Body Shame and Disordered Eating: How to Nourish Ourselves and Heal with Dr. Kara Pepper

For many of us, when things get stressful, the first thing we do is lean on old habits of body loathing and disordered eating. This becomes especially challenging on the fertility journey, however, when we know that egg health and the ability to ovulate depend on our nourishing ourselves. 

This is further complicated by the weight gain which accompanies the fertility journey for most people. Although it is multifactorial, the many consecutive months (and sometimes years) of being out of our typical rhythms of exercise and nutrition can be a significant contributing factor. We find ourselves gaining weight despite our best efforts, which makes us resent the process even more.

If these examples resonate with you, give this episode a listen. We discuss:

• how to think of your body as your partner
• how to rethink BMI and body size 
• how to get the support you need to navigate the journey, especially when you struggle with body shame and/or disordered eating
• how to take small steps towards self compassion and loving yourself again
• how to rediscover your worthiness and take back your power 

About Dr. Kara Pepper:
After 16 years in clinical practice as one of Atlanta's top doctors, Dr. Kara Pepper opened a hybrid in-person and telemedicine practice to provide high-quality, comprehensive, patient-centered care. 
Her practice style is informed by Health at Every Size philosophy, coaching practices, team-based care, and the recognition of harm that is perpetuated by our health care system. Her role as a physician coach who helps female physicians reclaim their autonomy, freedom, and love of medicine, and she is the host of the It's Not You Podcast.
 
Guest Links:

www.karapeppermd.com

As always, please keep in mind that this is my perspective and nothing in this podcast is medical advice.

If you found this conversation valuable, book a consult call with me using this link:

https://calendly.com/loveandsciencefertility/discovery-call

Also, be sure to check out our website: loveandsciencefertility.com

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Please don’t let infertility have the final word. We are here to take the burden from you so that you can achieve your goal of building your family with confidence and compassion. I’m rooting for you always.

In Gratitude,

Dr. Erica Bove

Transcript

Hello, my loves and welcome back to the Love and Science podcast. I am so honored to have a beautiful guest today. Her name is Dr. Kara Pepper. I'm so excited for our conversation. You know, as I am open about my previous history of a needing disorder and what it's like to navigate this world in recovery.

We're going to touch on a lot of the themes of what it's like to navigate the fertility journey with this history and all the complexities that go into that. So, Dr. Kara Pepper, she is an internal medicine specialist.

She treats adults over the age of 18 and her medical practice focuses on people with a history of eating disorders, which is amazing.

She also, like me, is a physician coach and she helps physicians build micro practices to reclaim their autonomy, freedom, and love of medicine. And how wonderful is that?

I think, you know, so many listeners find that as they're undergoing the fertility journey, trying to be female physicians, all the things like it just seems like there's not enough time and not even not enough personal power, right?

So we're going to talk about all that stuff. She is also the host of the It's Not You podcast. And if you haven't listened yet, please check it out. It's so full of wisdom. So all these things and even more, Dr. Pepper, it's so great to have you here today.

Thank you for having me. I'm so glad to be here with your community.

Absolutely. So, you know, I've been thinking about our conversation for a long time now. And, you know, I even in the last week, I've had some conversations with my patients and my medical practice about various aspects of previous eating disorder, you know, navigating the process of the fertility journey with all the stressors and really having a hard time knowing like what to do in that context.

And so, you know, I think, you know, one woman said, you know, I just am really trying to like manage life and this is my coping mechanism. And so how do I know what is what is eating enough to be able to support my fertility journey?

And, you know, another woman was very much restricting and said, you know, I know I need to eat more to wake up my body, but I don't know how to do that. And I don't know how to turn away the messages of like what my body should look like in this process to be able to move forward and give my body what I know it needs.

And she even used the word very she was very dissociated, you know, very dissociated from her body in the process and was like living according to all these rules. And so where do we start? You know, where do we start when somebody has a complex history like this, trying to live in a body, trying to eat every day, trying to manage stress, you know, where do we even begin to impact some of this stuff?

Yeah, it's such a great question because we, I think even with the two examples that you gave it is two people with seemingly different problems that they're trying to solve, even though the goal may be fertility or conception that that ultimately we all have been kind of indoctrinated from the time that we are born about what a good body should do, should look like, how it should behave.

And it's as if we are just all the same and we are not all the same, our bodies do not operate the same. And what they need is very unique. And I think it often becomes really adversarial like I just my body feels like it's betrayed me. That's what my patients will say.

I feel like, you know, I'm doing everything right and I'm not getting the results that I want. And especially for high performing individuals like physicians, we're used to just putting in the work, put in the reps and you get the output.

And the fertility journey, as you know very well, doesn't always feel like that. And so, our looking, perhaps for the first time at our body as our partner, as with compassion, as something that has been trying to keep us alive for forever, our body is literally designed to keep us alive.

And so often when it's under the stress that you described, either the stress of, I'm supposed to be thin in order to get pregnant, or the pregnancy process is so stressful I'm relying on restrictive eating patterns, your body is lovingly trying to keep you alive.

And so fighting against it is sometimes fighting against your ultimate goals. So there's a lot in there to unpack, but we can dig in as we go forward.

Yeah, absolutely. Thinking about our body as our partner, I think, you know, I've, you know, in all of the work I've done, I've never quite thought about it that way. And so I think if we just pause for a moment and think about what that actually means.

And it's our partner in sort of, you know, sort of our weight management and health and mental health and all the different things. And also the fertility journey, like a lot of my patients and my clients are like my body, you know, I don't trust it.

It's not doing what it's supposed to do. And I want to force it to do what it's supposed to do. And so I do think our bodies have this innate wisdom that we can return to.

Although we need to learn how to be embodied, to be able to tap into that. So before we get to those aspects, I'd love you to share with our listeners, what is the history of the BMI?

You know, it's frustrating from my perspective because anesthesia says a person's BMI has to be under a certain level before we can do, you know, moderate sedation without a breathing tube and all these things, which in our practice is 45.

In other places, it's different. But I, you know, I find that personally very frustrating because even be somebody with a BMI of 42, 43, 44, depending on how the weight's distributed, that can be, it's like, it's like this.

It doesn't mean anything to me because it's so different. So what is the history of the BMI and how might we be able to think about things differently?

Yes. So for those of us who are really data driven people, we often think of guidelines as like the rule of law, you know, the hand of God has written these things.

But I think the BMI is a pretty terrible metric and it's really because of where this data comes from. So for those of you who are very social justice aligned, I'm a thin white woman.

Don't listen to me. Listen to the women of color who've been screaming from the rooftops about this for eons.

In effect, if you think back about the Renaissance time periods, if you look at art on the walls, if you look at the kings and queens, people who had wealth, they were all in large bodies because health and wealth were synonymous.

You were able to feed yourself and feed your families.

And so it wasn't until Europe really started to colonize areas outside of Central Europe, particularly Africa, where women started to look at these women who were considered less than, who were in more curvaceous bodies.

And all of a sudden, it wasn't desirable to be larger figured. It was desirable to be thin because it differentiated you from the folks that your European ancestors were trying to take over.

And so that got tied in with the religious piety. So if you could be self controlled, restrictive, and morally quote righteous, you could be in a thin body as compared to everyone else.

And so the modern origins of our BMI was really in the 1830s. There's a Belgian astronomer named Adolph Kettelay, who basically looked at what "normal" men of Northern European descent look like.

So we think about the workers of that time who were out in the fields without a lot of food. These are very lean people.

And so he just came up with this bell curve and described it as a body mass index, and that is what we have today.

And it wasn't really designed to be used in medicine, and it wasn't really until 150 years later in the 1970s.

Ansel Keyes, who is famous, infamous, I should say, for his starvation studies, looked at the BMI.

And basically, you could bear the BMI to fat calipers, like pinching and measuring fat, to the underwater body composition, like submerging people.

And the BMI was the least bad choice. It was about accurate at predicting visceral adiposity about two thirds of the time, but certainly not great.

And so it wasn't really until the 1980s, 1990s, where the World Health Association started to get involved in this "war against obesity," which quite frankly is interpreted as the war against folks who live in larger bodies.

And the modern, our current, guidelines around BMI really, we allowed normal BMI to be up to about 27 and a half.

And the people who made the decisions on the board, there's two people from the weight loss industry who was manufacturing Redux and Fin Fin in the time, and they were the ones who said, "No, let's shorten that BMI range to up to 25."

And so overnight, millions of Americans then qualified for these medications.

So now all of this BMI range that we consider up to normal of 25 has been baked into every scientific trial and to all of our guidelines.

And I think it's worth looking at not only did that number come from a population that does not describe the people that I actually take care of in my clinic, we know that it is not validated in populations of black women, of Asian folks, of folks over the age of 65.

And so to use this as a blanket measurement for "health" is highly detrimental because it's not even an accurate measurement of metabolic health, of visceral adiposity, of any of the markers that we really think matter.

And so with that, just being a woman in America and being kind of conditioned from the age that we're really young to say like, "Hey, you need to be thin in order to be worthy and healthy," it's no surprise that 75% of people when they enter med school,

already have implicit bias against people in large bodies before we even get our medical training.

So it's a lot of information to simply say like, "The BMI is not telling me anything about someone's health."

And so as a general internist, particularly someone who takes care of folks who've really struggled with body image and their relationship with food body exercise, people say, "Well, don't I need to be thin to be healthy?"

I'm like, "You do not."

And I will...you know more about this than I do. This is my last comment. I'll stop talking for a minute about the anesthesia issue.

A lot of my patients who have really struggled to get pregnant as well because of the dysregulation related to nutrition and my understanding about the anesthesia component is really about high-risk airway management that many folks are doing these fertility procedures in the outpatient setting.

You need a trained anesthesiologist who has the capacity and the tools that they need, and you can be a larger body and have that done, and you just need the safety of being in a hospital that has the backup, which is so cost prohibitive for virtually everyone to have that.

And some centers are even doing regional blocks. Like, you know, you get your spinal and you have your egg retrieval, and then it takes a little bit longer for recovery until you can walk again.

But I think it's an interesting...because is it really...is the airway really the restrictive thing, or is it just one more way to discriminate, right?

Like, there may be other ways we can think. Like, I thought, you know, gosh, like, you know, if we can't access the ovaries transvaginally, guess what? We figure out a way to do it transabdominally.

You know, it's a little complicated because a lot of IVF centers are not set up with like a true main over where you can do an intubation and all those things.

Like, remember when I was at Michigan, you know, sometimes somebody would have like a significant cancer or something like that, and we'd need to go to like the main OR, and then you got to figure out how you're going to get the eggs where they need to go.

So it does cause increased layers, but there are centers who are tertiary centers who do this, you know?

So I think, you know, we need to think outside the box about how we can do safe procedures and have access, you know?

And I'm not, and I'd love to know your thoughts about this, like even this morning, our grand rounds by our wonderful second year fellow was on GLP ones and infertility and all that.

And, you know, it's tricky because I think they are a tool, you know?

It's like who needs them, but then there's this like, oh my gosh, like, if you're going to go on it, you know, don't, you got to contraceptive now, even though you have been in fertility, like, God forbid you get pregnant on this medication, which the preliminary data actually look okay.

Because it does help many people, right? With their weight and their fertility, right? And so like there's this whole thing, but then it's like, okay, but if you're intentionally on it and you want to do an IVF cycle, then like, you got to stop it for two months for the washout period because we don't really know.

And there's so I feel like, you know, this whole layer of GLP ones and sort of how much we don't yet know in the fertility space, I feel like it's driving us all crazy. What do you think?

Yeah. What's your perspective on that?

I have lots of perspective. So one is I agree it's a tool, right? And just like fire, fire can cook our food and keep us warm. It can also burn down the state of California. And so GLP ones, I think of in a very similar way.

They can be life saving medications for people who need them. They can also be highly abused and they also absolutely feed the anti fat rhetoric in our country.

And I find that I stand, but as someone who's trying to find the right solution for the patient in front of me, there's clearly the quote, war on obesity. Everyone needs to be thin in order to be healthy.

And there are the people who have been very harmed by that rhetoric who are aligned very from a social justice standpoint, saying like, it is not okay to intentionally create weight loss for people who don't need that or ever need that.

Like allow people to autonomy to say, I don't, this is not right for me. And so I find my entire practice is in the middle of that very nuanced conversation to say, what is the right choice for the person in front of us?

And sometimes that means me staunchly saying to a patient, this is really going to kill you. I mean, I have patients who are very, very sick on these medications and other people who have had their lives changed by that.

And I think particularly just like the fertility space, the eating disorder space is a very, we don't have great data on this. The obesity medicine community is like everyone should be on a GLP one.

It helps treat even cheating disorder, but we have no long-term data on this stuff and it absolutely feeds the restrictive eating pattern. So anyway, I think there's a lot for us to learn.

And from my viewpoint, I would always err on the side of safety for patients and protecting them psychologically and physically. So that's where I take it.

Thank you for sharing that. I think that's so nuanced and important. It's like focus on the person in front of you, their history, their goals, all of it, because it really, we do need a tailored approach.

And it's different maybe if somebody is 24 years old than if they're 39 years old, we might have different conversations about those things as well. And so, and more data.

I mean, I think the more we have data about these medicines, I think the better we'll be able to counsel our patients. But we're just in a gray zone and I think it's tricky. It's really tricky.

Yeah.

I wanted to ask you, so I have a lot of patients and clients and even just like people I know undergoing the process who are like, listen, Erica, I have gained so much weight since I started this process.

Like that is one of the most common side effects. And I think it's multi-factorial. I mean, again, my people are mostly female physicians in my coaching practice.

And so most of us have bought into that sort of model of like body image and at some level, maybe not everybody, but sort of in our society, part of being a high achiever is often linked to those sorts of notions about thinness, et cetera.

So, you know, when a person starts with a certain body shape size, et cetera, and then they undergo this process, which tells them when to exercise and when not to exercise, pumps them full of hormones.

Maybe they have stress eating and this is inherently stressful. Like the whole body changes, the whole mind changes. And it's hard for me to really help people in that scenario.

And, you know, how I approach it is like this is a chapter of your life and this is not going to be forever. And, you know, really like embracing the task at hand, which is undergoing the process, mental health, physical health.

But that may mean like not, you know, trying to lose weight right now, like to focus on the overall goal of fertility. But how can we help people understand that, you know, like weight gain is not necessarily a bad thing and how to reduce shame or even eliminate it of what's happening in that throughout this process.

Yeah, I like to think of it as what is the goal that you're trying to create. And I know that people want to get pregnant, but I don't think with any goal.

Let's use med school as an example. Like, yes, I want to be a doctor, but no one's like, well, in order to be a doctor, I'm really going to have to be awake for real on my feet for 30 hours and what that really means for my mental health.

Right. Or like, yeah, I want to be a doctor, but I'm going to see some really traumatic things and probably experience some personal trauma as part of my training. Like, that's not the part that's sold.

And so I do think that there's probably a little denial or avoidance in thinking about like, I want to have this child, I cannot wait for it. And I'm going to have to go through a lot of hardship, not just the frustration of getting pregnant, but it's going to show up in every aspect of our life.

I mean, I know your clients know that very well. It shows up in their marriages, it shows up in their friendships, it shows up everywhere. And so couple that with this idea that we need to stay in thin bodies.

I mean, I do think that's a huge barrier for a lot of people. And so the partnership of like, this is a season, this is what my body needs, this is how I nourish my body, my body changing shape.

I mean, this is one step towards the actual change of shape that's going to happen when I have a fetus inside of me. I mean, the ultimate test of body acceptance often is like, yeah, I get to have it change during a pregnancy. That's a big deal.

And I think having open and honest conversations about these things in places that support, that can just name what this is, like, yeah, it feels really hard. I just don't like that. My body is changing shape and having to have an honest conversation about that.

And you mentioned your client earlier, perhaps I was before we started recording that lives in a larger body and was really frustrated that they were having fertility issues while they were trying to diet and every body is different.

And your fertility zone, I love how you describe that. It may not be in that BMI range of 20 to 25 that we're conditioned to think is normal. So what does your specific body need in order to reach the goals that you have?

And I can't say enough about therapy. I'm sure that's a big part of the coaching that you offer your clients, but like, there's groups for women on purpose because this stuff is hard. It's not easy at all.

Right. You can live in a larger body and have a hypothalamic amenorrhea. Like, I just want to say that, like, yes, you know, that is a, that is a real thing. And, you know, I think, you know, thinking about there's that scenario.

There's also the scenario of somebody who, you know, really is doing their best to work every day, take care of patients beyond the fertility journey. And then they feel that restrictive eating creeping in, you know?

So what, you know, what could you offer that kind of person who struggles with that, who's like, you know what, like I'm trying, but this is my Achilles heel.

Yes. I absolutely think having a therapist and dietitian who understand eating disorders is critical. This absolutely, it would be like going to an internist, a general therapist.

Like, I understand a lot of things, but if you've got like, you know, an EF of 10%, like you need a specialist who really understands heart failure, right?

Right. Right.

And so I do think that that really matters because the language that people use, their implicit bias, hopefully they're like, eternally trying to excavate that. And it really does make a difference.

And the reason I do the work that I do is because I truly believe that women can change the world. And for people who are spending 80, 90% of their day thinking about food, body and exercise, like what are they not thinking about?

What is the impact that they're not able to make? What are the connections and the relationships that are being impacted by that? And so if we can reduce that noise in your brain, and I'm not saying by going on a GLP one, I mean, truly by addressing the trauma and the thoughts that are there, it is life changing and world changing.

So anyway, sometimes we don't feel that we are worthy of that or really fully recognize that that's the case. And I think it's actually great if they're trying to get pregnant, because if I can't do it for me, I know I'm going to do it for my kid.

And so your future kid deserves to have a mom who is not trapped by this. Your future kid needs you to show up fully in the best way that you can.

And the cost of that is that you get to address this relationship you have with food and try to excavate that in the meantime.

And so sometimes if we won't do it for ourselves, doing it for that person, like I don't want to eat right now, but like I got to eat to have this kid, like sometimes doing it externally is the way to incrementally stepwise it into our internal framework as well.

Yeah, that's a really, really good point. And I remember as a college student in a support group for people with eating disorders, I remember one of the group leaders, which I eventually became a group leader, but one of the group leaders when I was like just a regular member was like, I don't want to be that mom.

I want to be a mom who is able to teach my kids about healthy eating patterns. And I mean, in my house, like, and then maybe in your house too, like, we are very much like, okay, you don't have to finish everything on your plate, like listen to your body.

You know, just sort of really trying to understand that embodied intuitive wisdom of the hunger signals and all of that. But I think, you know, even without a history of restrictive eating, like medicine really does get us out of sync with our body.

Yes, it really, really does. And so I'm sure like a lot of the work that I do is helping people get in touch, coming home to themselves. Am I thirsty? Am I hungry? Am I tired? Like, what do I need?

Do I need to be like, and that's a sign of growth is like giving ourselves permission. And so what I'm hearing you say is like, you know, if you are listening to this podcast and you're struggling and you're like, that's me.

I'm that restrictive person and I'm really struggling and I want to do the right thing, but it's my stress. Like, give yourself permission to get support for the stress because there is a way through that is more expansive, that is beyond the restrictive eating.

And it's there for a reason. It's like, it's like the weather. It's like, oh, you know, for me, when that creeps back in, I'm like, oh, what's really going on? What do I really need to address that I'm not addressing, which is the harder path.

But I think we are also complex and we don't spend time with our inner worlds. And when we can feel our feelings and understand what's actually going on, sometimes those aspects start to get better, even without tremendous work because we're dealing with the root and not the root.

And not the symptom, if that makes sense.

What a beautiful opportunity that this stuff has gotten unearthed because I assure you as a parent of two teenagers, like it does not get easier.

It's not like I magically like had this stress free life after I got through my pregnancy. So those, the very child that you're trying to create is going to create a lot of opportunities for you to like unearth your, your, or to see that these are patterns of behavior that are unresolved.

So like better now, just do it. And as someone who takes care of only adults, I mean, my patients have been struggling with this stuff for 10, 20, 30, 50 years.

And to look on the back end of someone's life at what they have lost as a result of this, like, even though it feels so alluring, even though it feels so tangible and seductive, even though it feels true.

Like, of course I need to be thin. Of course I don't deserve to eat this. Of course I feel dysregulated. Like, oh my gosh, on the back end, it is such a loss. And that is the grief that I have for all my patients.

And so if you're listening to this and this feels true to you, there's never going to be a good time to address it.

And so today is the day to even just make the phone call or to tell one person to say, I'm really struggling and to get plugged in with resources so that you can actually have freedom in your life.

That's right. And I think, you know, what is one of the biggest gifts of coaching? It's to take back our power. And I think, you know, and maybe we have a sense that like we're giving away our power in other, you know, in ways, like even body image.

Like if we glance by a mirror and we don't like what we see, like, that's a small exit of power, you know?

And so like, how can we step into ourselves fully? And what could we do if we had all that mental energy and, you know, that backpack of shame and self-hatred and all the things that go along with it?

It's like, gosh, who could we become? What kind of relationships could we have? What kind of a legacy could we lead for our children?

Like, I love how you think about it. It's like the possibilities become endless. And it's like, who would not want that?

And we know that growth happens like through the discomfort. So we can't sidestep it. We can't find some like secret backdoor out. We're going to have to go through it.

But then on the other side, we're going to have the freedom. That's right. That's right. That's right. So powerful.

Yeah, thanks. It feels really amazing to be able to support our colleagues in this way. And I know that you appreciate that as a clinician and as a coach. And that's what feels very true to me.

I mean, the overlapping, frankly, nearly 100% overlapping Venn diagram of my coaching practice and my clinical practice is exactly that, like helping people recognize their own suffering and practice self-compassion, get activated into change and to find their power again and to actually do something about it.

And the noticing part, which for some of your listeners may be it right now, like, yeah, she's speaking to me, but I'd really rather like the discomfort of what I know is so much more familiar than the scariness of uncertainty and change.

This phase feels really volatile for a lot of people because it means like we're fixers. So like, oh gosh, I know that there's a problem. Now I have to do something about it.

Like you don't have to blow up your entire world. You can literally just start by like sending yourself an email that's going to get delivered in two weeks to be like, hey, you said you're going to call that eating disorder therapist or like, hey, you said you're going to go tell your doctor about that.

Or hey, I'm going to show up for myself and just remind myself that this thing is something that doesn't need to be buried in shame and secrecy, but it's something that I am wholly worthy of even if I don't believe that quite yet.

That's right. I know. And I, I mean, for me, when I was going through the worst of my struggles, like I truly felt alone. Like I was a competitive runner and my pathway to success was like all the things that I thought were necessary.

And then I got to college. I was like, oh, I might have to leave college. I don't want to leave college. Like, how can I stay in college? And when I went to my first support group meeting, because I like found a sign on the back of a bathroom stall in my dorm, thank God.

I went to my first meeting and there were like 90 other women there. And I was like, oh my God. Like it is not just me. All these other women are suffering and like we can heal collectively.

I mean, that's one of the beauties of my support group that I lead for my clients with infertility is like that group has, there's healing in the group. And when you understand you're not alone and you understand, you can see, you know, your other people serve as a mirror for, like, if I can't be self-compassioned,

if I can't be self-compassionate with myself, but I know what I might offer this person, then maybe, just maybe I can reflect it back. Or if I can't see myself as this is what this is one thing I love to do in college.

I learned all my, I'm sure you have lots of tips and tricks for your people, but like, I thought if I can't see myself as beautiful, guess what? My best friend Renee thinks I'm beautiful. So I'm just going to try on her perspective and I'm going to say Renee thinks I'm beautiful.

And so then I would then carry that with me until I could believe it myself. That's right. You know, that's right. Or like, like you said, the emails, like we don't, unfortunately our pants don't have too many pockets of these, but they're coming back.

A lot of dresses have pockets, but like, you know, write like a little something tangible, like when you have a moment of rational thoughts, like, you know, you know, whatever it is, like, I am beautiful regardless of X, Y, Z, or my beauty is not connected to my body size or whatever.

And like, tuck it in the pocket. And if you start to have that dissonance, pull it out and be like, oh, wait, when I had a rational moment, like this is, this was my truthiest truth. And so just that brain rewiring, it takes time and discipline.

But I mean, I can't think of anything that's more worthwhile, you know?

Yes, absolutely. It took, this did not happen to you overnight. No one ever grows up thinking, hey, I want to have an eating disorder and totally, you know, diminish my light and power and all that.

And so to be able to say like, this is something that I'm worthy of doing may feel like a big stretch, but just starting really small and borrowing thoughts from other people, I mean, that's where any change begins, right?

And I think particularly for folks who are trying to be pregnant, like, when we talk about, you know, from a meta standpoint, creating change, counseling our patients, you know, there's the big long-term goal, in your case, I want to get part of it.

In your case, I want to get pregnant. But the short term goal has to be more compelling. Otherwise, we never change our behaviors. Like, we need something today. And so, hey, I want to recover from an eating disorder may feel like super big.

And, you know, you've been dealing with it for years and years. But like, I want to get pregnant in the next three months, like that feels a lot more compelling.

And so whatever your reason is, it needs to be acute, it needs to be tangible, it needs to be, you know, we talk about smart goals, but we need something that matters today that's not nebulous.

Like, that's right. Getting pregnant seems like a pretty compelling reason, you know?

That's right. Using that as a motivation. Like, I always start my coaching programs with like, what's your deepest why? You know, and I think that when we have a strong enough why, any how is possible, right?

Yes. So, you know, the last thing I want to touch on is this connection between eating disorders and infertility and worthiness. Right. So, you know, I hear from a lot of people who struggle with one or the other or both.

I just don't feel worthy of feeding my body or maybe I just don't deserve to be a parent. And like, how can we reclaim our worthiness in a way where we can do the things that our body is truly asking us to do, right?

How can we understand that, you know, this is not the universe punishing us for XYZ, but that all people who desire to become parents deserve to be parents?

Like, I don't know. It's a deep question, but what are your thoughts on really this deep root of unworthiness and how we can start to break free of that to step into this power?

Yeah.

So I'll start with a story and I guess I'll answer your question. So when my nephews were born and I have two kids, I love them. But, you know, I think we have unreasonable expectations for our kids sometimes. So my nephews were like a step away from that.

I could love them 100% of the time and not be responsible for them. And, you know, when kids are born, they're kind of a pain in the butt, right? Like they provide no value to this world. All they do is poop their pants, they cry a lot, they disrupt your sleep.

They're super expensive. You know, they are like highly disruptive, right? And yet we love them. We worked really hard to get them into this world and we think they're amazing and we think they're worthy and we like rearrange our entire lives to like keep them alive, right?

And they are a quote, not productive members of society. They bring quote, no value to this world. These are heavy use of air quotes for your listeners.

Yeah.

And yet we think they're amazing. And at some point, we as individuals decide that we have to earn worthiness or someone along the way told us that we were not worthy or we experienced trauma or we experienced something that broke that idea that just by existing on this planet, we don't have to do anything else to be worthy.

And I often ask my physician coaching clients that same question, like how many more patients do you need to see to know that you have like paid your moral debt to this field? Even if your student loans are not paid off, like how many more, right? You're not stuck. How many more?

And I think that question really gets to the deeper issue of your question about worth. Like there's something that shifted us from believing that we are inherently worthy from being like a toddler with a crop top and a boa who just thinks that they're amazing to like a high performing exceptional individual who thinks that they're not worthy of food.

Like what happened in that gap?

And so if there is trauma, if there is a series or neglect or experiences that helped create this idea that you have to work in order to be worthy, it's worth unpacking that because that came from somewhere like you weren't born with that idea.

That's for sure. That was handed to you and internalized.

And I think there's a number of ways to get from I don't deserve food or I have to earn the right to eat or I'm not worthy of being a parent to I am inherently worthy regardless of what I do. There's like a thousand little baby steps in between.

And I love that you mentioned earlier about your friend thinking that you're beautiful because even if I don't believe it, I know that my kids think that I'm worthy of food.

Like they would never be like, mom, you're not allowed to eat food. I know that my parents think that I'm really amazing, even though I've messed up. I know my spouse of 26 years.

He definitely loves me and he knows everything there is bad about me. So is there an external borrowing of beliefs that you can start with? That's one.

And then I think often for those of your listeners who have heard of internal family systems, which is like we're made of all these different parts.

The part of me, you know, I think about the new mom version of me who's like drowning in new patients and two little toddlers and my husband who was traveling for a living and I thought I was failing every single day.

Like the me of now, like I look back on her and I was like, God, she was killing it. I mean, she was exhausted. She was burned out. She was touched out. She just needed like a moment where no one was asking anything of her.

But she was doing such an amazing job. I don't think I could do that now. Right. So is there a past version of you? Is that 13 year old version of you who's just showing up trying to do your best?

Like she was worthy. Like the med student version of me who was like getting indoctrinated with a culture of medicine and like seeing my first patient die for the first time, like she sure was worthy. She was doing her best.

Like that new parent version of me in my 30s, like she was really trying to kill it. So even if the 47 year old version of me today does not quite believe it, like I believe that on their behalf.

And I believe that they deserve better. And I believe that they were doing the best they could with the tools and the resources that were available to them.

And so it's like an inch wise way of getting a little bit closer to the you of today that's like bump this. Like I do not deserve to feel like crap at the end of every work day.

And I do not deserve to be burned out anymore. And I deserve to eat food regardless of my body size. Like that very activated, fierce self compassion. It takes a little while to get there.

And so doing it on behalf of other people, those past versions of you, on the people around you, I think that can use our innate powers of advocacy to really help us advocate for parts of us.

Until the whole of us is we believe that is so profound. I mean, I use a similar analogy when I talk to my clients who can't even imagine a world in which they would become pregnant.

I said, there was one day when you were a young hopeful and you were studying for the MCAT and you thought it was what?

One percent chance or less that you'd get into medical school and like, look, here you are like you're in attending position and somehow that all happened.

And so, you know, I think that people can really relate to that when they look back on different versions of themselves, when maybe even against all odds, they were able to do something and become a new version of themselves that was previously unthinkable.

I think it's the same thing. There's this book called hatching in our fields that is about fertility and motherhood and all of that.

I think of, you know, the blastocyst hatch, the blastocyst of day five embryo, day six embryo. And that's what we put in preferentially to help somebody get pregnant.

And I think like just as the blastocyst is looking for a home, we are all looking for homes.

And I think the more we can find that home within ourselves and with each other and these beautiful communities, I think I really think that's the secret sauce.

But you're right. Yes, in twice journey. And then I mean, the cool thing about self compassion is it then becomes the path of least resistance.

Like sometimes, you know, I'm sure you and again, like I think we both do this work. It keeps us honest and accountable.

Sometimes I'll be like, wow, that was a really self compassionate response. Like I might not have done that three years ago.

No way. But I'm like, but I'm almost like surprised and honored when I, you know, I choose the self compassionate thing without even thinking about it.

But it's it's a discipline that we build over time. It really is. It's just a learned skill, just like anything to learn skill.

But we're worth it. We are 100 percent worth it. And we are not failures. And there is more to life once we can embrace that and start taking steps towards towards our freedom.

You know, 100 percent. I totally agree with you on this. Wow. I mean, I'm going to have to re listen to this conversation and in, you know, just just share it with everybody I love in my life because I am just so inspired by your wisdom and and how much gold there is here.

So I'm sure my listeners are going to want to find you. So where can they find you? Yeah, if you can remember my name, you can find me. I'm Kara with a K Kara Pepper MD.

And so my handle on social media is care pepper MD. My website is care pepper MD. You can always email me at hello at care pepper MD.com.

So I just love to hear from your listeners, whatever resonated with them, questions they have if they need an internist who understands this stuff. I'm always happy to bounce ideas off of them. So amazing.

And remind us where you're physically located. I'm physically in Atlanta, Georgia. And I'm licensed in 17 states, mostly on the east coast. But wow, West is California. So yeah.

OK, so we'll put all your information in the show notes. And so if you are listening and you're struggling, I think Dr. Pepper would be an amazing, amazing resource for you.

Awesome. Thanks so much for having me. Thank you for all you do. Yay. Anytime. And is there anything else you want to share with our people?

No, I just I love that they are in community together. It's where healing happens. We deserve to be in a connection with people who uniquely understand. So thank you for building the communities that you have.

Yes. And I mean, it's my deepest honor. And I think that strong, powerful women, like you said, are changing the world. And so thank you for your friendship. Thank you for collaborating. And I can't wait for future conversations.

Sounds good.

OK, talk to you soon. Bye.