On today’s episode, Dr. Karen Nelson is joined by Dr. Jill Leer. They will discuss the intersection of eating disorders and bariatric surgery.
On today’s episode, Dr. Karen Nelson is joined by Dr. Jill Leer. They will discuss the intersection of eating disorders and bariatric surgery.
For a transcript of this episode click here.
Dr. Karen Nelson: [00:00:00] Eating disorders thrive in secrecy and shame. It's when we create a safe space for honest conversation that we'll find the opportunity for healing. Hi there, I'm Dr. Karen Nelson, licensed clinical psychologist at Melrose Center, welcoming you to Melrose Heals, a conversation about eating disorders. A podcast designed to explore, discuss, and understand eating disorders and mental health.
On today's episode, I'm joined by Dr. Jill Leer. Jill and I will discuss the intersection of eating disorders and bariatric surgery. Now, before I begin, I invite you to take a deep breath and join me in this space.
Well, welcome to the podcast, Jill. So happy to have you here with me today. Well, before we get started, I would love it if you could introduce yourself and tell us about your [00:01:00] role here at Melrose.
Dr. Jill Leer: All right. My name is Dr. Jill Leer, and I've been at Melrose about 13 years. As part of that time, I was over at the Bariatric Surgery Center supporting patients preoperatively and postoperatively. Now that I'm working at Melrose solely, I really focus on the treatment of eating disorders in bariatric surgery patients.
Dr. Karen Nelson: Let's maybe set the stage a little bit. Melrose Center has a special part in the assessment process for bariatric surgery. I would love it if you could maybe help our listeners know a little bit about that or what that looks like.
Dr. Jill Leer: Sure. Here at Melrose, we're very lucky to have a nice collaborative relationship with the Bariatric Surgery Center. And through that relationship, we're able to help patients who maybe are struggling with eating disorder symptoms or particularly may have binge eating symptoms. Binge eating disorder [00:02:00] is very common in patients who pursue bariatric surgery. Depending on the study, it can be up to 40 percent of that population. However, it's important not to rule out other eating disorder symptoms in that population. Sometimes people who come over will then endorse a history of purging. Or they may also meet criteria for atypical anorexia, meaning they are a different weight than what people would typically expect with anorexia, but they are significantly restricting their food intake. We're able to identify that and help support them in interrupting symptoms before they start their surgery process.
Dr. Karen Nelson: Absolutely. So let's maybe talk about that, as someone makes the decision that I want to pursue weight loss surgery or bariatric surgery, tell us about maybe some of the initial processes of that assessment and then what a patient might experience or what that might look like for them.
Dr. Jill Leer: So if you're [00:03:00] interested in bariatric surgery, a lot of times there is an online – a recording informational session related to surgery. And after you do that, you fill out some paperwork and then you usually meet with their multidisciplinary team, which includes a bariatrician, a dietician, as well as a psychologist. And then through the psychological intake, if the provider would feel you would benefit from extra support here at Melrose, then they may refer you for an assessment here.
Dr. Karen Nelson: And so let's make the assumption that it has been determined that someone could potentially benefit from support here at Melrose. Maybe give us a little insight into, what is that assessment like and what types of questions might they be asking?
Dr. Jill Leer: So, over at Bariatric Surgery, some of the questions that are asked involve your relationship with food. And particularly if you [00:04:00] feel when you eat, you lack control over stopping, or you have a lot of guilt and shame following eating, or feel like you struggle with portion control and it's emotionally driven. Those questions may cause the provider to refer to Melrose, just to further evaluate that as well as help with treatment if that's needed.
Dr. Karen Nelson: As we were talking about what some of those questions might be around someone's relationship with food. Are there emotional reactions to those types of questions? It makes sense to me that it could potentially trigger some shame. And these may be things that I don't really ever want to talk about with someone. What's your experience been of that?
Dr. Jill Leer: You know, it's interesting because I think when patients go through that assessment process, most of them will say they've tried everything to manage their weight. And people will also acknowledge feeling a little bit of desperation that they're kind of at this point of doing an [00:05:00] assessment for bariatric surgery. And so when they get to that assessment, they are relieved that there's an option, but they are also nervous about what that journey may look like. And so if the provider says that they need a referral to Melrose Center, a lot of times there can be different reactions. Sometimes patients will say, I wish I wouldn't have disclosed that because now it's going to slow down my process. Some patients will feel shameful because they didn't personally label it as binge eating or an eating disorder, but the provider is now using that language. I think they also feel pressure that this may be an extra step and may prevent them from surgery. So sometimes in that process, they just want to do the best they can, so they can then be approved for the procedure.
Dr. Karen Nelson: Well, and it would make sense, right? ‘These are things that I don't ever talk about with anyone. You [00:06:00] know, my relationship with food or my interactions with food, oftentimes I do keep that secret.’ May trigger shame. Let's maybe talk about, would there ever be a time where a patient might not want to, you know, completely divulge their interactions with food?
What may happen?
Dr. Jill Leer: I think if you minimize those symptoms or do not disclose them, a lot of times patients post operatively will admit that, ‘Yeah, I knew it was going on, but I didn't want it to get in the way of proceeding with surgery.’ When that happens, a lot of times, then they end up coming back to Melrose for support afterwards. I would also say that patients who do follow through with the referral and come to Melrose for support, they will say, ‘I'm very grateful to have learned those skills before surgery.’ Because they often identify those skills being very crucial in success postoperatively.
Dr. Karen Nelson: You know, a portion of my patients have been referred from [00:07:00] bariatrics, and I just am so glad that you bring that up. ‘I started this journey with bariatrics in my, you know, my number one goal is to get that surgery.’ And really what I encourage is to kind of slow down, and we're still going to reach the goal. But imagine if we set you up so beautifully to be able to encounter some of those post-op interactions that are going to come up with food. How might you encourage your patients to approach that delay in their planned bariatric surgery? Or what might some of those discussions look like?
Dr. Jill Leer: I usually will say time well spent, even though it is hard for most to get started. It's interesting, I usually use the analogy of straddling a fence between two worlds, right? A bariatric surgery where you're having recommendations of what you should eat, how much you should eat, what [00:08:00] foods you should limit, and your eating disorder world. Most people know if they limit certain foods, that is triggering for them. So how can we follow those post-operative guidelines, as well as have some respect for our thoughts and feelings around food, so we know that you're not triggered when maybe you are recommended to eat your protein first, that you also allow yourself a cookie. Right?
Dr. Karen Nelson: That’s right.
Dr. Jill Leer: If you want it. That way, in the future, cookies don't become in place of maybe the protein rich meal that they recommend post-operatively.
Dr. Karen Nelson: Just think our patients can appreciate that we really are working to give them the best possible outcome and assessing the psychological component in their relationship with food.
Dr. Jill Leer: I agree, Karen. I will also say for some patients, when they come over here, they're relieved. Mainly because they've always been [00:09:00] told that their weight struggles have been a source of lack of willpower. And they learn that there is a psychological component to their struggles, as well as often a genetic component to their struggles with portion control and food.
And so to realize that it's not only on them in terms of their lack of willpower can sometimes be very relieving and actually reduce shame in that population.
Dr. Karen Nelson: I'm so glad you bring that up. Some of the stigma that may come with people who have lived in a larger body or who have struggled with weight concerns, this minimizing that may happen, that their struggles are all just simply because of lack of willpower. And I'm so glad that you brought that up. Eating disorders are a psychological disorder. There is a lot of help in treatment for it and it can feel nurturing to [00:10:00] yourself to be like, ‘Gosh, there is help and support and it's not, quote, my fault.’
Dr. Jill Leer: Well, it's interesting because when they do come over here, although they will say, ‘I'm frustrated because I really want surgery. I don't really want to take time out and slow down the process.’ A lot of times, patients who will go through treatment here may also identify some comorbid issues that's related to the eating. For example, sometimes they may be struggling with mood. Depression, anxiety, very common in patients who are pursuing a bariatric surgery assessment. And maybe those issues, which underlie the eating, haven't been addressed prior to the psychological assessment. And so a lot of times they can find other things that contribute to their struggles, but they just weren't aware they were contributing factors prior to the referral.
Dr. Karen Nelson:And so I think too, helping our patients [00:11:00] maybe, reframe.
The support that we're offering here at Melrose if an eating disorder has been diagnosed is really just out of that space of compassion. And when I understand things in a different way, I can do it in a different way. Instead of saying like, I've just personally failed.
Dr. Jill Leer: And sometimes it's hard to say that in a weight loss culture, in a culture that emphasizes the thin ideal. It's hard to find that type of intervention off the bat, you're usually thrown a weight loss program.
Dr. Karen Nelson: Really good point. We don't make an assumption about what they may want or need for their body and well being. We just start that conversation. And we're looking for and assessing if there are disordered behaviors, a
question that, you know, comes up for me is, what may happen if someone does proceed through bariatric surgery and has an untreated eating disorder?
Dr. Jill Leer: There [00:12:00] are some studies out there that will say, well, bariatric surgery can treat binge eating disorder. I've actually heard medical physicians say that before. The problem with that is that if you think about binge eating, most patients will report, there's an emotional component to it. You know, you binge to numb. You binge to comfort. You binge to decompress at the end of a stressful day. And modifying your body from a surgical perspective isn't going to address that coping style. There's also a piece with bariatric surgery patients, there's a lot of factors that have been shown to be related to success after surgery. Social support is one of them. Melrose can give you an individual therapist for support. If you have binge eating disorder, there is also a group option. And patients will often say after surgery, just having [00:13:00] that support is helpful. If you don't get the eating disorder treated pre-operatively, post operatively, there's also a piece that binging still exists. It's just not at the same quantity. So literature really focuses on loss of control eating post-operatively and that actually being a criteria for binge eating and bariatric surgery patients. Other eating disorders that can show up is that there are restrictions with bariatric surgery. So patients may start to pick at food and develop a more abnormal eating style around food that they are worried about over-consuming. There can also be an intense fear of weight regain. And because of that, you may actually see patients kind of overshoot the mark, right? They are so concerned about not losing enough weight, about weight regain, that they do not meet their nutritional needs. [00:14:00] And they may actually never kind of work up that initial portion size. Or instead of stabilizing, their weight continues to drop post-operatively, to the point that their body isn't functioning the way it should if their weight was at a healthy level.
Dr. Karen Nelson: So, Lots of potential impact that if we are avoiding or not talking about this psychological component, I say it all the time to my patients: Eating disorders express themselves through food. But they're not about food. You and I both know they're about emotion. They are about managing, numbing out, distracting, like you said. That isn't inherently going to go away by a biological change in your body.
Dr. Jill Leer: Yes. And particularly with binge eating disorder, Karen, like if you will survey patients, they will acknowledge feeling deprived is a trigger [00:15:00] for binge eating. And if you think about the conditions that happen post-operatively, most patients will report feeling deprived.
They cannot eat the portion that they used to. They may not be able to eat some foods that they really enjoy because they don't feel good after eating those foods. So there's a piece also to realize, like, you may feel deprived most likely after surgery and how to cope with that.
Dr. Karen Nelson: I'm so glad that we're talking about just kind of the complex emotional attachment that many of us have around food. You know, I was chatting with someone a couple weeks ago and she was saying, ‘Wait, is it bad to comfort eat?’ And I was like, ‘Let's explore the word bad.’ Right? Like my therapist part kicked in. But I think we can get a lot of information in our general culture about how we should be interacting with food. And for most people, the majority of people have some type [00:16:00] of emotional attachment to food, and I like what you're bringing up. If that is not identified, explored, and understood, it potentially could be problematic if I'm not addressing it.
Dr. Jill Leer: Yes. I think that's very accurate because if you think about your life after surgery, you will likely experience stressors that you do prior to surgery, and you will need to learn other ways to cope with those stressors outside of food. And the bariatric surgery assessment process, as well as bariatric surgery alone, just really doesn't address those skills to the point that you feel like you have effective coping strategies to manage those emotions after surgery.
Dr. Karen Nelson: All that negative self talk does is make us feel worse. It actually isn't going to change the behavior. Where we come in as professionals at Melrose is [00:17:00] helping our patients understand kind of the function of those interactions with food. Like you said, if I'm stressed and the way in the past that I have managed my stress is with food, we gotta talk about that. And not from a place of shame, but just from a place of like, compassion and like, ‘Oh, I get it. When you feel stress, of course you want to feel better. And if the only way I know how to change my mood in those moments is through utilizing food, we may have a problem long term, especially if I've biologically shifted my body and had bariatric surgery.’
Dr. Jill Leer: Having an eating disorder and bariatric surgery is very different than not having an eating disorder and having bariatric surgery. So we actually offer a support group here that addresses that. And patients in that support group actually really like that space because they will say, although the [00:18:00] support group through the bariatric surgery department is helpful, it really doesn't address the eating disorder thoughts, the different feelings they have around food, or kind of a space to report urges.
Dr. Karen Nelson: I was chatting a couple weeks ago with a patient and she was like, ‘You know, this eating disorder therapy, we sure do talk a lot about thoughts and feelings and not a lot about food.’
Dr. Jill Leer: That's very true because if the patient maybe struggles with overeating cookies, they may say if they're pursuing surgery, ‘Well, Jill, I don't need to be eating cookies.’ Where the reality is that most people will have a cookie post operatively.
Dr. Karen Nelson: That's right, they're real good, right?
Dr. Jill Leer: Yeah, yeah, exactly. So to focus on kind of the thoughts and feelings around cookies, maybe messages that they got about cookies growing up. And I often will emphasize, it's not your lack of control because of the certain foods. Right? Cookies aren't the enemy, it's the conditions in which you eat them [00:19:00] under. Either you are deprived, so you're going to that situation starving, maybe you have very extreme thoughts about cookies and how they will impact your weight. And maybe you haven't allowed yourself to have a cookie in six months, so that cookie tastes very differently in that situation than it would if you would have permission to eat it when you want to throughout your life.
Dr. Karen Nelson: Absolutely. The goal of eating disorder treatment is really to kind of slow down and explore, What are my interactions with food? What thoughts and feelings are potentially triggered by it? It's not about the cookie. Cookies are good. I want to eat a cookie. Right? Like, never do I ever want a life that doesn't involve Oreos. I just really enjoy them. And if the way that I potentially cope with stress is to sit down and binge eat a box of Oreos, we got to talk about the stress. [00:20:00] We got to talk about the emotional component. Because like you said, it isn't just about eliminating a particular food. It's understanding my relationship with that food.
Dr. Jill Leer: Yes, I absolutely agree. Because particularly post-operatively, those patients will eat cookies again. And maybe pre-operatively they thought, ‘Well, I wouldn't be able to eat that or I'm going to take those out of my house.’ It's kind of very unrealistic to think that you wouldn't eat some of the foods you really enjoy post-operatively. And how to do that when your portion size is limited is also a new experience, right? How do I enjoy a cookie when I have difficulty eating the full thing?
Dr. Karen Nelson: Well, I think in treatment, we spend a lot of time really helping our patients be curious about their perceptions about food, thoughts and feelings about food. I think many of my patients come to [00:21:00] me and share, ‘I think I have a good food, bad food list in my head.’ And what happens, like you said, when I've potentially told myself, ‘Never should I ever eat these foods again, but I still really like them.’ It can really set up this space of, like, a lot of agitation, angst, feeling overwhelmed.
Dr. Jill Leer: There can also be a piece, like, for example, if post-operatively, the recommendation is to increase your consumption of vegetables. Right? Sometimes in therapy, patients will disclose traumatic events around vegetables. Or maybe I had to eat vegetables when other people got desserts. Because of my body size and type, they didn't feel like I should have cookies. That piece is very important post-operatively too. Because it's not just about changing your relationship with food. Through Melrose, you would work on eating regularly, where for most patients, they will [00:22:00]say, ‘I don't need to eat regularly because I'm overweight. That's why I'm having surgery.’ The other piece would be to increase food variety where, for example, that traumatic event with the vegetables may be limiting of those foods in your diet. So having that time to increase food variety, eat regularly, listen to when you're hungry and respond to it can be very helpful post-operatively when you are recommended to eat regularly, you're recommended to eat a variety of food. Having a balanced diet is very important and protein is part of that. And so sometimes that can be triggering for patients. So something that we may do in treatment is explore how you may have cravings for other food and how you can address those as well as satisfy your protein needs.
Dr. Karen Nelson: We do want to make sure our patients understand that we are not a weight loss center, right? That the goal of working to manage your [00:23:00] relationship with food is really to just decrease that level of distress and reduce and extinguish those eating disorder behaviors. So, weight loss is not something that we are talking about. That is not a goal of treatment. I think that is important for our patients to understand that. Tell me a little bit more about maybe what skills we may give someone or how we may help them intervene with some of those urges to engage with binging.
Dr. Jill Leer: Sure. So, going back to our example of the day: cookies. Like maybe the person typically eats cookies in secret and when they're alone because of the shame associated with eating cookies at their current size. Through therapy, we would work on de-shaming that process and labeling it as normal and really challenging those beliefs that they can't have that food. I [00:24:00] usually then encourage people to explore, ‘Let's talk about the cookies. How many cookies do you have in your house?’ If it's multiple packages, maybe we can reduce it down to one or two. So when you are vulnerable, it limits how much cookies are there. The intervention usually isn't to remove the cookies because people will find that typically doesn't work. If they are anxious, I may encourage them to set a timer and explore other ways that they can reduce their anxiety prior to eating a cookie. So, usually, like, it could be 15 minutes, 30 minutes, 45 minutes, and I will label different skills that they need to try first prior to eating the cookie. The goal isn't to have the cookie. The goal is to be able to assess, kind of, am I at an emotional state where I feel like I can eat them in a portioned amount? Some of those strategies would be, like, diaphragmatic breathing, progressive muscle relaxation, also sometimes doing a worry [00:25:00] journal where you express them, but you have a time limit for that.
Dr. Karen Nelson: So many skills, right? What we're really doing is like literally slowing down the experience. Appreciating, ‘Am I vulnerable? Have I eaten today?’ You were kind of talking about literally breathing. Taking a deep breath, checking in with yourself, creating space between the thought that I want to eat that cookie and the actual behavior. When I create space between those two, I may choose a different response. It is so much more complex than just, ‘I have a cookie in my house. And I overate it.’ It's far more complex.
Dr. Jill Leer: I think from a basic level, it's much more deep than just saying, well, don't eat cookies.
Dr. Karen Nelson: Amen. Oh my gosh. Thank you for saying that.
Dr. Jill Leer: So at the end of that time period, whatever time period they choose, I actually say it's up to you. If you want the cookie, you go ahead and eat [00:26:00] it. The goal would be to reduce your distress level and by putting a pause and time period between the urge and the response, a lot of times people are less impulsive in those situations.
Dr. Karen Nelson: Well, a term that we use a lot at Melrose is this idea of mindfulness, right? Like deliberately paying attention to what my behavior is doing through mindfulness, which is just fancy words for literally paying attention.
What am I thinking and feeling and what are the actual urges that I'm having? It can slow the process down and I can potentially intervene in a different way. The other piece, and I like that you pointed it out, Dr. Jill Leer: removing shame and guilt. There is no one food that is inherently bad. Food doesn't hold moral value. I'm no better if I eat a cookie or if I have roasted zucchini. They both can equally fit. And, boy, have we probably gotten a lot of messages about food, right?
Dr. Jill Leer: I think [00:27:00] that's very accurate, Karen. It's kind of slowing yourself down and recognizing kind of what you're saying to yourself. I often will say the eating disorder thrives on shame. And so typically what I find with patients is first they judge the food. ‘I shouldn't be eating this. I've ate too much.’ And then they start to judge themselves, right? ‘I'm a failure. I'll never be successful with weight loss. I can't have control of anything.’ And then usually there's one thought that gives the eating disorder kind of gas. In other words, it kind of sets the binge in motion, and it's usually kind of a rationalization thought like, ‘Well, it doesn't matter. I don't care. I'll start again tomorrow.’ Or, ‘Just this once. I'm going to enjoy it. It's not a big deal.’ Or ‘I'm never going to be successful, so I don't care.’ And a lot of times, if patients can recognize that thought and turn it [00:28:00] around, ‘Well, maybe I do care because I'm coming and talking to Jill and Karen on a weekly basis about it. Maybe the eating disorder isn't telling me the truth.’ A lot of times that can just break up that cycle.
Dr. Karen Nelson: Amen. I feel like so many of our listeners can relate to that. First I demonize the food, and then I say, ‘I'm so bad, I shouldn't want that.’ It is radically different the way we encourage people to think about food and self, right?
Dr. Jill Leer: So, so just imagine a process that you're not aware how it's occurring, and through Melrose you can step back and kind of observe what you're thinking, and then maybe with more support you can challenge or reframe those thoughts. It feels very powerful for patients, right, because here's this thing that they can recognize. They understand what it sounds like, and then they can use a coping plan to interrupt it. That's what helps them feel in control of [00:29:00] their eating, not taking certain foods away. And the ultimate goal through treatment would be that you’re your own therapist, right?
Dr. Karen Nelson: That's right.
Dr. Jill Leer: And those thoughts aren't as automatic, like you can recognize them and maybe you can insert maybe a little bit more balanced level of thought –
Dr. Karen Nelson: That’s right.
Dr. Jill Leer: – around food.
Dr. Karen Nelson: Absolutely. It's life changing. If there is a patient who had been diagnosed with a binge eating disorder, went through treatment, now is post-surgery. Are there any kind of unique struggles that they may have? You spoke to those a little bit, but it feels like some of those physical changes can create emotional responses, is what I'm hearing.
Dr. Jill Leer: Yeah, I think across all bariatric surgery patients, initially, it is quite an adjustment and sometimes there is this normal feeling of buyer's remorse. Right? That, ‘I wasn't fully aware what I was getting into, and I agreed [00:30:00] to it, and now I'm not sure I like it.’ Right?
Dr. Karen Nelson: Yeah, because this is different, right?
Dr. Jill Leer: Most patients work through that pretty well. However, sometimes there is a subset that maybe they need more support around that. Around eating and around others sometimes increases just because people are going to eat differently in social situation. Unfortunately in our society, because everybody wants to know how you lost weight, a lot of times patients will report they're bombarded at work about what method they're using and a lot of people don't want to share they've had bariatric surgery. And so how to work through those situations. I think that's where the support can be helpful.
Dr. Karen Nelson: Well, let's talk about some of the unique support that we do provide here at Melrose. You had mentioned that we do have a post bariatric surgery support group. Tell us a little bit more about that, Jill.
Dr. Jill Leer: Yes, this [00:31:00] group was developed here at Melrose out of patient request for it, and it's partly out of that not feeling that the bariatric surgery support group that's offered through your bariatric surgery center is enough for patients with eating disorders. Because the eating disorder thoughts will often come up again [post-]operatively, and we want the patients to feel permission to talk about those. Most patients say, ‘I don't feel like I can bring it up in those general support groups.’ Patients will often say, ‘I feel pressure to be the ideal patient and be successful post-operatively.’
Dr. Karen Nelson: So that shame stays prevalent, right, whether it's pre- or post- surgery. And these things become so challenging to talk about and again, it can feel like a personal failing rather than really appreciating all of the emotional triggers that may be happening, and just past experiences with food or relationship with food really impacts post surgery. Of course it [00:32:00] does.
Dr. Jill Leer: And then there's the piece, Karen, one more thing about the shame is that it's not uncommon in the bariatric surgery world that patients are asked to follow up after the first year. Part of it is related to insurance and coverage. Part of it's related to feeling that I'm doing okay. So one of the things that often happens through the bariatric surgery support group is patients who are connected with their bariatrician and the bariatric team will talk about how that's beneficial. And will work the other group members who maybe aren't connected with their medical provider to go back, because that support is important. Also interesting to know, bariatric surgery: relatively new field. So, things change over time. Recommendations related to food and dietary intake also change over time. And so, a lot of times, I'll actually have some staff from the Bariatric Surgery Center come into my group to [00:33:00] just inform patients of new recommendations. For example, how many protein grams they should have on a daily basis. Patients are kind of sponges for this information because they really do want to do well post-operatively.
Dr. Karen Nelson: I mean, to have that kind of place to connect sometimes when things aren't going well. I may start a dialogue in my head that says, ‘This is all my fault. I need to hide this or I got to get it back under control. I'll go see the doctor when I'm doing well.’ That type of thing. And we want to really encourage the support is there. You're important. And if you're struggling, we'll just partner with you and work to figure out a solution and move towards recovery.
Dr. Jill Leer: Yes. Because there's sometimes this thought, ‘I failed the surgery, like I even failed bariatric surgery that's supposed to help you lose weight.’ And over time, as I said, weight regain can happen and is a normal [00:34:00] part of adjustment post-operatively. And just to explore what's missing, what's contributing to that is sometimes very helpful because it's not uncommon that it's years of struggling that then patients come in, and instead of feeling alone, they feel more supported and also connected with newer information.
Dr. Karen Nelson: Well, you just, really, it's been just such a joy, Jill, to be able to talk with you. I just appreciate all of your insight and explanation. Thank you so much.
Dr. Jill Leer: Yes, it's been a pleasure, Karen. Thanks for having me.
Dr. Karen Nelson: That's it for today. Thanks for joining me. We've covered a lot, so I encourage you to let it settle and filter in. And as I tell my patients at the end of every session: Take notice, pay attention, and we'll take it as it comes. I'll talk to you next time. To learn more about Melrose Center, please visit MelroseHeals.com.
If you or a loved one are suffering from an eating disorder, we're here to help. [00:35:00] Call 952 993 6200 to schedule an appointment and begin the journey towards healing and recovery. Melrose Heals: A Conversation About Eating Disorders was made possible by generous donations to the Park Nicollet Foundation.