{{announce}}

#64 All Consuming: The Science and Stories behind Eating Disorders

Tracie Burke and Holly Dickinson from the Eating Disorders Program at Toronto General Hospital

Sept 11, 2019

Food is a part of our everyday lives and is essential for us to survive and thrive. For many of us, food is also a source of joy. We share stories, make memories, and plan our lives around meals. Photos and smells of food often bring nostalgic memories to mind and a smile to our faces. But what happens when your relationship with food impacts your life negatively? On this week's episode, we aimed to gain a greater perspective on Eating Disorders with the help of several guests. Tracie Burke and Holly Dickinson are two Registered Dietitians working with the Eating Disorders Program at Toronto General Hospital, who guide us through the steps their patients take in the program. You'll also hear from Candice Richardson who shares her lived experience with eating disorders. Candice and her colleague Ary Maharaj also work with the National Eating Disorder Information Centre (NEDIC), conducting outreach and providing support to and information for patients and their families. Finally, we dive into the latest research on eating disorders with Dr. Allan Kaplan, Senior Scientist and Psychiatrist at the Centre for Addiction and Mental Health who investigates the psychobiological factors of Eating Disorders and Shauna Solomon-Krakus, a PhD Candidate whose thesis focuses on the relationship between personality, emotions, and eating disorders. Tune in to hear our guests debunk myths and common misconceptions surrounding eating disorders and shed light on these poorly studied diseases.

Written by: Tsukiko Miyata

Research at the Centre for Addiction and Mental Health
The Eating Disorders Program at UHN
The National Eating Disorder Information Centre
Dr. Allan Kaplan's Website
Article: Maladaptive perfectionism in eating disorders
Article: Disordered eating and fitspiration on Instagram
Article: High vs low calorie foods: food preference in anorexia nervosa
Article: Genetics suggest metabo-psychiatric origins for anorexia nervosa

Stephanie Nishi [0:00] Welcome to Episode 64 and the launch of Season 4 Raw Talk.

Yagnesh Ladumor [0:08] Hi, listeners. This is Yagnesh

Stephanie Nishi [0:10] and Steph.

Yagnesh Ladumor [0:11] We are new show hosts for Season 4, and we're excited to bring you the first episode of the new season.

Stephanie Nishi [0:17] Food. It's a component of everyone's life, and, as we'll hear from our guests, food is medicine. It nourishes our bodies and often plays a role in our social interactions and activities, but what happens if your relationship with food becomes an experience that is no longer positive?

Yagnesh Ladumor [0:34] Our team has wanted to do an episode about eating disorders since we released Episode 55 on nutrition last season. This episode fell into place when we got the chance to speak to the psychiatrist Dr. Alan Kaplan at the Institute of Medical Sciences Summer Undergraduate Research Day. You'll hear from him and several other experts on development, treatment, and research related to eating disorders.

Stephanie Nishi [0:55] Please be advised that the following episode includes conversations about a sensitive topic, and content may be triggering to some individuals.

Yagnesh Ladumor [1:03] For about 1 million Canadians, eating disorders are part of daily life. In this episode of Raw Talk, we gain a bit of insight into the world of eating disorders from multiple perspectives. But first, when you hear the term "eating disorders", what comes to your mind? We took this question to the street to hear what you have to say.

Speaker 1 [1:27] The first thing that comes to mind is young people, like I know enough that it's not an issue that's solely related to young people. But that's what comes to mind for me. I think there's a lot of pressure now especially on our youth to, you know, cope with body image, cope with stress, cope with conformity in ways that a lot of generations haven't before.

Speaker 2 [1:47] I'd say I think a lot about like high school. I'd say that that, in my mind, is where it happens, I guess, most frequently or where you hear about it the most, but I know that it's a lifelong sort of illness that people will struggle with, and often doesn't get enough dialogue, especially when you think about the words that we use and how often we, I don't know, you go out to a restaurant or something like that with your friends, and you'll eat as much food and feel stuff and you talk about how fat you feel or something like that, and how impactful sometimes those words can be even on someone who maybe outwardly doesn't appear that way. One of my good friends, her younger sister has struggled with, like, an eating disorder for like, most of her life now. And yeah, appearance wise, you could have no idea, right? Like you expect, in your mind, there's sort of this stereotype that it would be somebody who's, like, emaciated and very tiny, but that's not necessarily what it is. And also in your mind, you sort of assume it's always females, but I think it's actually more common in men than you would think it is. And it's not always about not eating; a lot of it can be just how focused you become on your food and how much that starts to sort of impacting control your life around it.

Stephanie Nishi [3:03] I was wondering if you could describe the different types of eating disorders and also what types you mainly may work with here on the program.

Tracie Burke [3:12] So in terms of the different types of eating disorders, these all come from the DSM-5, so the Diagnostic and Statistical Manual of Mental Disorders. The DSM-5 came, newest version came out in 2013.

Holly Dickinson [3:29] So first is anorexia nervosa, which is what we primarily treat in the inpatient program, so those that are restricting their intakes have significantly low body weight. They have other criteria: an intense fear of gaining weight, and then disturbance in perception of their own body weight and shape. And then there are subtypes of those with the diagnosis of anorexia nervosa. So there's the restricting subtype. The restricting type doesn't engage in any episodes of binge eating or purging/laxative use. And then there's the binge eating-purging subtype. So, that individual will have recurring episodes of binge eating or purging/laxative use, over exercising, as a few examples. And then, there's bulimia nervosa. So that's binge eating, which is characterized by both eating an extremely large amount of food and as discreet period of time, having a sense of lack of control over the amount of food they're eating, and feeling like they can't stop, and then, there's usually a compensatory behaviour. So, that may be in order to prevent weight gain from the binge eating, so that could be in the form of vomiting, misuse of laxatives or diuretics, excessive exercise. And there are certain criteria that, in terms of, to be sort of diagnosed in terms of how frequently you do this. So you need this, binge eating would happen at least once a week for three months.

Tracie Burke [4:56] Those are kind of the the main diagnoses that we see. We do not treat binge eating disorder here in our clinic. With the recent DSM-5, Holly mentioned in 2013 came out, there was a little reorganizing of the classifications, and so they grouped eating disorders and feeding behaviours together. And so there's a new category called otherwise specified feeding or eating disorders.

Stephanie Nishi [5:20] You just heard from Tracy Burke and Holly Dickinson, two registered dieticians from Toronto General Hospital's Eating Disorder Program. They outlined the official classification system for eating disorders as they appear in the DSM-5. And while it's important for physicians to understand the nuances of the different disorders, what about those of us who don't necessarily want to memorize the DSM?

Candice Richardson [5:43] An eating disorder is really anything that involves extreme emotions, behaviours, rituals, routines around food, weight, body image that's causing your life to be negatively affected.

Yagnesh Ladumor [5:59] That was Candice Richardson. She's a volunteer and direct client support worker at the National Eating Disorders Information Center, or NEDIC, a resource hub for Canadians affected by eating disorders. You'll hear more from her and her colleague Ary Maharaj a little bit later. Now that we know what an eating disorder is, we want to unpack some common misconceptions surrounding eating disorders, including how they're caused.

Dr. Allan Kaplan [6:24] Each of the three eating disorders is somewhat different in this regard. But for anorexia nervosa, I believe, it's virtually impossible to develop anorexia nervosa unless you have some genetic predisposition, because, for just about everybody else, your body's not going to allow you to starve it to the point where your life is at risk. There's something hardwired about anorexic brains that allow an individual to do that without, you know, typically losing control and beginning eating again. You can lose weight, but it's hard to maintain weight, so anorexics are quite remarkable in the ease with which they lose weight and in the ease with which they lose weight once they regain the weight. They just shed the pounds. It's quite incredible.

Stephanie Nishi [7:10] Dr. Kaplan is a senior clinician scientist at the Center for Addiction and Mental Health. He spent his career closely studying those with eating disorders, anorexia nervosa in particular, but like most diseases, Dr. Kaplan explains you're not doomed by your genetics alone.

Dr. Allan Kaplan [7:26] It doesn't mean that if you have a genetic predisposition anorexia, you're going to get anorexia, right? You have to have an environmental trigger, which is true for most illnesses that, you know, we all carry risk for various illnesses. It could be heart disease, could be cancer; it doesn't mean we're going to get that illness. There has to be an environmental interaction with the genetic predisposition to actually cause illness. Bulimia is less genetic than anorexia, but there's still a genetic component, and the environmental factors are greater in bulimia and similarly for binge eating disorder.

Melissa Galati [8:00] What are sort of the environmental stimuli that you see for those two, well for all three?

Dr. Allan Kaplan [8:07] So we know one of the significant risk factors is having early childhood sexual abuse. That increases the risk, and that's about 30-35% of people who develop eating disorders have a history of that.

Melissa Galati [8:19] That's across all eating disorders?

Dr. Allan Kaplan [8:20] Yes, I would say it. It's stronger for anorexia and bulimia, but it also is there for BED, which is binge eating disorder. I mean, that's one environmental risk factor. There are many others. Being in an environment that focuses unnecessarily and unhealthily on weight and shape is probably another environmental risk. So, being a ballet dancer increases your risk for anorexia because of the environment; it doesn't mean it causes it.

Melissa Galati [8:51] It's just sort of a trigger for people.

Dr. Allan Kaplan [8:53] Yes, if you're genetically predisposed, you probably shouldn't be involved in competitive gymnastics, let's say, where being thin is actually a requirement to perform.

Yagnesh Ladumor [9:06] Beyond these factors, particular personality traits have also been associated with the presentation of eating disorders. But, which traits are the most commonly linked? Shauna Solomon-Krakus, a PhD student at the Department of Psychological Clinical Sciences at the University of Toronto, discusses one of the most common personality traits associated with eating disorders.

Shauna Solomon-Krakus [9:26] I think one that I look at in my research and that has been extensively looked at as a risk factor is perfectionism. It's a personality trait in particular. There's a new wave of literature, actually it's not new necessarily, demonstrating that perfectionism is actually multi-dimensional. So there's a lot of different forms of perfectionism, and something I'm really interested in is learning what dimension of perfectionism is more commonly associated with eating disorders compared to others.

Swapna Mylabathula [9:51] Interesting, what is, what does it mean to have multiple dimensions of perfectionism?

Shauna Solomon-Krakus [9:56] So, there's many different theories. I think, in general, the theories would agree that there are more adaptive sides and more maladaptive sides. So, in general again, very various theories that have different ideas of what the dimensions look like. I think, in general, the more adaptive side is setting really high goals, striving for those goals, and more the maladaptive side is setting extremely high goals, and unfortunately, when those are not met, perhaps it's not the fault of the goal, it's the fault of the individual, and we see a lot of self-criticism, which can be linked with a host of negative outcomes.

Yagnesh Ladumor [10:31] She also comments on comorbidities with eating disorders.

Shauna Solomon-Krakus [10:35] I think it would be hard to pinpoint exactly a common comorbidity. What I can say is, just like any other mental illness, it's rarely on its own. And so we certainly are seeing comorbidities with anxiety and depression. We've all seen OCD and PTSD and number of comorbidities; it'd be difficult to say specifically. I think everyone's experience is unique. I do think it would be fair to say that it's rarely on its own, just like any other mental health diagnosis.

Yagnesh Ladumor [11:03] There are many common misconceptions by eating disorders. So we asked our guests to help us bust some of these myths that they've encountered in their work.

Candice Richardson [11:10] So I think a lot of the times, there's a lot of myths and misconceptions around eating disorders. A lot of people think that eating disorders, when somebody presents, they're going to be at low weight, and, or, and/or using purging, which often we see in media is self-induced vomiting. And those are kind of the only mental images people have of eating disorders. But really, you can't even tell by looking at somebody if they have an eating disorder or not.

Ary Maharaj [11:36] The first one that comes to mind, and Candice is going to smile when I say it, is that the health is weight and that weight is, weight's going to be there, and Candice made a face for the listeners can't see it, where, like a lot of people especially those who were in it, think that that number on the scale very much is going to determine what is healthy and unhealthy, and in the media, images that we see in the conversations that we have, for some reason, we don't treat weight like we treat height. We kind of all know that we're going to be kind of where our parents are at. And we have a range for that, and a lot of it is genetically set. But for some reason with weight, in the language we use in the conversations we have with friends and family members and the media, we're super judgy with it. We think that we can overly control it when we can't. And there is, we do have a set point, and our weight is going to be in a range and some of it we can't have control over. But I feel like, in society, one of the really big misconceptions that we think we can control that.

Candice Richardson [12:30] And another one that is very problematic and quite stigmatizing for folks who have experienced an eating disorder is that people think it's a choice, like it's a lifestyle choice. And it's not, because I can assure you as somebody who has experienced it and has spoken to many others who have and I work with these clients, if it was a choice, this wasn't the choice any of us would have made. So I think you can be really stigmatizing for somebody to hear that, especially when they are trying to seek help and assistance with this, and I think eating disorders can be confusing to folks, because there's a delicate line between where is this behaviour that's "healthy" or we're trying to be healthier versus where is this a mental illness, and I think that line to be really fuzzy, which I think can also make it hard as a parent or a loved one noticing these behaviours, like what is problematic versus what isn't?

Tracie Burke [13:20] Who is the typical patient? I think that's a common misconception. Oftentimes, when people think about who gets eating disorders, they think about perhaps women, young women, maybe from an affluent family, and I would say that that stereotypical group is not true any longer. I see a lot of, we see a lot of women in their, in their 30s and 40s. Maybe, you know, they've, they've kind of had disordered eating their whole lives, probably fit criteria for an eating disorder, but never received treatment, kind of put the family first, and now the kids are gone, and they're kind of coming back to address their eating disorder, or they're realizing like that it's a problem that needs to be addressed. So, I think that's part of what I've seen in my, in my career; there's a bit of a shift towards women in middle age kind of coming for treatment. We've also seen probably a bit of an increase in men. It's still very infrequent, I would say for us, but we might have a man in our program five times a year. So the population's shifting a little bit. Yeah, and, and it really knows no boundaries in terms of socioeconomic status or ethnicity.

Shauna Solomon-Krakus [14:36] One that comes to mind first is that eating disorders do not just affect women. I think we're seeing eating disorders across the gender spectrum, and we are seeing it in across age spectrums, across different cultures. So, it's not, I think there is this misconception that it only affects women, and that is certainly not true. I think another big misconception is that you can tell someone has an eating disorder just by looking at them, and that is certainly not the case. We know that individuals across the body size and weight spectrum can experience an eating disorder, so that's certainly one we want to dispel right away. And I guess finally, another big one that unfortunately we still see on news feeds and in the media that we're trying to dispel is that eating disorders are a choice. We do know that it is certainly not a choice, that these are severe mental illnesses. And I think that is probably one of the most important misconceptions that we need to dispel as well.

Swapna Mylabathula [15:29] So, maybe we can shift now to Candice, your own lived experience and what you're comfortable sharing with us.

Candice Richardson [15:34] For sure. So, I think, the general disclaimer, like, of course, this is my own experience, and it's not in any way indicative of what others might experience. Like, I am a relatively able bodied and privileged to a certain capacity, white young person. So my experience isn't going to look like what a lot of other folks who have to navigate our system is, but for me, it started from a really young age. I was always very, very anxious, and I had stomach problems that never really went away. And all of we did the testing for, like lactose intolerance and all of that jazz, I was tested for everything and nothing really came back conclusive. And it only got worse as I got older. And so back then, ARFID, which is avoidant restrictive food intake disorder, that didn't exist back then, but that is probably what it would have been diagnosed with that that point, but things kind of perpetually got worse. And then, when I was in seventh or eighth grade, and I grew up in competitive dance my whole life, so that was a stressful environment. There's a lot of exercise involved; those were regimented. And so, the weight kind of started coming off, because I was doing that and was having a stomach ache so I wasn't eating. And it was kind of this perfect storm of issues. I was already very anxious and perfectionistic, and then people were noticing that I was losing weight, and I was receiving praise for it. And then, one thing led to another, and I ended up in not the greatest place. So for my, what I thought had happened was that my paediatrician became concerned, I was referred to a psychologist, and luckily my parents were able to pay out of pocket until I was able to access provincially funded treatment through hospital system. But there got to a point when I was seeing the psychologist that she just kind of like looked at me and my mom and was like, "this is way beyond my capacity. I can't help you," like, "it would not be helpful anymore," like, "this is medically too complicated." And so then, I was kind of left in this weird transition between I'm too sick for one place but not sick enough. I went on a six month waitlist for hospital-based programs. And so after the fact, I found out, like years and years later, that my mom was actually the one who was noticing all these things that there's a problem. My paediatrician wasn't taking it as seriously as maybe she could have. And my mom had written essays and was like, "please, we need help." And so that was what then finally, when my medical signs, my blood pressure was all messed up, my heart rate, things that were very problematic and shouldn't be happening in a child, was finally when the referral went in. But at that point, it was already kind of late in the game. So, I was, when I went to my first assessment, it was for family-based therapy. So my mom and dad, my sister, and the whole, we saw everybody; we saw the dietician, nutritionist, social worker, physicians, psychiatrist. It was like, I honestly can't even remember that day. And after the assessment, they were like, "you really should be like a higher level of care to do, like day patient," or whatever, which would mean I would have to not be in school and all that. And for me, that was like catastrophic, and my parents were very like, "no, we're going to do this at home," like, "we're going to show up. We're going to be here for appointments. We can do this." But, it just, it can be really frustrating as somebody who's trying to navigate the system that, at the point, when I was referred, which was like nine months ago, I would have been fine doing outpatient treatment at that point, but I didn't actually get seen until nine months later, which now you're telling me I should be an inpatient or day patient. I'm too sick to get the service that I was referred to. So it was a bit frustrating, but luckily we were able to manage it on an outpatient basis, and then so I was in treatment for heavily for a year. And then they kind of like wean you off, like you see people less frequently, all of that sort of jazz. And so, by the time I was out of high school, I was mostly done with treatment. But obviously, it's not something that just goes away. And I think that's another very common misconception around eating disorders. And quite often, when we see people who are in the initial stages of recovery or who maybe did the treatment, and a lot of the times, the way that treatment is structured is that if you have a restricted type of eating disorder, again, eating disorders don't always involve weight loss, but when they do, you can't be in therapy. If your brain is not functioning, like cognitive behavioural therapy isn't going to work if you're, you're not cognitively there. So you kind of have to focus on the weight gain first. They call it weight restoration medically so that you can actually show up emotionally and work on the stuff that is causing this. But the problem is, quite often, when you're trying to function in a society as all of these things are happening in your personal life that you're maybe trying to hide because you're not comfortable disclosing this to everybody as it's happening, people see you when you were potentially at a very low weight, and now they see you and you "look normal". And like realistically, none of the emotional work has even began at that point that now. You have all the problems you had before, and you're in a body that's drastically different than you were in a few months ago. If you're like, "oh, you look great" in thinking everythings are fine. So, that's probably the hardest point I would say, because you "look fine" and you're no longer occupying this sick role that everybody's so concerned about because of your physical being, but emotionally, you're probably worse off than you maybe had been. And then, people start treating you like you're fine at that point. So that's kind of like a very murky water to navigate. I don't blame people for thinking that way, because, of course, when something is physical like that, you think like, "oh, but you physically look better." So you are better, but that's the complexity of an eating disorder, because It's a mental illness, but it very quickly can become physical, and the physical effects of it are really just a side effect. Yeah.

Yagnesh Ladumor [21:07] Do you think the role that stigma plays in in just the manifestation of eating disorders, like does it, has that changed over time in like how did affect you personally?

Candice Richardson [21:20] I think, for me, and I think to, like, it's something I think about a lot, because I was like a kid when this all started happening, so I think I wasn't fully aware of the role that stigma was playing, but I think talking about it with my parents after like now that I'm in this like quasi-practitioner sort of role, not quite yet, but I think for them, too, it was hard to convey to others what was going on without them being judgmental about it and to really, a lot of the times, people don't have a full understanding of what an eating disorder involves. Dinner time in normal households is probably pretty normal. You sit around a table at dinner time in a household with somebody, a child, with an eating disorder is like going to war. It is not, I can't even do justice to the amount of stuff that goes on and the emotions and the fighting, and, and it's really, I say this to parents on the helpline a lot, I'm like, "this isn't your child. This is the eating disorder that's talking, and like, "you know the difference between your child and the eating disorder. And it's not you against your child right now. It's both of you against the eating disorder."

Yagnesh Ladumor [22:23] As Candice described, the management of eating disorders is analogous to going to war. And there's a whole host of soldiers fighting alongside those affected to support them and their family members. We asked Dr. Kaplan how he got started in the field of eating disorders research.

Melissa Galati [22:38] You obviously focus on eating disorders, and you have kind of an interesting story of how you became interested in eating disorders where you had a specific patient encounter during your residency, I believe. Can you maybe talk a little bit about how you became interested and what the eating disorder research landscape was like when you were in residency?

Dr. Allan Kaplan [22:57] Sure. So I started, I graduated U of T Medical School in 1978 and started my residency in internal medicine at the time. And one of my first rotations was on a gastrointestinal unit, where a lot of people with inflammatory bowel disease and other disorders were being intravenously, nutritionally rehabilitated. There was one patient on that unit who didn't have inflammatory bowel disease, but nobody seemed to know what was wrong with her. And I happened to go by her room one night when I was on call and heard her distress. She happened to have been vomiting, and I went in to see if she was okay. And she proceeded to tell me her symptoms and then more of herself and her life story, and I surmised, even though I hadn't ever seen a patient with anorexia nervosa, that this was what she had. That year that I was in internal medicine, she happened to be the Chief of Medicine's patient and became clear to me he wasn't sure what to do with her, and she primarily had a psychiatric illness, and so his office would call me every few months, maybe once every six weeks, she would have a visit with him for an appointment, and he would call me down to talk to her. I didn't realize it at the time, retrospectively, I was establishing some form of psychotherapeutic relationship with her that she began to trust me and began to reveal aspects of her history that, you know, kind of explain how she came to have such a serious illness. So, I mean, that was an interesting experience for me, not that I knew what I was doing at the time, but you know, it pointed out that the non-specific aspects of being an empathic physician, listening carefully, being non-judgmental, being open to hear what people have to say, are very important in establishing trust.

Stephanie Nishi [24:48] Dr. Kaplan's experience led him down the street to an eating disorders unit that's now part of CAMH, where one of the world experts in eating disorders convinced him to switch from internal medicine to psychiatry. The rest is history. The psychotherapeutic relationship he spoke about is an integral part of managing patient care. Dieticians, Tracie and Holly, also acknowledge the importance of incorporating the psychotherapeutic component into their practice at the Eating Disorders Program at Toronto General Hospital. In fact, both continue their education to become registered psychotherapist to complement their role as dieticians. They share their insights about the program and the steps someone may experience once receiving a referral.

Tracie Burke [25:30] Here at Toronto General Hospital, we have intensive, we have an intensive inpatient treatment program, we have an intensive day treatment program, we have the relapse prevention program that we were mentioning, and then we have MEDACT (Modified Eating Disorder Assertive Community Treatment) program. So generally, what happens when you look at the patient journey: someone is referred by their family doctor to the program, and then they have a consultation with a psychologist who will more thoroughly look at their diagnosis and just what the best kind of treatment approach would be, and then they would, depending on on that outcome, the patient would either go directly into the inpatient program or directly into the day treatment program. And so, in the inpatient program, we have 10 beds; really, that program's meant for individuals who are a little more medically unstable. And they kind of, in the early stages of normalizing their eating, they might need a little more medical surveillance to ensure they don't go into repeating syndrome or have any other complications associated with the repeating process. Generally, the length of state that they're looking at in the inpatient program would be about six to eight weeks, and then they would come to the intensive day treatment program, and they would likely be there for probably another six to 10 weeks. And then, once they've completed that, then they would go into the relapse prevention program, which is individual CBT for relapse prevention where you would meet with a therapist for 15 minutes initially twice a week then moving to once a week for 16 sessions, and then they're discharged back to the community.

Stephanie Nishi [27:11] When Tracie mentioned CBT, she is referring to cognitive behavioural therapy. It is a goal-oriented therapy that helps people to develop skills and strategies for becoming and staying mentally and physically healthy. For more on this topic, check out raw talk Episode 47 on graduate student mental health, Tracie and Holly go on to share the nutrition aspect of the treatment program. They preface and reiterate here that treatment is a team approach including the health professionals as well as the patient.

Holly Dickinson [27:41] There are some clients that will start just in the day hospital. So they may struggle with bulimia, binging and purging, and they wouldn't start in the inpatient. There are occasionally some that have really severe symptoms of binging and purging that really need containment for their binging and purging symptoms. So they may stay an impatient for perhaps a couple weeks and then transfer to day hospital. But primarily, those that struggle with a binging/purging would start just specifically in the day hospital; their stay's six to eight weeks, primarily. And then they, too, would go to the the relapse prevention as well.

Tracie Burke [28:18] We have a non-dieting philosophy here. So, we work with a message that all foods can fit and all foods should be incorporated in moderation. And we do that; we provide balanced meals for our patients, oftentimes in the initial stages of normalizing eating, and for people who are in intensive treatment. They are working to incorporate avoided foods, and so when they're doing that, they might have to work harder to incorporate those avoided foods initially. So, in intensive treatment, someone that can only have a piece of cake in a really disordered way might have to practice having that in a normal way. And so, you might see more of that happening in the intensive phase of treatment, just because they are trying to kind of normalize that into their lives. And we call this food exposure. The idea is that the more they kind of incorporate these foods, the more they're able to start to tear apart some of the thoughts about the foods that maintain the eating disorder as well as start to reduce some of the anxiety that might come with eating those foods. So exposing yourself to things that cause anxiety during treatment is really important, because that's how we get at the underlying cognition and help people to kind of rewrite some of that stuff.

Holly Dickinson [29:34] We try as much as we can that goals are patient-directed, that we try to certainly work with where clients are at, and that if things don't go just so we're certainly not going to end treatment. It's just again, the team meeting together, meeting with the patient, trying to figure out, you know, what went wrong? How can we do things differently? Take another approach.

Yagnesh Ladumor [29:55] When it comes to treating someone with an eating disorder, all of our guests were unanimous; familial and social support is crucial.

Melissa Galati [30:04] Are there also therapies that centre around the home? Can people do family-based therapy?

Dr. Allan Kaplan [30:10] Yes, that's a good point. The only therapy that's been proved effective in randomized trials are for young patients, so these are early adolescent individuals who develop anorexia, and family-based therapy has been proven to be effective for that group. It's not effective for older patients. And again, the goal there, because it's the families have control over those young people, right, so you involve the families and actually the monitoring of food and the eating. They become sort of secondary therapists.

Yagnesh Ladumor [30:42] Like Dr. Kaplan mentioned, eating disorders are treated in various contexts depending on the severity of disease. Another movement, there are friends like NEDIC spearhead to increase public education surrounding eating disorders, and this includes education on media literacy. This got us thinking; now that social media's a part of most of our daily lives, what impact does it have on people with eating disorders? We headed out to the streets to see what you have to say.

Speaker 1 [31:12] So much different now. Like, I'm not hip with the kids anymore. I really like, it pains me to say it, but I'm not. When I was in high school, it was hard enough fitting in, and now kids these days, not only do you have to discover who you are, you have to build a brand and advertise that and hope that's accepted by your peers. You're throwing yourself out there not just to your peers, to the world. And, you know, now you can quantify popularity, which that can't be easy at all. And it's not something I'm used to because, again, I'm not hip with the kids anymore. But uh, no, it's a pressure I've come to appreciate.

Speaker 2 [31:43] I see a highlight reel when you look at Instagram, and everything is all social media. But I guess at this point, it's Instagram. You just see what people want you to see. So you really have no idea what's actually going on behind the scenes. And I would say that our exposure to the influencers of social media also makes a big impact because a lot of them are very fit, beautiful people. And that emphasizes how important that is. And even to be successful in that sort of industry, you do have to sort of meet those standards to fit in like that. So I'd say like, your exposure is just even more so than it was before. And even just like how much you can't really escape from school and your peers and maybe all the pressures that you're facing from them when you go home, just because it's like all around you on social media. And honestly, if you're not on social media, it'll have social impacts and that sort of thing. So there's really no way to, like, isolate yourself and be like, "no, I'm not gonna, like, I'm just against it sort of thing," because then you'll miss out on other things. But, sort of being able to mentally control how you interact with it and engage with it can be really difficult, because it can become really all consuming.

Yagnesh Ladumor [32:55] It's apparent that the increased focus on social media today can influence our perception. Shauna, Candice, and Ary weigh in on how that can impact eating disorders.

Shauna Solomon-Krakus [33:05] Social media is certainly a very powerful way to depict a life that perhaps isn't a realistic picture of life but the idealized picture of life, and unfortunately, a lot of that time, that's centred around the body and appearance. And so I think it's important to continue talking about how these images are altered and how it's not a realistic depiction of what the body looks like every single day. In research, we see the term inspiration quite a bit when we're thinking about social media. And this is the idea that individuals are striving to achieve this thin ideal that is defined by different cultures. And now, we're seeing in social media this idea of inspiration, which is starting to be studied more in research, which is essentially this idea of maintaining and achieving this thin and fit body, which is slightly different from before, it does show. I think how social media can perpetuate these ideals that men and women are facing that are typically unrealistic and only apply to a very small percentage of the population, though it's really hard to disentangle and to know if somebody is experiencing like disordered eating or exercising in a way that is not as adaptive and not as healthy. It's really hard to tell that apart just based on a single picture on social media. So, it can be really dangerous for someone who is struggling with an eating disorder to be on social media and see these images, because it is perpetuating those ideas that can be quite central to the eating disorder.

Ary Maharaj [34:40] Especially in this last decade, because I always forget social media and its modern form came out in like 2007, so like, in terms of like, human evolution, it's come out in a very short period of time and had a lot of impact. And, I think this, the psychology behind it and the science behind it is very much, I'm still waiting for, like, high-end, high-power, like, applicable research on it. But, what we have seen is that there is increased body dissatisfaction, generally speaking, and people who use social media more, especially Instagram as a visual social media platform, because there's theories behind it on, like, whether it's like that self-comparison you're making where like before, maybe like 50 years ago, or even actually like 20 years ago, and Candice and I was like, we're a kid, we kind of had to worry about it in terms of like TV you'd compare or like magazines, but it's a little bit harder because you can turn those things off. When we have our phones with us all the time and Instagram is a quick thing that you're just scrolling down, that body dissatisfaction and those negative self-comparisons you end up making repeatedly can happen so much more often that, neurologically, you're firing that synapse; you're like Keep going, keep going, keep going, keep going, becomes a really easy pattern to kind of repeat over and over again. And, it's why we see it as, it shows up as a risk factor for eating disorders and body dissatisfaction as a whole. And then like, we see the proliferation of diet culture on social media very often to both in the form of what we see traditionally as laxatives and then ideal bodies or muscular ideal bodies but also in like the way sometimes exercise and fitness, or sometimes that multibillion dollar industry can sometimes make people feel like that's what they need to do to have their body look a certain way and can be really combined with dieting. NEDIC is in full support of joyful movement for people; we think physical activity is wonderful, and every Canadian, every human should have equal access to participate and the opportunity to in their life to participate. But we should do physical activity when your body feels good, and you are listening to your body and it's joyful, and it's social, and you're doing it with friends, and not the rigorous kind that you're going through pain and your body screaming at you, because we're not all going to be elite athletes and we all don't need to maybe be doing the rigorous kind. And we're, we have to be, I think, as a field, a lot more conversation with our friends in diabetes prevention and obesity prevention and all that stuff, too, to have a unified public health messaging on this topic, because we don't want now the public to get really weird misconceptions about like, well, like they're telling me to exercise and we're not doing enough and like these people now are telling me it's too risky. We, I think, we all think exercise is good. Like, let's, like, we all think is eating is good. But we need to get on the same page to better educate Canadians.

Swapna Mylabathula [37:25] Yeah. And I really appreciate the emphasis on joyful movement with the positive reinforcement of that.

Candice Richardson [37:31] And it can be enforcing in itself, too, because a lot of people, if they begin some sort of exercise or organized sport and they're going into it with the idea of like, "Oh, I want to do this, so I lose weight" and then they don't see that physical marker being met, a lot of the times, the motivation to continue engaging goes down. Versus, if you go into it as like, "Oh, this is a fun activity. I'm going to do with friends,"

Ary Maharaj [37:55] Much more sustainable.

Candice Richardson [37:56] It's more sustainable. There's motivation to continue returning, and it's something that people actually bring enjoyment out of, and then any cardiovascular benefits or any of that is really just like a side effect of the fun that they're having.

Swapna Mylabathula [38:10] And, you see those misconceptions kind of moving in terms of with more awareness and more education, we're seeing a lot more understanding.

Ary Maharaj [38:19] Yeah, like, I'm, I'm like waving on that, only because I think we had, NEDIC very much don't want to, like, be patting ourselves on the back kind of organization. We try. And, we very much try to believe optimistically that, with outreach and education work with evidence-based prevention in schools and in community settings and in our physical activity centres etc, that we can start to shift the conversation. And, I think this decade has seen some headway as we've seen broadly with mental health but also with eating disorders. But, I think there's still so much left to do and so many communities who are way more underserved that I don't want any kind of padding on the back to make us think that we're, we're there yet, because I think we still have a long way to go. And, I'd rather everyone in the field or people listening know that they can play a part and having this conversation.

Swapna Mylabathula [39:08] Absolutely.

Yagnesh Ladumor [39:09] So just going off of that, what exactly is NEDIC? And what kind of populations do you serve? And what kind of resources do you guys provide?

Ary Maharaj [39:18] Yeah, so, we very much try to be the bridge, almost, between community and care. So we would like to provide that information, education, referrals, and support. We do that to clients experiencing eating disorders or loved ones who are concerned about someone, if they call our national toll-free helpline or go online at www.nedic.ca and go to our online chat service. Those are things that are free nationwide; you just need an internet connection or phone.

Swapna Mylabathula [39:45] and, we're going to be posting that in the information surrounding the release of this particular episode. So listeners, you can check that out.

Ary Maharaj [39:52] Right, and there are trained support workers and wonderful humans like Candice, who are on the other end of that helping people with a support conversation if they're really in it, helping with that system navigation piece, because, unfortunately, we do have a really fragmented system of care across Canada, across Ontario. Work is being done to unify that, but to a client who's in it or a family member who's trying to help, that can be really hard. So, our support workers are there to help with that. And then, the other big component that we do is our outreach and education piece, which can involve our bi-annual conference. It involves our workshops in schools in community settings, and we're working with youth with health care professionals who unfortunately haven't maybe received the do training to be as eating disorder-informed as they could be and also the loved ones and caregivers who are looking to support folks that's mainly based in the GTA right now. But I've connected with folks across the province of Ontario to kind of do more on that on a provincial level and hopefully, inform things like Eating Disorders Awareness Week, which happens at first week of February 1, the seventh every year, that's national with other eating disorder organizations to really do public health education on the topic.

Swapna Mylabathula [41:01] Fantastic. And both of you now have mentioned the workshops that have been through NEDIC. I'm wondering if you can describe a little bit about what they look like?

Candice Richardson [41:09] For sure. So, we definitely, it might look different depending on which audience or kind of gearing towards, so we try to tailor. Yeah, so, we have our workshops. Actually, we're wrapping up camps, which we do in the summer. So, we go into kind of in the Toronto area and the camps and do body pride with the kids who are there, so focusing on like activities that foster self-esteem, literacy, and things like that. We also, I quite often, I'm the one going into high schools and really challenging kids to think critically about what we see in the media, and like, how does advertising work, and what about Photoshop, and what are the resources available, and things like that. But, we also do a lot of work with educators. We have Beyond Images, which is a plugin turnkey curriculum for grades four to eight that any teacher can access through the network website that really tries to build in that piece that's missing in our curriculums about body image, media literacy, and things like that. So, we also do a lot of work with educators about how to create like a more culturally sensitive classroom where food isn't necessarily seen as good and bad and like all of that sort of stuff. Yeah, so more of like a sensitivity sort of training.

Stephanie Nishi [42:26] We were blown away by the amazing outreach work done that NEDIC. But as Ary said, it's important not to pat ourselves on the back. Eating disorders are still a poorly understood and a poorly treated group of conditions. Despite dissemination of resources, like those that NEDIC provide, eating disorders can still be hard to recognize, even for physicians.

Melissa Galati [42:47] Because you've been in this field for a long time, is there a change in the way that we are educating physicians about eating disorders? Has there been either to the MD curriculum or in residency? Is there like changes and maybe the stigma associated with it or the way that physicians are sort of educated about these?

Dr. Allan Kaplan [43:06] I would say, unfortunately, not a significant change. So, it's still undertaught in medical school. The recognition of eating disorders, probably anorexia nervosa, is a little bit more easily recognized, because you can just see somebody. Doesn't mean that physicians know what to do with patients. Believe me, it tends to be a secret illness. Physicians aren't going to find out somebody's bulimic unless they ask the questions. Most physicians are uncomfortable asking those questions. Binge eating disorder patients tend to be obese, so they come to physicians, but the physicians tend to focus on weight loss, which is what the patient's asking for. So we have, we have a challenge to enhance both professional and public education in the area of eating disorders. I think we're behind in that.

Yagnesh Ladumor [43:54] Candice and Ary also shared insights on what you can do if you think someone you know might be experiencing an eating disorder.

Yagnesh Ladumor [44:01] What would you suggest we do if we notice that a family member or friend is going through something like this?

Candice Richardson [44:09] For sure. And that's quite often a question that we get a lot of the times on helplines. We're always happy for folks to call in or chat in over a website and kind of guide them through that conversation, because it can be really tricky. Generally, you want to come from a place of concern, like speaking to the person is often best. Sometimes you feel like this person is sick, and we're going to hold an intervention, and we're like, "okay let's hit the brakes a little bit there and, like, unpack some of this," because intervention, like, yes, that is a show that exists, but quite often, that's not really effective. For folks going through this, they're going through a lot to begin with, and to be kind of over targeted all at once by everybody, they care about their life, and it can actually cause a lot of defensiveness, which is already something that's really, really common among folks with eating disorders. So generally, we encourage people to come from a place of concern and, you know, not necessarily pointing out things of like, "oh I've noticed you've lost weight," because that can cause a lot of emotional issues. But maybe like, "I've seen you're more withdrawn lately," like, "you're not interacting with your friends the way that used to," like, things that are, like, you're noticing in their life, like, they're who they are.

Yagnesh Ladumor [45:16] Something not directly related to

Candice Richardson [45:18] Exactly, not directly related to the looks, but maybe like, "I've been noticing you've been feeling down lately and you're not seeming yourself" and things like that, and kind of gently guiding them to what they're comfortable with, because somebody also, a lot of the times, if you're a friend or something who's really well-meaning, that person might already be in treatment, and they're just not open about it. So that, they could already have their support systems and their family or anything like that and just not want to be out to the whole world about it, and there is a certain level of privacy and autonomy that we have to respect, but generally, being kind of encouraging and letting them drive how they see this moving forward, because a lot of the times, we go into well-meaning, thinking like, "Oh, I want to take you to help," but like, help may look different for somebody or somebody that might be seeking like hospital-based treatment for somebody else that might be seeing a therapist once a week, or like, there's different ways that people might want to approach recovery or that might be appropriate for them, given their life context.

Ary Maharaj [46:20] And, that's why that being patient is so important. And, I can understand how hard someone who's supported many people with mental health issues across the board, I think that patients can be really difficult because you are frustrated and you see this happening to your loved one. But, if you don't come from this place of patience, then maybe you're triggering that defensiveness and only doubting yourself as a not-safe person to talk to eventually. So, if you come from a place of patience, and you're like, "I'm noticing these things," like "this is how I'm here for you," this, these are some potential options, almost like if you're fishing; you're casting lots of bait, and but it gets up to the fish to take the bait. And that's like what Candice is talking where like they're the fish and they will take the bait and it'll be there. But always making sure that, that bait's there and remembering that a person is more than their eating disorder, too. So, you can still try your best to do things with your loved one that they, they do love. If they loved art making, or they loved movies, or they they love playing with their friends, or like going outside for walks. Those are all things you can still try to incorporate and do with your loved one, even while they're experiencing some concerns in their life.

Candice Richardson [47:25] And, ambivalence toward treatment is very, very normal especially among this particular population. And, just because somebody isn't ready right now, that doesn't mean they're not going to be ready a few days from now, weeks, months from now, like the whole stages of change. And really, we want to be able to capitalize when that person is ready and willing. We're there to help with the resources in whatever way they feel comfortable.

Yagnesh Ladumor [47:50] We need people like our guests advocate for attention and ultimately research surrounding eating disorders. Dr. Kaplan and Shauna both weighed in on their research and what they see as future questions that tackle in the field. In particular, in the anorexia nervosa community, researchers around the world have banded together to answer the question: what are the genes contributing to this disease?

Dr. Allan Kaplan [48:12] The international collaboration is the Psychiatric Consortium Genomics and sourcing for anorexia nervosa. So that's a group of investigators across the world. We're interested in the genetics of anorexia. And, the main goal is to collect enough DNA to be able to do whole genome wide association studies. And to do that properly, you need huge numbers of cases.

Melissa Galati [48:36] When you say huge numbers, what are the numbers?

Dr. Allan Kaplan [48:38] Yes, so giving an example. The consortium for schizophrenia is now over 100,000

Melissa Galati [48:43] Wow

Dr. Allan Kaplan [48:43] DNA samples, and it's really bearing fruit now, and it has to do with the statistics of g wash because there's so many measures and calculations being done that you have large numbers to correct for false findings. And so, we're not there yet. Bipolar consortiums, I believe around 60,000. So we're now about 20,000-25,000. But, we're getting there. Yes. And, we're still collecting.

Melissa Galati [49:09] And so, what is your sort of current research looking at? So you mentioned you have a couple of clinical trials that you're trying to.

Dr. Allan Kaplan [49:15] Yes. So, we've just finished a number of studies. We did a large drug study, and it's very hard to do drug studies on people that are anorexia; they're not that compliant. And you know, especially a drug where they could gain weight, they tend to drop out of those studies, but we really focused a lot on compliance in this study, and we were successful in recruiting and involving over 150 subjects and five sites in North America.

Melissa Galati [49:43] And so, what was the, what was the study looking at?

Dr. Allan Kaplan [49:46] It was looking at the effectiveness of a drug called olanzapine. Olanzapine is drugs, and psychiatry are very much dose-dependent. They have different effects at different dosages. So at dosages, used high doses, olanzapine is an anti-psychotic, and it is used to treat schizophrenia. At lower doses though, it's not so much an anti-psychotic as it is an anxiolyric; it reduces anxiety. And we felt, because it works primarily through dopamine, a neurotransmitter dopamine, now, dopamine regulates areas of dysfunction that we see in anorexia, mood, for sure, activity. So the classic disorder of dopamine inactivity is Parkinson's where there's a loss of dopamine cells in the substantia nigra, a different part of the brain reward - so anorexic patients are anhedonic; they get no pleasure from the things that are typically human, in the human, pleasurable, food, sex. In fact, it's hard to create a situation where an anorexic will take a drug like cocaine, because they just don't get the same impact. Cocaine works and is so addicting, because it releases dopamine in the brain. And dopamine has a role to play in that, too. So because of all that, it's seems to be involved in the core symptoms of anorexia nervosa, you know, the weight loss and the restriction of calories are a result of those dysfunctions.

Melissa Galati [51:08] and you did see an effect.

Dr. Allan Kaplan [51:10] We saw, we, in a subgroup, not all subjects, a subgroup seem to have a therapeutic response by allowing themselves to gain weight without completely getting so upset that they dropped out. So for them, it was a therapeutic weight gain, they described less of a drive to exercise; you know, typically, the people with anorexia are driven to exercise. They described much less anxiety. They described less feeling of body image being large and being bloated and actually talked about enjoying meals, right? Because for most anorexics meals are aversive. Yeah, they don't get pleasure from having a steak dinner.

Melissa Galati [51:51] And, you said the response was in a subset, but in an area where there are virtually no treatments,

Dr. Allan Kaplan [51:57] It's significant. The another remarkable finding in that study is, if you gave that drug to other patients, even normal people, healthy people, you would get changes in blood glucose. It can induce a type-two diabetic state; you get increasing lipids and cholesterol. We didn't find any of that in the anorexic subjects. Their Lipid, cholesterol, and blood glucose didn't change. And, when I've talked to people who, let's say work with those, you know, people with schizophrenia, that, they found, they saw that as quite remarkable. But there's something in the brains of anorexics that make them somewhat impervious to these kinds of negative side effects, if you can get a positive effect.

Yagnesh Ladumor [52:44] If you're interested in learning more about this study, Dr. Kaplan and his group recently published their findings in the American Journal of Psychiatry. We'll link the article in the show notes.

Melissa Galati [52:54] What do you see as sort of the major questions in the field right now? What are people really tried to tackle with the technologies that you mentioned.

Dr. Allan Kaplan [53:01] Yeah. So, that mean, the key is taking the genetic findings and translating that into better treatments. So we're now, we're now, we have identified at least eight genes that contribute, risk anorexia nervosa. So, what are we going to do with that information?

Melissa Galati [53:15] Yeah.

Dr. Allan Kaplan [53:15] Can we somehow either get pharma interested in drug development, because we don't develop drugs? That's not what we can do.

Melissa Galati [53:25] And olanzapine, as you said, is already FDA approved

Dr. Allan Kaplan [53:28] that we're just repurposing it for another disorder. It's approved for schizophrenia and other disorders. So that's the challenge. What can we do? Can we make those genetic findings have an impact on the actual disorder?

Melissa Galati [53:41] And the genetic findings, are they genes that make sense?

Dr. Allan Kaplan [53:44] Yes, so they are genes that are involved in metabolism, primarily. So we wouldn't have necessarily predicted that. We had been focusing previously on genes that regulate hunger, appetite, impulsivity, mood; these are different genes on a different chromosome.

Stephanie Nishi [54:00] We asked Shauna the same question: what big questions may be a focus in the future of eating disorder research? She shared what she's researching now and what she's looking forward to exploring.

Shauna Solomon-Krakus [54:11] My first area of research wanted to look at "are there different personality traits that are more commonly linked with eating disorders compared to other traits?" and just so that we can understand, "is there a way to then use these traits to tailor treatment?" That's the ultimate goal, not quite there yet. But of course, that's the ultimate goal. And from there, I also wanted to see, there's also emotional experiences that can be often precipitating factors to an eating disorder symptom. And so, wanting to understand, "are there specific emotional experiences that are more commonly associated, say with eating disorder symptoms, compared to others?" so we know how to tailor treatment, we know what specific traits and emotions to be looking at.

Stephanie Nishi [54:51] Eating disorders are not just about food. As we have heard, there are many other factors involved. It is a mental illness that can chronically affect a person's life and the people around them. However, there are resources available such as NEDIC. Tracie and Holly also have some words of encouragement.

Tracie Burke [55:08] Sometimes people think of eating disorders as an acute disease that can be treated and cured. In some cases, some people come for treatment once and can walk away and not really have to deal with their eating disorder in a, in a big way for the majority of their lives, but that's, I would say, that's the minority. And so, we see, we certainly see a lot of people who are dealing with an eating disorder as a bit of a chronic disease, looking at how to, how to live with an eating disorder. You know, many, many people come to treatment more than once. So we always talk about recovery as a bit of a journey. And so someone, depending on their life stage, who's supporting them, the environment that they're in, their motivation to change, the readiness to change, they might come in and do a piece of work and then live their lives for a bit and realize they need to come back and do more work. So we do have kind of, you know, an open door policy around who can come how many times, and we, we kind of appreciate that it is a bit of a journey and that people might come back to do another piece of work. So, treatment is oftentimes just the first step in, in a larger journey. And really, the hard work for many people come when they've left treatment and they're integrating back into their, their normal life where many of their stressors might be, and there are environmental cues that might kind of trigger some of their old coping behaviours related to the eating disorder.

Holly Dickinson [56:41] It can be easily discouraging if sometimes treatment doesn't "work" the first time or doesn't feel like a fit for you. I think there's the door, like the idea that the door is always open, never to give up, and we've seen some individuals come into treatment, and, and have one sort of dose the treatment and recover and move on with their lives. And then we've had experiences with individuals that have been sick for many years. And then for whatever reason, they are able to make that change and, and, and stay well. So I think the idea that, yeah, not to give up, and it's a journey for sure.

Yagnesh Ladumor [57:18] We learned a lot from our guests, and we hope you did, too. All of the resources mentioned in the episode are listed in the show notes. Hosting for this episode was done by Yagnesh Ladumor and Stephanie Nishi, interviews by Melissa Galati, Amber Mullin, and Swapna Mylabathula. Alex Jacob is the audio engineer, show notes and content creation by Tsukiko Miyata, and photography by Nathan Chan and Mehran Karimzadeh. Thank you to our guests Dr. Alan Kaplan, Tracie Burke, Holly Dickinson, Shauna Solomon-Krakus, Candice Richardson, Ary Maharaj, and to all those who shared their thoughts for the word on the street segment, and thank you for listening.

Melissa Galati [58:00] Raw talk podcast is a student presentation of the Institute of Medical Science and the Faculty of Medicine at the University of Toronto. The opinions expressed on the show are not necessarily those of the IMS, the faculty of medicine, or the university. To learn more about the show, visit our website rawtalkpodcast.com and stay up to date by following us on Twitter, Instagram and Facebook @rawtalkpodcast. Support the show by using the affiliate link on our website when you shop on Amazon. Also, don't forget to subscribe on iTunes, Spotify, or wherever else you listen to podcasts and read us five stars. Until next time, keep it raw.

Stephanie Nishi [58:35] Welcome to Episode 64 Okay,