honestly say to me "hey, I've been there. I understand". Going through treatment for an eating disorder is one of the hardest and scariest things to do. I remember being asked to do things that scared me. Things I now know ultimately helped me to get better. But, at the time, I had serious doubts and fears about it. If even one of my providers had been able to tell me "I know it's scary, but I had to go through that part too. Here's what will probably happen...." then perhaps I would not have gone in and out of treatment so many times. My own experience ultimately led me to specialize in treating eating disorders. I wanted to be the therapist I never had; the one who "got it". I will be giving you my perspective and information as an expert and clinician who has been treating patients for over 2 decades. But don't just take my word for it...keep listening to hear the truly informative insights and knowledge guest experts have to share. I am so happy you are here!


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Podcast Transcription

[DR. CRISTINA CASTAGNINI] Behind The Bite podcast is part of a network of podcasts that are good for the world. Check out podcasts like the Full of Shift podcast, After the First Marriage podcast and Eating Recovery Academy over at practiceofthepractice.com/network. Welcome to Behind The Bite podcast. This podcast is about the real-life struggles women face with food, body image and weight. We're here to help you inspire and create better healthier lives. Welcome. Well, hello everyone. If any of you out there have ever been frustrated with trying to access or get coverage for mental healthcare, I'm sure you're not alone. More specifically, if you've ever tried to get either one of those for eating disorders, I can only imagine the hurdles you've faced. I would love nothing more than to see the day when mental health illnesses are viewed and covered the exact same as any other illnesses. But until then, thankfully, there are organizations that are out there trying to do something about all of this, and I'm really excited to have someone here today from one of those organizations to talk more about what they do and discuss more about barriers to treatment. Rebecca Eyre is the CEO of Project Heal, the leading national nonprofit focused on equitable access to eating disorder support. Project Heal offers direct services to people who are unable to access treatment, providing free treatment, assessments, cash assistance, insurance navigation support, and community education. Rebecca is a licensed mental health therapist who has been treating individuals with eating disorders for over a decade, and she's a vocal advocate at the intersection of eating disorders and social justice. [DR. CRISTINA] All right, Rebecca, welcome to the show. [REBECCA EYRE] Thank you so much for having me. I'm excited to be here. [DR. CRISTINA] I'm happy you're here. There's so much to get into and I haven't had anybody on here really to get into the nuts and bolts of Project Heal. For the audience, for me even to to know more, can you tell us about Project Heal, like how it got started and how you started to get involved in it? [REBECCA] Absolutely. Project Heal is a national nonprofit, and were the only national nonprofit that's focused on equitable access to care. We were founded in, gosh, 2008 by two teenagers who actually met in treatment, Cristina Saffron and Leanna Rosenman. They essentially saw how many people's insurance prematurely cut off and how many people couldn't even get in because it was too expensive or their insurance didn't cover it and so when they were 15 years old, they decided to start Project Heal, to raise money to help people pay for treatment. I think what's really fascinating and beautiful about that story is that a lot of teenagers in recovery have big hearts and they really want to pay it forward and they care a lot about the recovery community. Then those passion projects fade away as they graduate from high school and go to college or need to get jobs. I think what's really special is that Project Heal is still here 14, 15 years later. We really were a back burner, I think, passion project for these two brilliant teenagers for a number of years while they did go to high school and college and focus on their own healing. Certainly, did some really cool things during those years, but it really wasn't until they graduated from college that they made a decision, like, do we keep going or do we call it a day? So they doubled down and they really took it seriously and started hiring staff and Cristina became full-time CEO and so poured all of her blood, sweat and tears into making this a reality and Project Heal became one of the leading eating disorder nonprofits in the country. So in 2019 when Cristina stepped aside, she's now on our board of directors, but she left Project Heal, the nonprofit space to start Equip, which is a for-profit eating disorder program that's offering virtual bundled FBT care and it's really, really remarkable. I think she saw that as a really incredible way to accomplish her same heart for Project Heal, which is to make sure people can access care. But Project Heal still needed to exist, but it was also the beginning of the pandemic. Anytime a founder leaves a nonprofit, there's a crisis of identity. It's built around the shiny founder and everybody loves a founder, CEO of a nonprofit because it's so personal. So I think everything was really up in the air, like I said, it was the beginning of the pandemic and I was the program director of our treatment access programs at the time, and I was approached to step into the CEO role and I was like, yes, yes, let's do this. It was a really interesting moment in time and not just a month and a half later, George Floyd was murdered and the whole eating disorder community started reckoning with some of the ways in which it's not equitable. So our role as a treatment access focused nonprofit became really clear that we needed to do much, much, much better around talking about the systemic barriers to eating disorder care in addition to the financial and healthcare barriers that we had been talking about for a really long time. So we dug into who is not accessing care? Are there communities that are disproportionately affected by these barriers, and lo and behold, absolutely there were. So really in the last two and a half years since I've been CEO, we've focused on all of the ways that systemic barriers compound those very pervasive financial and healthcare barriers and focused on, I think going above and beyond and out of our way and centering people who have long been excluded or just absent from the eating disorder community. It's been really transformative for Project Heal, for me. It's a very interesting space. I've said this while we were getting set up for the call, but the eating disorder field is one of the most inequitable spaces in all of healthcare and the disparities are really profound. The homogeneity of the eating disorder field is so far off from the actual statistics of who has eating disorders, that there's sort of no justification for the stereotype that eating disorders are like a thin, rich, white girl problem. Those are not the only people affected by eating disorders so why are they so often the only ones in treatment, the only ones who end up healing and then joining the eating disorder community and then joining the eating disorder feel as providers? It's this cyclical problem that perpetuates itself as long as access to care is limited and biased and cost-prohibitive and under covered by insurance, then it's going to be only like the privileged few who can actually receive treatment that they need in order to heal. So we look around and go why are there only 12 black dieticians that treat eating disorders in the entire country? What's that, 12 human beings? It's just, there's so many wild statistics about this, but it's been a huge privilege and challenge for me as a cis-white lady to tackle I think a lot of those disparities and make sure that Project Heal's representative of the entire eating disorder field on our staff and on our board, and making sure that we're centering those communities that need the most resources and thinking about it as equity and not ne not just equality, but like actually disproportionately and prioritize it, disproportionately prioritizing those, those folks who are most likely to have multiple barriers to care. We certainly do serve all kinds of folks. Everyone we serve is low-income and has insurance barriers but there's certainly a lot of ways in which either body size or disability or race or gender or sexuality or identity essentially have provided additional barriers on top of all of those other barriers. So I really love what I do. It's a huge privilege and honor to be able to lead this organization during this particular season in history. We've certainly pivoted a lot, but we're also doing so much better than we ever had in terms of actually delivering treatment access to folks. I know I've been going on for a long time, but how I actually got into this, eating this into Project Heal in the first place is that I'm an eating disorder therapist, and I've worked in treatment centers and in private practice, and I've s I've worked in admissions at treatment centers. I know how many people will get turned away because they have Medicaid, how many people get turned away because I know we can't get insurance authorization because they're not underweight. How many people get misgendered in treatment. How many people essentially walk into a treatment space that's primarily designed for folks with anorexia and assumes body image disturbance and all of these things that are not necessarily a core part of everyone's eating disorder. So I care a lot about eating disorder treatment and access to it and so I can't believe how lucky I am, I think, to get to do this work at this time in my history. I think ultimately, I'll end up being, just going back and being an eating disorder therapist and a trauma therapist, like I'm a clinician at heart. I'm not a nonprofit executive in my blood. but I really love this specific organization and I just get to work with some of the most amazing human beings and do work that I feel really matters and gives my life a lot of meaning. So I feel really lucky. [DR. CRISTINA] Well, and it sounds like the people you serve are very lucky too, because you have such a history and background. You've seen the other side of things when people aren't able to get care and that's the part that I would love to talk about a little bit more. You talked about all these barriers to care, and I think maybe people listening are going, what if they don't have those barriers? They might not understand what they are. Certainly, if some people are listening, they're going, yes, yes, yes, I get it. But maybe we could delve into some of those a little bit because I think that we don't talk about them enough. and certainly, myself as a clinician I see them as well. I'm very frustrated with insurance, just mental health in general, let's not even get into eating disorders. Insurance for the most part doesn't cover mental health treatment. It's very frustrating as a clinician for that end. I don't think mental health is seen, treatment is seen as necessary or I don't know, even as respected as other areas of medicine or other areas of health. So let's get into what happens with eating disorders that you've seen because you've been in clinics, you've been in treatment centers and you've tried to get authorizations for treatment. So what have you seen? [REBECCA] I think of the barriers to care in a couple of different categories and project Heal's Mission specifically names systemic healthcare and financial. So I'm happy to dive into what some of those are. I want to just add that there are a lot of other barriers that Project Heal being a relatively small and underfunded nonprofit can't necessarily get into but I think of, I'm trying to pull up this list. So we have I think an understanding of systemic, there's also cultural barriers to care, like social stigma, the glorification of fitness, a lot of representation issues in the media, but there's also qualitative, which I know you probably understand a lot of as a clinician, like how few people are getting trained to treat eating disorders, how limited quality control is for eating disorder care, how ununified the eating disorder field is in general and like what standards of care is, what treatment protocols are for different diagnoses, different genders, different ages, et cetera. I think there's also logistical, geographic barriers. There's no treatment center anywhere near me. There's no specialist anywhere near me. I live in a rural area. I can't physically get there. I don't have the technology to do telehealth, all of those sort of logistical or I can't get away from my pets, or I can't get away from my kids, or I can't get away from my job. I mean, there's, there's a lot of things that stand in the way logistically. The thing that most people talk about is the personal, and I just want to name that, there's internal barriers. We think about resistance and shame and denial a lot as clinicians because they're still there when a person is in treatment. They're always working through some ambivalence, some lack of understanding about their own eating disorder or about eating disorders in general. They're oftentimes thriving in isolation and hidden and not articulated. They're needing to be observed or they're behavioral. I think a lot about how many people, out of the 30 million folks who will be diagnosed with an eating disorder in their lifetime, if 24 million of those are never getting care, a good chunk of those are never getting care because they're not acknowledging they have an issue, they're not willing to reach out for care, they don't think it's serious enough. They would never tell anyone about it. So those are not necessarily folks whose barriers were helping overcome. I mean, my mom was one of those people who never got eating disorder treatment and struggled for decades. It's not because she didn't have the money or the insurance or anything else, it's because she simply didn't want to go to treatment and so she never healed. The barriers that Project Heal is focused on are the systemic healthcare and financial. So healthcare is a little bit easier to understand. Insurance doesn't cover every level of care. Insurance is not in network with every single treatment center. Most healthcare plans don't delineate eating disorder specialists on their provider finder tools on their websites. A lot of eating disorder specialists are not in network with insurance because low reimbursement rates or administrative overhead is just too onerous and frankly, they can keep their practices full with cash clients because there's so many people with eating disorders. So the cost-benefit analysis of taking insurance sometimes just doesn't rise to that level but what that means is that people who can't pay out of pocket between $50 and $200 a session are not getting access to those outpatient providers. There's also some issues with the medical necessity, which I put in quotes. That is a really core part of insurance authorization. Treatment providers are beholden to this very nebulous ill-defined idea of medical necessity. We know that if a person is medically underweight, has significant abnormal labs or has an abnormal EKG, those things will help a person get authorized. What's really wild about that is that eating disorders are a psychiatric condition in the DSM. They're a mental health condition that have in many cases medical symptoms and medical implications but to have medical criteria requirement for a mental health condition is totally unique to eating disorders. You don't have to be able to show in your lab work that you're depressed. You just believed and you get care. You don't have to be in liver failure in order to get alcohol treatment. You just have to use alcohol. So the fact that this mental illness, which should be measured by behaviors, thoughts, and impact on quality of life is being measured only by medical necessity, which is not universally defined by these insurance companies nor transparently communicated, it's just a blanket, an umbrella statement that gets used as a justification for unfair insurance denials. That's troubling and should trouble all of us. It's a huge loophole that insurances utilize in order to avoid paying for what is understandably very expensive treatment. So those are healthcare barriers. I know that we all have experienced those. As long as, even private insurance, so inadequately cover eating disorder treatment we're that much further behind with Medicare and Medicaid, which basically means that anyone who is poor, old or disabled is like off. They either have to be super, super, super high acuity, even then they can only get into inpatient, which is very unlikely to have high-quality eating disorder care or they're an outpatient, again, within network providers who may or may not be any good. I don't know, there's just not enough of them. There's not a large network. I mean, we're talking about a handful a couple dozen in the country that take those government funded insurances. And yes, if you're struggling with a disability or you're over 65 or you're low-income, you're probably not going to have all the resources it takes to do all of the work to navigate finding these providers because it's really, really hard even if you have money and time and clarity of mind and all of those things and like super high functioning health. It's already hard and add onto that maybe even immigration status or a like lack of insurance altogether, or a language barrier. I mean, good luck. Add onto that a family who doesn't support you, a family that doesn't believe you, a partner who doesn't believe you or support you. I mean those things are really hard. Financial, I mean, eating disorders cost a lot of money to treat. They're just expensive to treat. Like I mentioned, the outpatient costs are high. I mean I'm a CEO, I pay $175 out of pocket for my therapy sessions and it hurts every time, and that's just one provider and needing disorder patient might need a therapist, a dietician, a psychiatrist, a primary care provider, and who knows, maybe like a rheumatologist, maybe a GI doc. There's so many different kinds of things that a person may need an outpatient. Then with the higher levels of care, maybe it's even you're lucky enough to have it covered by your insurance. Most of the time you have a few thousand dollars of a deductible. So you're still paying thousands of dollars out of pocket and if your insurance cuts you off, maybe you'll dig into your savings. I mean, I've seen families take out second mortgages, huge loans, rack up tens of thousands of dollars in credit card debt because their child is sick and they are going to do whatever that it takes to get their childcare. It puts people in a lifetime of debt in many cases and even the privilege of having access to a credit line to get go into debt is a privilege. Not everybody can borrow money. Not everybody has a credit card with more than a thousand dollars limit. Not everybody has a network that they could raise money through a GoFundMe or borrow money from a parent, or, do you know what I'm saying? All of these things are like totally rare. So yes, ideally insurance covers and your eating disorder treatment, but even in those cases, there's just so many tertiary costs. How do you pay your rent if you're taking a leave off of work? How do you pay for your childcare while you're in php during the day? How do you cover your flight? How do you pay for your family to live nearby while your kid is in php out of state because there's no in-state place? I mean, this is expensive and so those are I think, really, really tricky things to overcome and again, really limit the viability of getting eating disorder care for many people. Lastly, systemic, I mean, this is really a lot of what I've talked about before, but I think it's really important to note that it's very well documented. And Project Heal is in the middle of publishing a report based on some research we've conducted that there are barriers in place with eating disorder, treatment providers and treatment centers and insurance companies, and just in our clinic cultural imagination around who has an eating disorder. So when you are a transgender person, when you're a person of color, when you are a higher weight individual, when you're a disabled person or a neurodivergent person, if you have these things that sort of fall outside of. Or if maybe even you're just older than 24, if you're just like an older adult, maybe you're in your fifties. All these things make you a "non-traditional" eating disorder patient or just like, sort of outside of that stereotype of who is most likely to be in eating disorder treatment. I mean, this is just the truth. Anyone who's been to a treatment center looks around and it's like most of these people look like each other. Most of the providers look like each other. So if you are outside of that stereotype you are going to feel really, other than the whole time you may have to sleep in a room with someone who's not your gender because you're trans, but your papers haven't been documented and may get misgendered the whole time you're there. You may like be Muslim and not be able to eat the food that is being served by the treatment center. You may have a bed or chairs at the facility that physically do not hold your body. You may have expectations of your treatment plan that just simply do not work for you in your neuro divergence. Or you may, may have to climb stairs to get to the treatment center, but you, you have a disability; all these ways in which our healthcare system and our society at large is just designed for a "norm," which I again put in that is simply not true. It's like there is no universal experience of having a body and there is no universal eating disorder experience and the treatment landscape has really designed a standardized one-size-fits-all. I mean, there's a lot of claims of individualization of treatment, which I love and hope is happening. But a milieu is like very standardized. We have this schedule, we have these meals, we have this group format, we have this frequency of sessions, we have this language we use, we have this furniture that we have, we have this medical equipment, and it's like, it doesn't account for the actual diversity and breadth and kaleidoscope of the eating disorder community. So a lot of people who can walk into those spaces and know it wasn't designed for them don't feel safe right away, which is not conducive to their healing. It's another space in which they feel othered or even pathologized for their difference. Those are the things that I think a lot about when we're talking about systemic barriers. So when you lay them all out, I mean, we have a running list at Project Heal that we're working with of like 150 barriers to care, so it's not easy. All of this amounts to what I said before, which is like anywhere from 10 to 20% of people with eating disorders are able to access care and the other 80%, 90% are not accessing it. I think we really need to ask ourselves why, especially when this illness is one of the most fatal mental illnesses claiming at least one life every 52 minutes. Let's figure out how to make sure that none of those deaths are preventable through access to care. [DR. CRISTINA] Well, that's a big list, but as you were talking, my head was spinning to squint, yes, yes, yes, there's so many things. And I can see just with some of the ones you were talking about in terms of even just the family, the burden it would put on the family. I've heard this certainly from my patients, like the shame and the guilt that alone would, excuse my word, but like weigh on them, like the strength of that. That's where they would be like, no, I'm not going to go in because I'd feel too guilty. It would burden me too much emotionally to go in. I can't. So it was, even if the family were willing to do it, someone taking on all that guilt or responsibility, sometimes it's too much. It's so sad for me to hear all of these levels and I think you're right, the criteria, I so often how, I don't know how often you hear this, but I hear all the time, well, they don't look like they have an eating disorder or even the patient themselves, why don't look like I have one? They're no one's going to believe me. That right there is so telling. Like, I know they know they're struggling on some level, but they're like, they don't want to go into a group. I'll say why don't you come into a group? No, because I'm not going to look like I'm sick enough, that term sick enough. [REBECCA] Yes, exactly. That's one of the huge costs of this stereotype and why we have to be talking about it because it's not just that we're misinformed, it's that it's totally gaslighting and invalidating individuals who a hundred percent have eating disorders and need access to care because they have that stereotype too. As long as it has any space in our cultural conversation, let alone medical and clinical conversations, we're going to have a bunch of people whose mental illness is telling them that it's not that serious and then everyone around them agreeing with them. If your insurance literally denies you based on medical necessity and your mom is trying to put you on a diet and nobody in the facility looks like you, I mean, what else are you supposed to think? [DR. CRISTINA] Well, this going back to medical necessity too, like I cannot remember the last time, it's probably been about a year and a half, that I have had one patient come back with a lab that had one abnormality on it, and I know they're very, very sick. It is so rare to get a lab that has anything show abnormal, even if somebody is like on the brink of death. It is just so rare. I've talked to colleagues about this because it gives us false sense of I'm okay and that's the scary part to me too, is oh gosh why I was questioned, that why is that this person is so sick and not eating enough or just, something's got to be off and there's a system, but why is this showing stable? What's going on? It's wild. [REBECCA] Yes. It's like, especially when you've had this an illness for a really long time, and I mean, I'm preaching to the choir here, given that you're a doctor, it's like your body can adjust to a lot. Our bodies are really resilient. I think about, yes, how many people who I've seen, who I'm hearing how restrictive they are, how many times they're using these behaviors in a day, how long they've been using it and I'm just literally like looking at them going like, if I did that even for three days, I would be in a coma. But they have basically acclimated over time and their body has done all who knows what to protect them. Whether it's like growing leu or shutting down reproductive organs or diminished cognitive functioning. The body is trying always to keep its organs running, especially it's essential organs. So those whose bodies are more resilient shouldn't suffer because their bodies are able to survive in unthinkable circumstances. Then there are other folks who are so medically fragile who seem to be like even in a treatment setting, I'm watching them eat adequately. I know they haven't used these behaviors and like they're just still have these abnormal labs and it's like, I just think this isn't a good metric. I think it's something, it's not a good, it's important to measure, it's a really bad determining factor. It should not be a requirement because it's too inconsistent. [DR. CRISTINA] No, I totally agree with, I mean, we could get into the medical field. I know you and I were talking a little bit before we recorded just, I mean, even that alone, the messages from medical doctors and the criteria when you just go for a checkup or something this perpetuates so many ideas about body size and health and all sorts of things that I think you said contributes to people's ideas about what, when I ask people like, what do you consider healthy? They just go to labs and they go to weight and they go to like all these criteria that like, you're avoiding one or you're ignoring all these other areas of health, like your emotional wellbeing and how are you doing on all these other areas of your life? But I think when you go to the doctors maybe you could touch base with me on this too, but you know the BMI needs to go away. Oh, the discussions on "healthy" verses unhealthy foods and the people drilling out the information on what that even is. This focus on this diet culture we're in, and I mean, you go on the internet, it's a scary toxic world out there. I don't know what are your thoughts on all that? [REBECCA] Yes, I mean, I couldn't agree more. I think weight is just usually an unnecessary measure to take in a doctor's appointment. I mean, weight fluctuations, yes, but I mean, I've experienced so much unnecessary weighing throughout my life and so much unnecessary commentary about my weight. What's really interesting to me, and I always use this as sort of an inverse example, is I'm a genetically thin person. I've always been thin. For that reason, I've always been presumed to be healthy by everybody. Meanwhile, I have had like terrible anxiety. I've had poor sleep, really poor hydration for so long. I smoked cigarettes for years. I've had periods of like drinking alcohol as like a primary coping thing. I wouldn't say reached the threshold of addiction, but like absolutely over the recommended amount for alcohol intake in terms of frequency. But because I was thin, everybody's like, but I'm not too thin. It's less like, oh, the just total blanket, you're fine. So to me that's such a like, helpful inverse of someone who then is in a higher weight body or has other health considerations that are absolutely, just like my health was assumed based on my appearance I feel like a lot of folks health is assumed based on their appearance and obviously to much greater detriment, like the world is totally set up for me as a thin person. So I don't experience any hardship about my body size, which is such a huge privilege but when you're large or in a higher weight body, it's like the world is not designed for you. You're pathologized by everyone you see, you're judged when you're at a restaurant based on what you order, you're judged at the gym, whether people are cheering you on or telling you to go home. Like all of these assumptions that are made and to have those same assumptions happening at the doctor's office is really, really scary. A doctor prescribing a diet, this is like one of my absolute, I just can't handle this. So many doctors are prescribing basically eating disorder behaviors, weight loss measures without evaluating any of the other levers, any of the other, like what is your intake? What is your relationship with alcohol? What is your relationship with exercise? How is your sleep. How's your hydration? What is your mental health status? What is your historical weight? What was your growth chart as a child? There's so many things to ask before you jump to the prescription of a diet, which importantly is 97% ineffective. Imagine if you had a medicine that was only 3% likely to work and would increase your chances of developing a fatal illness by 50% and you prescribed it without asking any other questions. That's what the medical field is doing. [DR. CRISTINA] I love that you said it like that. It's outrageous like that [REBECCA] It's so dangerous. It should be illegal. [DR. CRISTINA] I agree with you, 100%. I said that so many times, diet should be illegal. [REBECCA] And the idea of a diet, I want to be clear, we're talking about body change behaviors, like size reduction strategies. I'm not talking about, oh, I get inflammation when I eat broccoli, so I need to change my diet. Cool, work with a dietician to figure out a way to get whatever vitamins are in broccoli because you can't have it because it makes you constipated. I don't care. It's about changes in input and output that are aimed at the ultimate health goal of weight loss that are just like so destructive and never, and almost never actually take. I know you understand this. I'm just saying this to whoever's listening where it's just like, right. We're not saying that there isn't a way in which your food can be helpful in your sense of feeling in your body. If intuitive eating is not a thing that you have access to, then great. Work with a dietician on flexibility, variety, adequacy, all those things. Cool. Think about what you're eating. Great, I love that for you. But to think about it to the point of preoccupation for a goal of changing your body will always be bad for you. [DR. CRISTINA] Yes. It's interesting because there's still that connection, and I won't repeat this on so many podcasts, sorry, but, for anyone who's listened before, I apologize, but it has to be said over and over because I was even listening to another podcast the other day and they had a sponsor for Weight Watchers and it just made me cringe. This person was talking about, I had to go and for my health, I had to lose weight and it helped me lose weight for my health. I mean, it was said so many times over and over. So then I brought in my friend and told them for your health, you need to lose weight too. You can go there and get healthy there. I was like, why are they equating health and weight loss? This is making me sick but it's perpetuated over and over and of health and weight, to your point. You can't look at somebody and know if their physical wellbeing has any illnesses or diseases or you don't know what's going on. Health and weight are not correlated, and yet our society perpetuates that so people feel the pressure, like my doctor told me I need to lose weight to be healthy. I'll ask like, why? What is that going to "fix" what's happening? [REBECCA] I know. Well, and interestingly, science is fairly clear that the actually problematic thing is dramatic weight fluctuations and rapid weight fluctuations. So it's actually, if you happen to temporarily succeed at this diet, you're actually less healthy. I just think about that so much where I just, I'm like what would it be like to think much more about weight change? To me, if you gain X number of pounds in a very short period of time, definitely think about that. What's going on. If it's not correlated to a medication change or a pregnancy or like a typical, I mean, gradual weight fluctuations over time, a hundred percent, they're universal, they're unavoidable. There's nothing that anyone like we should expect them. I'm talking about like dramatic weight fluctuations in either direction. So what's really troubling to me is that someone who starts at X number of weight and loses a dramatic amount of weight really quickly, might still technically be seen as high-weight, might still not be underweight, but they could be just as sick or more sick than someone who's extremely thin and who might get a ton of attention for that. [REBECCA] Because it's actually the weight loss that is so damaging. Then again, because so many diets result in weight gain, it's those at yo-yo dieting that's resulting in so many of the health complications that are attributed to being higher weight. It's like, no, it's the diet you prescribed that's causing the rapid weight fluctuations that are leading to the symptoms that you're then going to try to fix with another diet prescription. That all the while this person is going to feel like they keep failing at these diets rather than realizing that they're being prescribed a toxin [DR. CRISTINA] So the psychologist is also thinking of the psychological damage that oh, that that toll takes on somebody that I'm not good enough, I'm a failure, I need to try harder, the shame, the embarrassment of if they did lose and "become successful" and then they gained it back, what does that mean? It's just a nightmare. It's takes such a toll on the body emotionally, physically, and so anyone listening, please hear what we're saying, just stay clear of diets. They're awful, awful. I know there's the pressure out there and it seems like they're like the holy grail to give you all this, whatever you're searching for, but they're really, they're just going to bring you down a road to hell, in my opinion. I've been there, done that. It's awful. [REBECCA] Yes, and I feel really strongly that doctors are the main audience that has got to change their mind about this because they have the most power, they're perceived I think by many as trustworthy and should be entrusted with a person's wellbeing and committed to not doing any harm. So that is just scary. The diet industry, all the ads you see, all of the magazines that are selling before and after photos, just like know that you are, they're making a lot of money off of you and that cycle of shame and I need to do better and I have to try again and all of those things. That is a beautiful business model to give people a completely unattainable ideal that they will spend all of their time and money being preoccupied with. I get that. I think it's disgusting. Yes, I would love to burn all of those buildings down. [REBECCA] Of course, I can't handle it. It's the doctors where I'm just like, come on, we just like, do better read the research. What are you up to? It's really where you realize that doctors are people who have their own bodies and their own relationship to body image and their own history of dieting or family members. They're being really influenced by a cultural idea and not the actual medicine. Because I think doctors who are paying attention should notice not only how ineffective it is, but how damaging it is. That's where I'm just like if you're not making billions of dollars and you're not evil, could you cut it out? That'd be nice. [DR. CRISTINA] Just now in my private practice and doing this, but I worked at a hospital for 15 years and I cannot tell you the frustration I had. There was not one primary care doctor that was willing to really partner with me and be like the eating disorder person doctor that I could go to send my patients. It just wasn't, they didn't know enough about eating disorders and I guess they were, they didn't feel comfortable because they didn't know anything about them. So that scared me out of this whole hospital full of doctors and not one I could find that was knowledgeable enough to work with me? I was like, wow, this is really eye-opening [REBECCA] I actually say that a lot where I feel like eating disorders have fallen into the gap between medical and psychological, where it's like so many medical doctors like you just described are like, "That's too complicated. Psychiatric, I'm not that, I can't handle that. I don't know how to handle it." Then a lot of mental health professionals are also like, "That's too medically complicated. I don't want to touch it with a 10-foot pole" like, liability issues alone. I think that for a lot of mental health, it's too medical, for a lot of medical, it's too mental health and they're not talking to each other and it's costing people their lives. It's not okay. I think we need to have, I wish I could, I wish I had more money and power and agency and audience so I could just bring all of these people together in a stadium and go, "Turn to your neighbor. Talk to them." I mean, and this is another cost of the stereotype and I know we're running out of time, but it's like most eating disorders are not that medically severe. Most, like the majority are mild to moderate. They're happening in people's daily lives, are persisting for a really long time. They're impacting their quality of life, but they're not probably about to drop dead any second. It doesn't have to be this huge medical mystery. For the doctors who are trying to figure out how to bring eating disorder competency into their practice, it's like sit down and listen just for a little while. It's not actually that complicated necessarily. It's complicated and it just doesn't have to be the boogeyman that you won't touch because they're in your patient pool, like these folks are there and you're just choosing not to learn about how to help and how to prevent. That's just unacceptable. [DR. CRISTINA] Yes, because whether people ask the right questions or want to acknowledge what's really going on, you're absolutely correct. They're seeing patients who are struggling with the eating disorders and need help and [REBECCA] Have no idea. [DR. CRISTINA] Yes, or conversely, because of the way these biases are occurring in the medical field, people aren't coming in for treatment. They don't want to deal with the biases and all of that. So it's causing problems the other way too. People just don't want to go in. [REBECCA] Even if they're like, I don't want to be an eating disorder specialist, I don't want to have this as a primary focus, just be eating disorder-informed so you could stop telling people to lose weight because it's, like just if you are going to be trauma-informed, if you are going to be just knowing that it's there so you can do less harm, that's really the main thing I'm asking. Because it'd be really awesome to have fewer people go into eating disorder treatment and say, this all started when my doctor said X. That'd be really helpful. At the very least if they're going to be predisposed and maybe they'll develop an eating disorder anyway, maybe you could not be the one who triggered its onset through your lack of information. That'd be really helpful. [DR. CRISTINA] Oh, yes. The amount of stories I've heard, even experienced myself, I'm sure we could do a whole other podcast just focused on things that got triggered in certain offices by different providers. [REBECCA] Yes. [DR. CRISTINA] Well, I'm glad we're on the same page with that. I mean, we could, we could probably talk for hours on so many different aspects of things, but I'm so grateful you're doing the work you're doing and providing the help to people that really need it. If somebody is listening and or they know somebody who really could use your services, how can they get in touch with Project Heal? How can they seek the resources you have? [REBECCA] We're really active on Instagram, so follow us there if you just want to learn more or stay up to date on different program offerings. But the best way to actually get help is to apply for support at our website. Our website is theprojectheal.org with the t-h-e at the beginning. Yes, apply for support. We have, we can get people into treatment for free. We can do free diagnosis and harm reduction-based treatment recommendations. We provide cash assistance, which covers those tertiary costs I mentioned earlier, we have an insurance navigation program that helps people understand their rights, that helps people get insurance that will cover it, that helps people file appeals or get single-case agreements. There's help available around a lot of these barriers and certainly if you're having a difficult time getting into care, don't give up before you try Project Heal. We do everything we can to say yes to as many people as possible with some resources and your life is worth trying to save. I know that it is really, really hard to have an eating disorder and to feel motivated enough to jump through all of these hoops. I want to acknowledge that and do it for future you who deserves some freedom from this thing. I really, really hope that we can create a world where eating disorders are not a life sentence or a death sentence, but are something that is easily treatable, affordably treated and something that can be something that happens and is easily handled early on in a supportive environment. So that's my goal. In the meantime, get the care that you need. [DR. CRISTINA] Love the goal and everything you're doing. Thank you so much and as a provider myself, I just thank you. More people to get help and treatment. It's for the better. Then is there anything coming up at Project Heal that you want to mention for anybody who might want to, maybe they don't need treatment, but they want to donate or help the organization? [REBECCA] Yes, we have our annual heal week, the week of October 2nd. But we are entirely donations-based. We don't have any organic revenue and so we really rely on the generosity of people who understand what we're doing, corporate partnerships, foundations, and peer-to-peer fundraising. So maybe raise money for Project Heal on your birthday or for the holidays or if this is an issue that's close to your heart, we need all the help that we can get. Raising money for equitable access to eating disorder treatment is not the most glamorous, easy-to-understand thing. So if this is something that you get, it would mean a lot to have the resources we need to say yes to every single person who comes to us. [DR. CRISTINA] Well, Rebecca, thank you again so much. Everyone, if you need help and treatment, head on over to the Project Heal. Thank you again, so much. [REBECCA] Thanks, Cristina. This is really great. [DR. CRISTINA] This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, accounting, clinical, or any other professional information. If you want a professional, you should find one.