In this episode, Dr. Jennifer Gaudiani (“Dr. G”), a leading expert in medical complications of eating disorders and underfueling, joins us to explain what female athletes need to know about the many effects of fueling on your performance and health.

She explains how underfueling can significantly impact your bodies and mind — and what signs you should be aware that you might not even realize are actually related to your nutrition.

Key Takeaways:

• The physiological signs of undernourishment and how they can affect athletic performance
• Actionable strategies for athletes to fuel their bodies effectively
• Misconceptions around eating disorders and athletes
• How to navigate the complexities of nutrition in sports

Dr. Jennifer Gaudiani, “Dr. G”, is a renowned expert in medical science and physiology, specializing in the medical complications of eating disorders and underfueling. As the founder of the Gaudiani Clinic, she combines her extensive clinical experience with a compassionate approach to empower individuals on their health journeys.

Links and Resources:

• Gaudiani Clinic
• Dr. Gaudiani's book: Sick Enough: A Guide to the Medical Complications of Eating Disorders and Under Nutrition

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Quick Content Warning for this Episode this episode discusses the medical complications of eating disorders and under fueling in athletes.

If you are navigating recovery or you find this topic challenging, please listen with care.

Reach out to your support team if needed.

What if the thing you think is making you stronger or faster is actually breaking you down?

You don't have to look sick to be struggling.

You don't have to have an eating disorder to be undernourished.

And that PR you just hit, it could be the last one before you fall off of a cliff you didn't see coming.

Let's talk about the lies your brain and body tell you when you're not feeding it enough.

Spoiler alert.

Your brain and body are liars when they're hungry Dr. Jennifer Gaudiani, known as Dr. G, is one of the country's leading experts on what happens to the body when athletes under fuel.

She's an internist, founder of the Gaudiani Clinic, and author of the book Sick Enough.

A book that strips away diet culture myths and gets into the real physiology of what undernourishment does to performance recovery and long term health.

This episode is for anyone who's ever been told their labs look fine while their body suggests otherwise.

For anyone who's been praised for discipline when what they really needed was permission to eat more and rest harder, here's what you'll learn how to tell the difference between an athlete's heart and a starving heart.

The coral reef analogy that explains why symptoms sneak up on you one by one.

Why your metabolism isn't broken, it's just protecting you from starvation.

The physiological signs your body is running on empty even if your weight hasn't changed.

Why some athletes perform their best right before they crash, and how to avoid that fate and what sick enough really means so you don't need permission to care for yourself.

Dr. G brings the science, the empathy and zero tolerance for diet culture pressure.

This conversation might be the permission slip you didn't know you needed.

Let's tune in.

Okay.

Dr. G, we are so excited.

I just told you before we started recording.

I squealed when you confirmed this episode.

I just finished your book nerding out over it for our listeners.

Tell them a little bit about who you are.

Sure.

So first of all, thank you so much for having me.

And I think my version of a squeal is when my toes wiggle.

So, you know, that is my sort of like embodiment of being so excited and having no cool about something.

Yes.

Which I do all the time.

I am an internist who specializes in eating disorders and I have for the last 18 years.

I started my career in an inpatient setting caring for critically ill adults with anorexia nervosa.

And then I opened my own outpatient clinic here in Denver, Colorado with telemedicine all over the US 10 years ago.

And I have three brilliant partners, the best nurse in the world, and a support staff of people with deep, deep decades long roots in the field.

And I basically take care of what happens to the body when people undernourish, Whether that is in the service of an eating disorder or whether that is in the service of trying to do your sport the best and thinking like this is how I'm supposed to eat.

Or for people who fall into medical issues that keep them from being able to nourish properly.

And I try to use a lens that is very non hierarchical, very warm and relational and feminist and kind of encouraging the development and blooming of each.

Each person's unique individual badass.

So that as so often happens with, with those with eating disorders, other identities kind of get pushed down.

And I love welcoming people to re embrace their other non eating disorder identities,.

Like finding themselves and owning themselves again and having agency.

Yeah, yeah, that's it.

Tell us about, tell us about your book.

Sure.

So about a year and a half into opening the Gaudiani clinic in Denver, I was like, look, I have this unique knowledge base and I'm only going to be able to see so many patients one on one.

And one of the pillars of values that I had when I opened the clinic was to improve the quality of medical care for people with eating disorders around the world.

And so I thought, okay, let me write a book that's sort of case based on for patients, their loved ones and clinicians that really tries to give as much information as I know about all the stuff that happens to the body and the way I talk through it.

I was an English major who close read poetry.

So like science, not really my forte, but communication and like using language is.

And then I was just in practice for the next seven years and you know, raising my daughters and enjoying my husband and my friends and my life in Colorado.

And suddenly so much time had gone by and I was like, oh crap, I know a lot more now.

Like, I've really been humbled and retrained and then humbled and retrained and humbled and retrained.

And I have a lot more to share.

So I promised myself that when I dropped off my oldest daughter at college that fall, I would like tear the first edition up and I would like redo the lit search and reorganize it and add a bunch of new chapters.

And so I'm so delighted to say that In November of 25, sick enough, two came out and then I got to do the audiobook this time.

So the audiobook just came out like a month ago.

And it's super fun that my words are, in my words, very cool.

And tell us about the title and how you decided the title would sicken off.

Yeah.

So for the last 18 years that I've been doing this work, and I know you and I were just saying for the show that you hear this all the time as well.

Something intrinsic to the brain of a person with an eating disorder.

But also, let's face it, to just the average overachiever, probably a little bit perfectionistic, little maybe hard on herself, says, I'm not whatever enough to change, to recover, to care for myself differently, to rest.

So when it comes to people with eating disorders, part of the psychopathology is I'm literally not sick enough to warrant your concern to change what I'm doing.

They might narrowly pick one thing and be like, because I don't have that one thing, my potassium is normal, so I must.

But in fact, the whole point of the book is that anyone with an eating disorder or undernutrition, if they have a single physical thing or if they don't, because they've just got one of those resilient bodies, a single values oriented aspect of their life that's being blocked by this disorder, they are sick enough to seek help and make change.

And then in the, in the sort of the broader group of humans, gosh, how many times have we said, I haven't gotten enough on my checklist done to be able to put my feet up and chill?

You know, I'm not, not busy enough, I'm not accomplished enough, I'm not whatever enough.

But I routinely tell my patients in the course of very deliberately walking the talk that the only reason that I have been able to be as productive professionally as I have and in other ways that just really matter to me is because I have decided to regard myself with compassion and to literally say, I get home at the end of a Workday, and I have a shitload of notes to write and I got a bunch of emails to do.

But what I need right now is to take a walk and then a bath and read a, like, you know, fantasy book or a, like, romance book.

Yes.

What I'm going to do, because I know my work will always get done.

That's so hard to learn that I think, especially, you know, for me, for our listeners.

Right.

In kind of this do it all culture, which we've been having a lot of conversations about lately, I think.

And this might be a nice kind of segue into some of the.

Kind of the medical complications and what's happening under the hood.

One of the things I love about the book is the analogies I love as a therapist, I love analogies.

I'm using them all the time.

And so fortunately, I now have a couple more.

So let's start with your coral reef analogy, because that really resonates with this whole idea of like, well, because I don't have such and such.

Like, this is the only thing that we're really seeing.

And whether it's menstruation or performance plateaus or changes in heart rate, which we'll also talk about today, how do you explain the coral reef analogy?

Because that also applies to this hustle culture that you're talking about.

Oh, my gosh.

It really does.

I feel like this metaphor can be used for so many things.

So basically, here's the essential metaphor.

Imagine that you got a fish tank and it's got corals of different heights in it.

And when the fish tank water is full and you don't see any coral sticking out over the top, you don't have symptoms that day.

Symptoms could be you don't have IBS symptoms.

Symptoms could be you don't have anxiety as much.

It could be your, you know, your mood is.

Is even.

It could mean your performance is kicking ass.

It could mean that your chronic neurologic condition isn't very symptomatic.

So if the tank is full and you don't see coral tips, you're performing at an optimal level.

As the tank water starts to decrease, we start to see little tips of corals sticking through it.

And those little tips start to show symptoms of whatever it is in someone's life that's relevant.

For me, symptoms, because I have a lot of health privilege might be that I get more snappy, I get less present.

I'm a little more likely to dive into my phone because I'm retreating.

And so the more the water goes down and the more coral tips that show, the more symptoms you, you have.

And so the, the lesson here is not that there exists a coral less tank.

All of us have stuff that's going to poke through the surface.

It's that we need to keep our tanks full.

And that is going to mean different things to different people.

But fundamentally as, as human beings, we keep our tanks full through consistent, adequate nourishment, through reasonable sleep, through rest, and not pushing ourselves so hard that we break.

Whether that's on the field, on the stage, at work, whatever it is, and it's surrounding yourself with people who are fundamentally non toxic, you know, relationally, you have to keep your tank full and then everyone else is going to have other things that uniquely fills their tank.

But I think those are the things to think about.

And, and of course those little corals could be physical symptoms that emerge, or they could be emotional or functional ones.

Sure.

And the key is likely to pay attention as well, because if the, the water is very slowly getting lower, you may not actually notice that there have been these signs kind of popping up.

Or I think it's easy to just justify it with one, like it was just a day.

This, it was just because of such and such as opposed to looking at the pattern.

Yeah, well, so many of your listeners are going to be women with incredibly high capacities, you know, where they can really haul and they can haul over long term.

And when things aren't optimal.

That is a wonderful superpower, except that there's gonna be a tell and you know, I would just like to invite everybody and this isn't a sort of like, dude, hang 10, everything's cool, just chill.

I love being a super accomplished woman.

And again, if I were to go with sort of the nature that I was hatched with, and that was frankly kind of nurtured in my family of origin, I probably would have dropped out of medicine altogether years ago because that was too harsh, it was too judgmental, too perfectionistic.

Those were felt as proxies of excellence.

They're not, they're just mean.

So it's so much easier to be an to yourself and be like, well, I'm not allowed to do this and I have to push this.

And I know I'm at my limit here, but I'm going to keep going and just rely on this like endless resource of energy and determination.

But the truth is, is that something in your body is going to put you on your ass if you do that.

And to honor the fact that many of us are women who can choose Certain paths in our life when lots of women across the planet cannot.

We are women often who can have agency.

And so if we don't use that to assess what we need and try to accommodate it, we are actually relinquishing one of the great pieces of magic that the world has offered us.

Sure.

Like taking away our own agency in a lot of ways.

Yeah, yeah, yeah.

And what are.

So you use the, the cave person analog, another analogy to really explain the body's response to under fueling or undernourishment.

Right.

I assume, you know, some of these things can also happen or worsen when you're not getting as much sleep, when, you know, exercise patterns change, et cetera.

These all interact, obviously.

But can you talk us through kind of what's happening when, when someone starts under fueling consistently, how does the body respond?

Yeah, it's one of my favorite metaphors to try to give patients and their loved ones sort of an entree into this.

Because so often they're coming already pre programmed with diet culture and with wrong ideas, like scientifically actually incorrect ideas.

And so, for example, like, I'm a clean eater.

Right.

You prob hear that all the time, especially us as athletes and active women.

Like we care about how we're feeling.

Yeah, yeah, absolutely.

That's, that's a great example of sort of we come pre programmed thinking.

Well, this is clearly the only way to do it.

And I've got rules and all of this stuff.

Okay, so cave person brain is basically the part of our brain that evolved through millennia to protect us from undernourishment.

We are only sitting here today because our ancestors millennia ago were the most successful in not dying due to caloric deprivation.

And therefore that means this is so deeply baked into our underlying operating system that it is like laughable to imagine that all of these magazine covers could just give us a few little tips and tricks and we're gonna, we're gonna override that.

Nope.

Biology 30 days.

Biology is gonna win every time.

So, you know, essentially the fundamentally wrong piece of information that doctors continue to be taught and that many of us have learned tacitly or, or explicitly is metabolism is fixed.

Meaning it's, it's like it is in place.

It is, it is where it's going to be and it's not going to change.

And therefore that if we eat more than that or move less, we'll gain weight.

And if we eat less than that or move more, we'll lose weight.

This is scientifically inaccurate.

Like, yes, at extremes, of course, you're going to see some stuff.

But what actually happens is, is that we, we all start out with a metabolism.

And by metabolism I roughly mean sort of the way that your body uses energy to, to live its life.

We, we start with a metabolism that is influenced by our genetics.

It's influenced by, you know, our experience of food security or insecurity or the presence of diet culture as we grew up, by various traumas, by medications, by medical issues, etc.

But fundamentally, sort of, here we are, we've got the metabolism we have.

And let's say that that metabolism is a healthy, happy metabolism because we're eating adequately and consistently through the day, which is the thing to do when we start to undereat, our metabolism slows a little bit so that we're still even.

And then if we under eat a little bit more, it slows a little bit more until some basement is achieved.

And the way that the metabolism slows is through a lot of the medical complications that I treat.

So we see hands and feet get cold or people generally feel chilly all the time, which is basically the cave person's way of being like, yo, there's not enough food around.

I'm not going to burn calories to keep you warm.

I'm going to make you feel chilly so that you seek out sweaters and a hot mug of tea.

You keep yourself warm.

I, I got to keep you alive here with the calories you're giving me.

It, it involves slowed digestion and that sense of fullness or bloating or nausea after you eat, you know, a pretty standard meal after you've been undereating for a while, and you're like, oh my gosh, what is that sensation?

That's gastroparesis.

It involves a bunch of other things, you know, slowed heart rate, decreased blood pressure, all this stuff.

And people experience different of these symptoms.

But fundamentally this is how the cave person brain slows us.

And then someone finds themselves and often again, thank you, diet culture in a place where they've been undereating for a while, they lost some weight, maybe initially because everyone's obsessed with that, and now their weight is about even.

And they're like, dude, even I know I'm undereating.

I know I'm not eating enough, but I'm not losing weight.

And they then think my metabolism is broken and if I eat more, obviously I'm going to gain weight because I'm not losing weight on this few calories.

This again, happily is totally wrong because when we begin to eat more again, our Metabolism speeds up and then more food, more speedy and like the whole body blooms again.

In the context of adequate nutrition, some people might gain some weight initially, some people might not.

But the truth is, is that our metabolism is beautifully dynamic and ready to show up for us and take care of us.

And yes, again, at extremes, we're going to see changes in weight, perhaps not in everybody, but in many.

And so to know that our body is tuned to protect us from undernutrition just as, as well as we are tuned to take a next breath, that we have to stop thinking, we have to stop having the hubris that we can sort of transcend biology and, and trick it.

No, we are the ones who are going to get tricked.

Yeah.

What are some of the.

So you mentioned gastroparesis, which sounds like that, that's the gastric slowing digestion kind of slows people feeling really full or bloated after even a small meal.

Constipation can be another one.

Correct.

Yep.

Um, what are some of the other signs of feeling cold?

Brain fog.

Brain fog is classic.

Um, and you know, it's of course happening right in this period where our hormones are getting funny and you're like, am I brain foggy because my estrogen is sputtering or because I've been eating too clean and I'm in energy deficit?

I think, yeah, especially women in like perimenopausal transition, you know.

Yeah, body composition, composition starts shifting in a lot of us have been in seeped in diet culture for decades.

And so then, yeah, 100%.

So, you know, the answer is hormones are tricky.

What you can definitely control, however, is making sure you're, you're getting enough nourishment.

And so that brain fog, it's memory, it's concentration, it's a sense of joy and sort of easiness in your own brain.

Mammals that are undernourished get very serious and focused.

They are not playful, they are not like, creative.

They're like nose to the ground finding food.

And they're a little paranoid because they know that their bodies are at risk.

And that's what humans frequently who are undernourished get to.

There's an irritability and edginess and somebody might be like, dude, I don't have an eating disorder.

I'm just eating in the way that this person online told me to while I trained for my marathon, you know, or I'm, I'm just doing low carb because I had to go gluten free a year ago.

And slowly the carbs kind of dropped out.

The truth is, is that we need these nutrients.

And so we see these changes of, of just undernourished bodies.

You know, hair starts to fall out more, our skin gets more fragile.

We know for sure that periods can stop or become more spaced out, which reflects low estrogen, not due to perimenopause, but due to under nutrition.

And that can cause bone thinning.

You can get blood sugar drops.

There's a bunch of things.

And these are just in the early stages.

We're not talking sort of advanced active chronic malnutrition.

And then people are so amazed to see how much better they feel when they do nourish.

You know, I'm lucky enough to work with a lot of elite athletes, and to a person, they say when I am undernourishing, I don't respond as well to my workouts, I don't heal as fast, I don't perform as well.

Although there can be that confusing little loop which we may talk about where like you initially start to do perform better and then fall the cliff where they're more prone to injury and that they're not responding to PT as well.

And when they are nourishing, well, they're like, oh, yeah, I had a super hard set of workouts and I feel pretty darn good after it.

And I'm not getting injured.

And if I do get a little injury, I'm healing so fast and my brain's really in the game.

And I remember my love for what I'm doing.

Like that is the response of somebody who's well nourished.

And when I talk about nourishment, I'm not talking about body weight necessarily.

I'm talking about the fuel you put in your face.

Because people's bodies come in all shapes and sizes and you can have.

You can't assume that because someone is in a somewhat higher body weight that they are well nourished.

Right?

Yeah.

That they're healthy.

Yeah, exactly.

How does sleep change?

Is that pretty common as well?

It's super common.

A number of patients have told me the thing that will keep them from relapsing in their eating disorder is that they never want to sleep as poorly as they did when they were undernourishing.

Again, that, that going back to that cave person brain when our ancestors were undernourished because they just found themselves in a time of want, not plenty.

If they slept deeply, they were more likely to fall prey to a predator, and they knew that they were not resourced to run as fast or climb A tree as fast to get away.

So there's this level of both wakefulness, sort of exhausted activation that people experience when they're under nourished and trying to sleep.

But then there's also these distracting food obsessions, which, you know, food noise has become an interesting phrase right now in a society that's very GLP1 receptor agonist, me medications.

But the vast majority of food noise is the cave person brain saying, hey, we're not getting enough, feed us more.

What kind of physiological hunger exactly?

It's, it's hunger and, and it might not be, you know, it might just be someone who's not eating enough carbs.

Plenty of people who are sort of obsessed with food, thinking about it all day long.

They're eating a low carb diet for a reason that made sense to them at some point, and yet they get a little bingy when they actually have access to carbs.

No, I. Oh, see, you know, I've got a carbs problem.

No, they have a restriction problem.

Yeah.

And once they allow back in adequate amounts of what their body has been craving with the wisdom of millennia of evolution, the food movies goes away.

Right.

And talk to me a little bit about the athlete heart versus the starving heart, because this is something I hear a lot about.

I'm sure you do as well.

I mean, and then I don't know if there are any nuances you can speak to in terms of like heart rate spiking more quickly versus, you know, having a plateau for intervals for athletes over training under fueling.

Cause that's always, I think, something worth paying attention to, especially given how many of us are tracking that nowadays.

That's a beautiful question.

So a lot of the time somebody who's undernourishing will go into their doctor and they'll be like, oh, my pulse is 70 because I'm a runner, period.

And you know, the doctor's busy and they see someone who looks like a high achiever who's sort of, you know, not flagging some of the weight stigma boxes in a, in a physician's head and they're like, yeah, yeah, yeah, you're a runner.

Cool, cool.

But here's the difference.

A really serious athlete who's taking care of themselves nutritionally and with regards to rest may have a relatively slow resting heart rate.

Usually not slower than the low 50s, maybe high 40s, but like, you know, even Olympic athletes typically have heart rates that are resting in the sort of low 50s range.

And when that person is seated, their heart rate's in the low 50s when they're, like, walking down the hallway to go, you know, get a pair of slippers, their heart rate's in the 50s.

Like, it doesn't change too much until their body is actually asked to do something meaningful because they are well nourished, well hydrated, and well rested.

By contrast, what I'm going to call a starving person, and this doesn't mean a skinny person, it means someone who's not nourishing enough has gone into metabolic hibernation.

And when bears hibernate, they radically slow their heart rate, their breathing, their core temperature, and they essentially enter a state of suspended animation where they can survive for months without food.

And this is through elevation and vagal tone.

A person who is undernourished, a person who is starving, may well have a heart rate that's 48 at rest.

But when they just stand up to walk down the hall to grab their phone, they may find that their heart rate rises 75%.

It's not fast, it's nobody's idea of tachycardia.

But a 75% raise when really their body isn't doing that much is something that we have to scrutinize.

Now, this does not happen to all people.

There is a bell curve of physiologic experience.

But essentially what I do in clinic is a walk across the room, test, where we take a resting pulse, and then we just say, would you just walk to the door and back?

And we check it again.

Not in everyone, but in a lot of people, you'll see this reactive heart bump, and it's because the person isn't well nourished.

Their muscles are empty of glycogen.

Even if they're still working out hard, they are fundamentally, like, deconditioned in really important ways, and their body is showing.

It's an empty tank.

So, you know, I encourage just primary care doctors, pediatricians, even though it's an unvalidated measure, to just be like, just check it, because it might be normal and you might not have an aha moment.

But if you have the aha moment, you can use it and be like, hey, you know, this is not what an athlete's heart does.

If you're training hard and you're not nourishing well enough, this is what your heart looks like.

So I'm going to call you on the fact that you are a runner.

You might be running, but this is not an athlete's heart.

This is a starving person.

Yeah, that's really helpful because I think it's so often just Dismissed of, oh, you've got an athlete's heart.

What about the top end?

Are there any differences?

So let's say you've got an athlete who's undernourished or, well, nourished.

Are there going to be differences in terms of how high their heart rate can go or how quick their heart responds?

I will always be humble when I don't exactly know the answer and I don't have good data on this, but my scientist brain says, yes, absolutely.

Yeah, yes, absolutely.

Because, you know, I've had the benefit of really experiencing, taking care of people with the physiology of critical, critical malnutrition and underweight during the years that I was at a hospital program and they were on telemetry and, you know, I would see people who at rest had heart rates in the twenties with variable block and who would get up to brush their teeth and their heart rate would go to 180.

So if that's at the low end of, like, any kind of activity, then it makes perfect sense to me that at high rates of activity, this would still be a problem.

And so I think when people are trying to optimize, historically our culture has said when you're trying to optimize something, cut things out like carbs or like adequate calories, like, care for yourself less.

And I would say if you're really trying to optimize, do more.

Like, really listen to a smart sports dietitian who can tell you, oh, yeah, 50% of your intake needs to be from carbs because that's what's going to fuel your muscles.

And around certain, you know, comp times, things may have to adjust a little bit, but fundamentally, people are going to perform best when they're really taking care of themselves.

Yeah.

And then I imagine recovery, like recovering from a long run.

So let's say someone is working their way up to marathon training.

They do a 14 to 16 miler.

What might be the difference in recovery for someone who's well nourished versus someone who's undernourished?

Oh, my gosh.

I mean, it's huge.

It's huge psychologically, physically, in terms of the wear and tear of the run.

Their joints, their muscles, their energy, at the end of the day, their sort of psychological state.

The person who isn't nourishing enough is just going to be really depleted.

And then they start to feel that sense of burnout, that dread of going on the next one, or conversely, that like, sort of neurotic attraction to, like, I was only supposed to do X number of miles.

Tomorrow.

But I think I'll do X miles too.

You know, just the brain can go in either direction, like sort of push too hard or really start to burn out.

Whereas again, having seen this with my elite athletes before, you're going to be able to follow a training plan and have your body actually benefit from it.

I mean, that's the other irony is that people who are so focused on these incredibly detailed training plans, when they're not nourishing enough, they're just breaking down their muscle and ending up weaker.

So if you actually want to train in ways that make you stronger and more durable, you gotta be doing the whole thing, not just moving your body.

Right, yeah, I've seen that.

As well as just like pure exhaustion.

Just being like a zombie or a space cadet the rest of the day.

It's like, it doesn't have to be like that.

Carbs, my friend.

Right?

Yes, yes.

Yeah.

But I think it's, you know, again, when we're steeped in diet culture and there's all of these rules and guidelines and unsolicited advice on the Internet or social media, it's hard to know.

So exactly at what point.

So you mentioned, you know, it's essentially you are sick enough or a person is sick enough if that coral is starting to show and affecting their ability to kind of, you know, live true to their values on a day to day basis and show up as a version of themselves that they're proud of.

Is that safe to say?

Yeah.

At what point do you, does it become medically concerning?

Like what are some of the things that you're looking for?

And let's say, you know, an athlete comes to you and they want to be medically cleared to participate for the season and there are concerns about fueling, how do you make that decision?

Yeah, yeah.

I think about it in as complex a way as possible because I want to give every opportunity to the athlete to remain in their athletic identity as possible.

Because right now, you know, at the point at which they come to see me, their athletic identity and their eating disorder identity are really warring with each other.

And to every extent possible, I want to foster their athletic identity.

So I think about a couple of things.

Medically, the most dangerous thing that can happen to somebody who's restricting is low blood sugar.

People might be surprised to hear that because they might be like, oh, you get low blood sugar all the time.

I don't know.

Is that really dangerous?

It depends on the person, of course.

But you know, if in the course of an average day where I'M eating well, but I'm also doing a lot.

I sort of get that, like, ooh, I'm a little, little shaky.

I think I need something because I don't have an eating disorder.

I know I will immediately go get a snack, and I will resolve that feeling.

By contrast, the more one's tank is empty nutritionally, again, regardless of body size, if you've really been under eating for a while and you have no glycogen left in your muscles and your body is kind of an empty tank, that low blood sugar can last long enough to cause really serious damage.

And in the context of somebody with formal anorexia nervosa, where their body tissues are also very much atrophied, you can end up with a seizure, a coma, or death.

Low blood sugar is the number one cause of death in anorexia nervosa.

It causes the heart to stop.

So when someone's blood sugar starts to go, it's like, yo, stop everything.

This is really serious.

But we have a lot of other things that we look for in athletes, like injuries, stress injuries, stress reactions, time out of play or out of performance, where you're like, you know, you don't have hypoglycemia, but that stress reaction is continuing to come back and you're not able to do your thing.

This is a problem.

Now, I would say that I try to overlay the individual person's narrative because, again, everyone exists on the bell curve of genetic physiology with.

With, like, what they want athletically.

And so if I see someone who has a set of increasing signs that their personal body isn't managing the way it's being treated, then we try to take a moment.

I'm also, though, pretty aggressive, as long as the patient wants it, about getting people back into sport.

I think that the old model of don't move a muscle or you'll burn calories while your body is recharging just reinforces the eating disorder idea that exercise is for calorie burning.

And that's really not right.

Now, if somebody's like, Dr. G, this is hard for me to say, but I need a break.

I am burnt out in my sport.

I don't know if I want to continue gymnastics.

I need a hot minute.

Great.

I'm ready to, like, sign any letter they want, be, like, not medically cleared, and give them that cover.

But a lot of my patients will be like, it does help me to get back out there.

This is something that is good for me.

And so with their dietitian and their Therapist, we'll try to.

And the patient themselves, of course, at the helm will try to come up with what would be a reasonable minimal set of behaviors in terms of rest, nourishment, hydration and parameters.

I can measure maybe vital signs, etc.

That show me that you can start getting back out there.

Usually it's not vital sign based unless something's very extreme.

Usually it's like when your dietitian tells me you're fueling enough to sustain your basic function and what you want to do that day athletically and continue to allow your body to rehab and recover.

I'm in.

And I love being a little bit of a maverick on this because I think patients respond to like, oh, thank God, I thought this was taken away from me.

But if you're actually my advocate in getting back to sport, I might be able to bend a little bit on the rigidity of my eating disorder demands because I really would actually like to play this season.

Yeah.

And from a psych perspective, I see this all the time.

Where rest is then seen or perceived as a punishment.

You know, where it's then they feel once whenever sport is taken away for anyone with a history of eating disorders or disordered eating or, you know, chronic injuries, like that's the first thing that's taken from them.

And again with the athletic identity.

And so then what can happen is, you know, non disclosure where they're doing these things and then they're not telling.

Their treatment team and then we can't.

Actually care for them.

Right.

And this is especially true for my patients who are neurodiverse, ADHD and autism.

Both are so benefited by movement that I'm essentially putting a patient at a grave disservice if I just arbitrarily take movement away from them.

That said, movement needs to be.

Needs to be done when it's well fueled, well hydrated and appropriately rested.

And if somebody's like, Dr. G, don't take away my identity, but I'm going to triple my running distance and I'm going to be dissociated the entire time and I'm not resting an injury and I'm not fueling dueling, I'll be like, dude, you're telling me what you want to do with the athletic, but you are not doing any of the tickets to ride that would allow that.

So let's talk about the barriers.

And I do have to insert myself here and, and ask you to, to change what you're doing.

I also had a really great learning from a couple of different Teachers that there's a really helpful way to determine if undernourishment is primarily in the service of a sport.

You know, maybe relative energy deficiency of sport, reds, et cetera, kind of accidental or just trying to be a better athlete, whether an eating disorder is fueling it.

And the differing point is that an athlete who is operating from athletic identity will do whatever it takes to get better, including eat more, allow their weight to come up some, and rest more.

They literally, as long as they've got a trusted source, they will do whatever it takes to get better.

Whereas someone who's coming from an eating disorder identity, even if they're an athlete, will be driven by fear and they will not be able as easily to make those changes because the other voice is going to be like, oh, oh, oh, you can't trust this, you're different from everyone else, etc.

And so that's very helpful for distinguishing.

Yeah, that's a really helpful framework.

I hadn't considered that.

And then I imagine it can be a mix, of course.

Yeah, it's.

But it's a matter of messy behavioral change.

Yeah, I mean, this is, this is like hard stuff.

And yeah, it's, it's hard for the patients because they're the ones really living it, you know, and then.

So you alluded to this earlier and this is something that I know, you know, listeners often wonder.

I've wondered.

Clients of mine have commented, you know, using essentially performance as a proxy for health.

So the athletes who may be undernourishing, they're hitting PRs, they're winning races, they're getting new, you know, FTP, you know, new power number, whatever the thing is.

And we assume that whatever they're doing, they're fueling adequately in order to get that.

What is the danger with this framework and why does it happen?

Yeah, that's such a good question.

And it's probably the one that's most confusing to my elite athletes when they come to me because.

But, you know, if they're coming to me, they know there's something awry in their nutrition.

But they might be like, Dr. G, I'm doing some of the best work I've ever done in my life right now, and I know I'm not doing what I need to do.

So it's very confusing.

It's hard for me to resist it or to do something else if my results are so positive.

And those results can not only be performance results, but they can also be coach commentary.

You look great or you're such a role model for this team or whatever it is like, yeah, that's so painful to hear and so confusing.

And the truth is, especially for the strength to weight ratio sports, there can be these complicated windows where people's body weight has diminished and yet they're still strong enough.

Remembering that we always lose muscle when we lose fat.

So, like, it's not that people are just quote unquote, paring back their fat mass.

And what I generally say is, I can see the complexity of this for you.

I might ask patients, like, tell me the complexity for you.

Because some might be like, my scholarship is on the line.

You know, my, my professional endorsement is on the line.

My, my spot on this elite level team is on the line here.

So I hold the complexity.

I'm not like, don't think about that.

Just think about your health.

Like, of course, humans, these things matter.

But what I'll say is, we don't know when you're going to fall off the cliff.

The performance and health and mental health cliff.

You might be one of those really unique people who can hang on there a couple of months.

I beat it next Thursday.

One of those tendons gives and you are out the rest of the season.

Yeah, it might be that your mental health cracks and suddenly you're engaging in behaviors you haven't done since you were a teenager because you just pushed the limit a little bit too hard.

And so while I understand that the sports world demands sort of absurd, superhuman things from our athletes and that the temptation is always like, ooh, maybe I can get that little extra edge just for one more week, just to get through this one.

And the truth is that you're playing with fire.

And the sport world has at least decided that, for instance, we're not going to allow anabolic steroids, which are harmful, even though they bring a performance edge.

Sports should similarly stand up and say, we do not want athletes to starve themselves, to undernourish themselves for a short term theoretical fix, given the immediate medium term and long term risk to their health.

So if we go by performance, it's a little bit like when people are like, you know, Dr. G, I have a 4.0.

I couldn't possibly be that sick.

Dr. G, you know, my weight's not as low as it ever was in the past.

I'm, I'm not sick enough.

It's just sort of one more experience that's trying.

You know, the eating disorder is trying to protect itself.

And I get it, we have to call it what it is.

Yeah.

And it's like, when when athletes crash and fall off that cliff, they crash hard, like.

And I think that's, you know, and that's when.

That's when they come into my office as a sports psychologist, and then you're.

All the athletic identity stuff is wrapped up amidst the injury or the ED or, you know, the autoimmune concerns or whatever the thing is.

Right.

That they're grappling with.

And.

I mean, again, like, something's gonna give.

Yeah.

You don't want it to be you.

Right.

Like, you know, don't.

Don't roll this roulette wheel.

Don't.

Don't do this.

Let's.

Let's figure out how to help you totally kick ass in ways that are also sustainable and will allow you to continue to grow as an athlete and not have this.

Be like the last race you ever do.

Yeah, yeah.

One.

One other.

And this kind of gets to that, you know, the messy middle and the difficulty of the.

You know, the.

Just the recovery and rehabilitation process, regardless of where someone is on their journey.

Right.

Going beyond the breakers.

Can you talk a little bit about that one?

I used that with a client the other day because I was like, this is glorious.

And so I think that can be a really helpful way to capture, frankly, a lot of different kind of rehabilitation kind of doing the inner work or the physical work.

So talk us through that one.

Yeah.

So when a patient just says, Dr. G, I'm burned out.

Yeah.

I'm just tired.

I'm overwhelmed.

I'm exhausted by what I've been asked to do.

And that might be rehabilitation.

It might be psychological work.

It might be eating disorder recovery work.

What I can sometimes observe to them is you're in the breakers, metaphorically.

And we know that if you're at the ocean and you're right in the breakers, if they're big enough breakers, they're not like, the fun ones you want to play and, like, boogie board in.

Being in the breakers is exhausting.

The waves keep crashing right on your head, and they push you under and they tumble you, and they're scary.

Barely come up for breath and wipe your eyes before you're getting hammered again.

That is exhausting.

And oftentimes that exhaustion pushes people back into shore, and they're just like, no, I can't do this.

And sometimes what I'll tell my patients is, you've done just enough work to be in the breakers, but to not swim another 20ft out and get to the swells, if you will be brave enough to wholeheartedly embody the work and push that extra bit and get brave, you're just going to be like, bobbing gently up over these swells and you're not going to be having your ass kicked.

And then you're finally free.

It reminds me.

So I'm a cyclist, and I'm sure plenty of listeners who cycle will relate to this one, and especially anyone who's raced is when you get kind of quote unquote dropped from the peloton and you're trying to close that gap again and you're just, you're burning so many matches and, you know, it's so close but so far away to close that gap and it's so hard and you just want to, you know, pull the umbrella.

But if you dig a little bit harder for a little bit longer, you can catch that draft again and start to conserve energy and you won't lose the pack and the race.

Right.

Like, there's just so many benefits, but in the moment it is so hard.

Bodies screaming at you, right?

The.

All of the weird and twisted feelings that we appreciate as endurance athletes.

So I think that analogy really resonated with me because often in the moment it's so overwhelming, like, I can't do this.

I love that.

That's.

That's a great one.

Yeah.

Yeah.

What are some of the biggest misconceptions or maybe the things that you really wish?

Coaches, trainers.

I mean, those are kind of the main two, but even, you know, physical therapists, other providers, athletes, you know, need to know about kind of the medical complications of really undernourishment, whether intentional or not.

Yeah.

I think, interestingly, the, the thought that comes to mind emerges from a really fun talk that I got to do for elite and club level Nordic skiing coaches around the country recently about eating disorders.

And I put together a series of, of theoretical cases after talking with folks in that world.

So I understood what are the commonest presentations that, that especially adolescents and young adults experience.

And a lot of it is a, is a visual mistake thinking that having a body that looks a certain way means necessarily that you have a body that's going to function in a certain way.

A really interesting fact that I learned is that for a lot of these young endurance athletes who might have just been early superstars, you know, their, their bodies were set up in a way and their, and their psyches and their training ability were set up in a certain way that they were just dazzling and just about as, as these young women hit their sort of late teens so often, very appropriate adolescent young adult body changes finally sort of take place.

Their weight may go up, their training may decrease their, their outcomes may decrease their.

And they, they sometimes, you know, either end up with an eating disorder because someone's like no, no, you have to go look like your 15 year old self and that doesn't do well for performance.

Or they leave the sport and they're like I don't want to do the sport if I'm, if I'm not doing it at the level where I was always a superstar.

But what I learned in the course of preparing for that talk is a number of those athletes, if they will just stay in the world.

Yeah.

And accept that there could be a few years where they're just not going to be the superstars they once were.

They sort of get into their early 20s and like without any eating disorder, without any undereating, their bodies just sort of naturally re shift back into a place that happens to perform super well and suddenly they're at elite levels again.

And I think that's very inspiring.

Our athletic careers are non linear.

Periodicity doesn't just mean within the week or within the season.

It can take placed over the season of our lives.

And I think for women who are perimenopausal that may also be true.

Just because your body isn't in a place right now where you're maybe performing as you wanted to.

If you can keep the love of the sport, if you can keep cross training, if you can keep taking care of your emotional health and your nutritional health and your relational health in great ways, you might be surprised what sort of shows up down the road for you.

I'm so happy you spoke to that.

I know Trent Stellingworth has done a good amount of work in that area on, he calls it patience through puberty in that plateau that so many female endurance athletes experience.

When puberty hits and it's like stick with it, it's worth it and you'll get.

It's like the, it may be more, somewhat more linear for guys.

That's right.

But then, and so then women are, you know, they're comparing themselves and it's just a whole thing and it's like trust yourself, trust the process.

Easier said than done.

Especially when you're, you know, 16 years old.

Yeah.

And you don't know, you don't know what's going to happen and it's so challenging.

But if the alternatives are quit the sport or get hurt and, or have to quit because of injury because of an eating disorder.

Wait.

Hanging in there and like finding the joy and and remembering who you are as a whole human.

Sounds like a really good alternative.

Yeah.

And there are so many other ways.

To, like, work on being a good athlete.

Like, it's not all about the fitness.

It's not all about the power or the strength.

Like, it's, you know, so much.

And that's where the sports, like, comes in handy.

The fueling and nutrition, like, nerding out over gear and equipment.

Like, there are so many things that you can do to.

To improve, and then your body catches up to you and look out, you know?

So, yeah, it's such a hopeful message.

Yeah, it really is.

For folks who want to learn more, tell them about the Gaudiani Clinic, your book, where they can follow you, support you, all of the fun things.

Thank you.

Yeah.

So on social media, we are at Gaudiani Clinic.

G A U D I A N I clinic.

We are gaudianiclinic.com as far as our website.

Our clinic is in Denver.

We have four amazing doctors, and we see people.

I think we're licensed in 48 US states and do a ton of telemedicine, which is really fun.

People don't have to have an eating disorder to see us.

They might have reds.

They might just need to be like, I need someone to synthesize the fact that I'm an athlete with POTS or with mast cell activation syndrome or with complex digestive stuff, and I want to have sort of the best care that also will honor me as an athlete and not be intimidated by complexity.

Yeah.

And then.

Sick Enough to the.

The book is officially called Sick Enough, A Guide to the Medical Complications of Eating Disorders and Undernutrition.

And it is available online on Amazon in some bookstores.

Love to see it in more.

But for the meantime, it's available online.

Yeah.

For anyone who enjoyed, you know, this conversation, I really encourage them to read that book.

It's.

It's so good.

Um, it just.

And I'm a bookworm.

I'm a book nerd.

But, like, the way that you brought in, I mean, you can tell that English is like your former English major.

Just like, you are such a great writer.

And I know that writing is.

It's a long and grueling process.

So for you to completely rip the part, rip the book apart, and then put it back together with all of this new information is quite an endeavor.

So kind.

And, you know, people may not want to read the whole thing.

They might want to read, you know, guidance for parents.

They might want to read uniquely about what affects them or their loved one even.

They don't have to be like, holy smokes, this is a lot of book.

You know, just dive in where it feels good.

And my goal is for people to be empowered and to be able to be educated and then speak for themselves or for their loved ones in a somewhat faulty medical, you know, milieu and, and to get better results as a result.

Yeah.

For people to say, oh, I just read about that.

That's a thing that happens.

Like, let's get you checked out.

Let's get you some support.

So yeah, Dr. G, this was amazing.

Thank you so much for taking the time and joining us today.

This was so much fun.

Thank you so much for having me.

And that's a wrap on Today's conversation with Dr. G. Honestly, I could have kept talking to her for hours.

Here's what I hope you're walking or rolling away with Your body isn't broken.

It's brilliantly designed to protect you, but only if you give it what it needs.

Adequate fuel is not optional.

It's foundational to performance, to recovery, and showing up as the person or the athlete you really want to be.

If your tank is running low, whether that shows up as brain fog, irritability, injuries that won't heal, or a heart rate that spikes when you stand, your body is talking, so listen.

One thing to consider this week Notice your own coral reef.

What symptoms are starting to poke through, and what would it look like to refill your tank instead of pushing through?

If this episode landed for you, share it with someone who needs to hear it.

Leave a review and please check out Dr. G's book subscribers.

Sick enough?

It's a game changer.

Thanks for being here.

We'll see you next week with another conversation worth having.

Thanks for tuning in to the Feisty Women's Performance Podcast.

If you enjoyed this episode, please subscribe, review and share.

This podcast is for informational purposes only and does not establish a therapeutic relationship.

In other words, I'm a licensed psychologist, but not your licensed psychologist.

Always consult your healthcare provider before making important decisions about your health.

Find show notes and resources at Feisty Co. Join us next time as we continue to move the needle in women's health and performance via evidence based conversations.

Until then, keep living your healthiest, feistiest active life.