Exploring Eating Disorders with Dr. Kara Pepper
Trigger Warning
This episode focuses entirely on eating disorders.
Contrary to common belief that only thin individuals struggle, eating disorders come in all shapes and sizes.
In this episode, Dr. Kara Pepper and I explore the complexities of eating disorders – discussing signs, biases, and how to differentiate between disordered vs. balanced eating behaviors.
Dr. Kara Pepper is an Internist and Executive Coach based in Atlanta, GA. She operates a hybrid telemedicine and in-person practice dedicated to patient autonomy, clinical excellence, and compassion. She is also the host of the podcast It's Not Just You: Stories of Survival, Humanism, and Career Sustainability. Additionally, she offers executive coaching and is the founder of Micropractice Mastermind, a community for physicians in solo practice.
A Closer Look to Eating Disorder
Eating disorders go beyond just food or exercise—they are serious conditions that can significantly impact a person’s life. They often arise from a combination of genetic, environmental, and emotional factors. At their foundation, these disorders involve a struggle with how one views food and their body. What may begin as an attempt to eat “healthier” or follow certain diets can sometimes lead to unhealthy behaviors, such as avoiding certain foods or even over-exercising. When these behaviors start interfering with daily activities, relationships, or overall well-being, they turn into eating disorders.
It's important to remember that health isn’t just about what you eat or the number on the scale. True health includes emotional well-being, a sense of purpose, and enjoying life without unnecessary restrictions. If focusing on eating “clean” or staying physically healthy starts limiting activities like spending time with loved ones or traveling, it may be time to take a step back. Eating disorders can thrive in this imbalance, so recognizing when health becomes a negative force is essential for fostering a full and happy life.
Health at Every Size
Health isn’t about a specific number or fitting into a chart—it’s a deeply personal concept that looks different for everyone. Unfortunately, the idea that health is tied to body size or BMI still dominates much of medicine and society. In reality, BMI is a flawed measure that often conflates weight with health, but that’s not how our bodies work. For some people, their weight may not have any negative impact on their health. They might have great lab results, hike regularly, and feel energized, with no medical reason to lose weight. Shifting the focus from weight to overall well-being—like strength, mobility, and energy—allows for a more meaningful conversation about what health truly means.
This is why the concept of "health at every size" is so important. Health encompasses much more than physical metrics—it includes emotional well-being, mobility, and the ability to live the life someone values. For instance, a patient might say they want to lose weight to feel healthier, but when asked why, their true goal might be playing with their grandkids or having more energy. These goals often have little to do with weight loss itself. By centering care around the patient’s personal definition of health, doctors can provide support that feels empowering, not restrictive. It’s about helping people live their fullest lives, regardless of the size of their bodies.
Breaking Myths About Eating Disorders
A common misconception about eating disorders is that they only affect thin people, but that couldn’t be further from the truth. The stereotype often centers on thin, young, white women, yet research shows that only about 5% of people with eating disorders live in small bodies. Eating disorders can affect people of any shape or size, including those in "normal" or larger bodies. In fact, many individuals with restrictive eating patterns or malnutrition don’t fit the expected image and are often overlooked. This lack of recognition can delay diagnosis, making recovery harder and leading to prolonged struggles with a serious condition.
It's important to understand that a person’s healthiest weight doesn’t necessarily align with societal expectations or a low BMI. Bodies are naturally diverse, and someone’s set point—the weight where their body feels its best—might not conform to arbitrary standards. For those living in larger bodies, restrictive eating can be an incredibly stressful and harmful experience. By shifting the focus from weight loss to balanced nutrition and well-being, we can help reduce the physical and mental toll of disordered eating behaviors, creating a healthier path forward.
Binge Eating Disorder and Misunderstandings
Binge Eating Disorder (BED) is marked by episodes where a person consumes significantly more food than usual, accompanied by feelings of loss of control, distress and/ or discomfort. These episodes occur regularly and can lead to both emotional and physical distress. While occasional overeating happens to many, BED involves a recurring pattern that deeply affects well-being.
A common misunderstanding involves the confusion between binge eating disorder and the binge-purge subtype of anorexia. In the binge-purge subtype, individuals restrict their food intake throughout the day and then overeat in larger amounts due to extreme hunger, often followed by feelings of guilt and purging, whether through self-induced vomiting or laxatives. People caught in this cycle might believe they have BED, but their behavior stems from severe undernourishment rather than overeating patterns.
Clinics frequently see this pattern in individuals who skip breakfast or eat very little during the day, only to feel a strong urge to eat excessively in the evening. This isn't a lack of willpower—it's the body’s natural response to being deprived of adequate nutrition. Misdiagnosing this can lead to ineffective treatments, such as appetite suppressants, which fail to address the root issue: chronic undernourishment.
This issue also ties into broader concerns about dietary advice, particularly with fasting. Intermittent fasting has become popular, but it often worsens this cycle for those prone to restrictive eating. Prolonged periods without food, coupled with the stress of daily life, make it difficult to eat mindfully and in balanced portions when hunger eventually takes over.
For many, the solution lies in maintaining consistent, nourishing meals throughout the day to support both physical and emotional well-being, and to prevent the stress that drives overeating. Tailoring dietary guidance to an individual’s needs is essential for achieving sustainable and healthy outcomes.
Debunking Myths About Binge Eating Disorder
Another common myth is that binge eating disorder only affects people in larger bodies, but that’s not true. In reality, it can occur at any body size. Statistics reveal that only about half of those with the disorder fall into the higher BMI category. Despite this, individuals in larger bodies are far more likely to receive a diagnosis, while those in smaller bodies often go undetected.
There are likely two key reasons for this. First, anti-fat bias in healthcare can discourage people from seeking help. Many individuals in larger bodies face judgment or shame during medical visits, leading them to avoid healthcare altogether. Second, there’s an assumption that if someone is in a larger body, they must be overeating, which increases the chances of diagnosing binge eating disorder in this group. Meanwhile, those in smaller bodies with the same condition are frequently overlooked, perpetuating harmful stereotypes and leaving many without the support they need.
Challenging Assumptions About Body Size and Health
In mainstream media, many health coaches promote the misconception that a smaller body indicates someone is doing everything "right." This is frustrating, as individuals with a “normal” BMI are often viewed as models of healthy behavior. However, these individuals may not be adhering to superior habits. They enjoy desserts, appetizers, sodas, and other foods that are frequently criticized in those with larger bodies. Many of these smaller bodied individuals can honestly attribute their “normal” BMI to genetics rather than healthier choices.
Genetics play a significant role in body size and health, yet this factor is often overlooked in favor of simplistic narratives. Social media influencers promote the idea that adopting their diet or lifestyle will yield the same physical outcomes, ignoring the complex interplay of genetics, environmental influences, and personal history, such as past traumas or adverse childhood experiences.
A one-size-fits-all approach does not account for individual differences. Maybe we should call it one-size-fits-none. Two people could adhere to the same diet and exercise regimen yet experience vastly different results. This highlights the importance of personalized care in healthcare. While guidelines offer a helpful framework, every person’s body and circumstances are unique.
Effective healthcare places the individual at the center, considering their values, experiences, and goals. It’s not about following a prescribed formula but tailoring approaches to meet each patient’s specific needs. This personalized perspective fosters truly impactful and compassionate care.
Fasting and Disordered Eating Behaviors
Fasting has become a popular approach to managing health and weight, but for many, it can lead to negative effects, especially for those struggling with disordered eating. Our bodies rely on regular, balanced meals to function optimally, and fasting often disrupts this natural rhythm.
In clinical practice, I’ve observed how fasting can trigger cycles of obsession with food, binge eating, and periods of under-eating. For some individuals, prolonged fasting causes extreme hunger, leading to feelings of loss of control with eating, and possibly guilt and discomfort afterward.
Not everyone responds the same way to fasting. Some may feel fine, while others experience negative consequences. The challenge lies in identifying who is at risk. Additionally, early exposure to restrictive dieting, whether from societal pressures or medical advice, can set the stage for long-term struggles with food.
Rather than restrictive practices, a health-centered approach focuses on nourishment, movement, and connection. Encouraging balanced eating, engaging in physical activity, and fostering meaningful social interactions promotes well-being without the harmful effects of fasting, especially for those at risk. By prioritizing these practices, individuals can build healthier, sustainable relationships with food and long-term health.
Finding Safe and Inclusive Care for Eating Disorders
If you’re resonating with some of the discussions we talked about and are wondering what to do next, I highly recommend finding a local physician who practices health at every size or exploring Dr Pepper’s practice at https://www.karapeppermd.com/. Additionally, seeking a dietitian or therapist specializing in eating disorders can offer immense and individualized support. Most importantly, don’t suffer in silence!
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