How To Fix Health Class

You’re listening to Burnt Toast! Today, my guest is Denise Hamburger, founder and director of Be Real USA. Be Real is a nonprofit that imagines a world where every child can grow up with a healthy relationship to food and their body. They work with body image researchers, psychologists, teachers and public health officials to design curricula about nutrition and body image that are weight neutral, and inclusive of all genders, abilities, races and body sizes.So many of you reach out to me every September to say, “Oh my God, you're not going to believe what my kid is learning in health class.” Food logs, fitness trackers, other diet tools are far too common in our classrooms— especially in middle and high school health class. Denise is here to help us understand why those assignments are so harmful and talk about what parents and educators can do differently. This episode is free — so please, share it with the parents, teachers and school administrators in your communities! But if you value this conversation, consider supporting our work with a paid subscription. Burnt Toast is 100% reader- and listener-supported. We literally can’t do this without you.PS. You can always listen to this pod right here in your email, where you’ll also receive full transcripts (edited and condensed for clarity). But please also follow us in Apple Podcasts, Spotify, Stitcher, and/or Pocket Casts! And if you enjoy today’s conversation, please tap the heart on this post — likes are one of the biggest drivers of traffic from Substack’s Notes, so that’s a super easy, free way to support the show!Two Resources You’ll Want From This Episode: Here’s how to access the BeReal Let’s Eat Curriculum: And here’s a roundup of everything I’ve written on diet culture in schools: Episode 211 TranscriptDeniseWell, this all started I would say about 10 years ago. Actually, about 12 years ago. I was an environmental lawyer in my first career—that's what I'm trained to do. I went to law school, was practicing in big law firms. Which has nothing to do with body image, except I was an environmental lawyer who weighed herself every day and got her mood affected by the number on the scale for 40 years. So that's four decades.VirginiaSo many times getting on a scale.DeniseI really felt like I didn’t want anyone else, especially young women today, to waste the amount of time and energy that I had wasted distracting them from what they need to be doing in their lives, figuring out their own person possibilities. That’s really what you’re here to do. And it takes us away from what we’re supposed to be doing.With that in mind, I went back to school at the University of Chicago, and I was thinking of get a social work degree and doing something with body image. But then I wrote a paper on my own body image for one of my classes at the School of Social Work and I found 50 years of research on body image. And then 30 years of discussion and research on how to prevent eating disorders and body dissatisfaction. Like, wow, there is so much out there, so much research on this. But I haven’t heard any of this. It feels like it’s not making its way into resources that people can use.So I started speaking on it, and I was speaking to middle-aged women, and I thought the message that we all would really benefit from would be everybody’s got this. Because I feel like, especially my generation, where we didn’t really talk about how we felt about our bodies. I’m at the tail end of the Baby Boom. So I’m 62 and I felt that people in my generation—again, I was 50 at the time—weren’t in touch with their own feelings on body image. After talking about this for so many years, younger generations have access to it I think a lot more. But I felt like we could all benefit from knowing that everybody’s got it—so kind of a common humanity. It’s not our fault, which helps with the shame around it.So everyone has it, it’s not our fault, and society has given it to us. And I think that this is something that would resonate with my generation. So I started speaking in local libraries and community houses to women my age, and quickly learned that it is really hard to undo decades worth of thought patterns and feelings around food, body and eating. People came to hear me talk about body image, and I think, in general, when I started out, they were hoping I had a new diet.VirginiaOh, I’m sure they were. I’m sure they were like, “Oh, we’re going to go hear her talk about how to love your body by making it smaller!”DeniseAbsolutely. And all of the women, because they were women in my workshops, were starting to talk about their daughters. They’re saying that my daughter’s got this, and she’s coming home and saying this. Then in one of my audiences, I had a health teacher at my local high school. There was a health teacher who came and said—this is about 2015—you should hear what the young girls are saying. They’ve got this new thing called Instagram and and they’re seeing pictures of, “perfect” looking people and feeling bad about themselves or feeling flawed in comparison.So she said, “What resources are there for for the students in my class?” And I said, there has got to be something because there is 50 years’ of research there, there has got to be something fabulous for you. And I called the professors listed on the the studies. The granddaddy of the industry, Michael Levine, I called him up. I said, “Michael, just tell me, what can I recommend to these teachers?” And he’s like, “I don’t know. I don’t know. We don’t have it. It’s not there. Even though the research is there.”So there was a curriculum created for high risk kids. It needed to be given by facilitators called The Body Project. And I called one of the professors who wrote The Body Project and said, “Listen, I’d like to give this tool to a teacher for universal,” which means giving it to everybody in the classroom, and and she wants to bring it to her high school, but it looks like you need to be trained. And it was a script. The Body Project was a script. And this teacher said to me, I’m not reading a script in a classroom. You’re not going to get a high school teacher to read a script.VirginiaYeah. I would imagine high school students sitting in a classroom aren’t going to respond to someone just reading a script at them.DeniseNobody wants to hear it. It’s not useful. It wasn’t created for that use. So this professor, Carolyn Becker, had actually written a paper on how the academics need to work with stakeholders to make sure that their research makes it to the public. And I said, I’m calling you. I’m a stakeholder. What do you need? And she said, “We need somebody to translate it.” And I said, “I’m your girl.”VirginiaI mean, it’s wild that the research has been there. We’ve known what works, or what strategies to use for so long, and yet it’s not in the pedagogy, it’s not in the classrooms.So you started with the body image curriculum, BodyKind. And now this year, you’ve just released your weight neutral nutrition curriculum for middle and high school students, called Let’s Eat.Full disclosure: I got to be a early reader of the of the curriculum and offer a few notes. It was already amazing when I read it.DeniseThank you.VirginiaI did not have to add a lot at any by any means, but it was really cool to see the development process, and see where you ended up with it. It’s really remarkable. So let’s start by talking about why nutrition. You’ve done the body image thing, that’s really powerful. Why was nutrition the next logical place to go?DeniseI have spoken at this point to probably 10,000 teachers. And they’re always asking me, what nutrition curriculum do you recommend? Same deal. There’s not one out thereAnd I had asked one of my interns to give me her textbook on it, like what are you learning about nutrition? And in my intern’s textbook, it was 2018, you saw encapsulated the entire problem of what’s wrong with nutrition curriculum.They are asking the children to weigh and measure themselves, and they’re asking the children to count calories in different ways, and to track their food. Food logs. Again, these were best practices in the 90s and and 2000s on how to teach nutrition. So this is all over the nutrition curriculum.Then, of course, they’re talking about good and bad foods, which foods can you eat, which foods you can’t you eat, and all of these things in the research we know cause disordered eating and eating disorders, they all contribute to it. I have a list of probably nine research papers that point to each of these things and tell you why these are bad ideas to have a nutrition class.And we also know there have been two papers written, where they polled students or young people coming in for eating disorder treatment and asked them, what do you think triggered your eating disorder? And around 14% in both studies said, “My healthy eating curriculum at school was where I started getting this obsession.” So you know, what’s out there hasn’t been helpful, and even worse, has been part of the problem in our society.[Post-recording note: Here’s Mallary Tenore Tarpley writing about this research in the Washington Post, and quoting Oona Hanson!]VirginiaIt’s so rooted in our moral panic around “the childhood obesity epidemic.” Educators, public health officials, everyone feels like, that’s the thing we have to be worried about if we’re going to talk about kids and food. It all has to be framed through that lens. And what you are arguing is: That weight-centered approach causes harm. We can see from the data that it’s not “fixing” the obesity epidemic. Kids aren’t thinner than they were 40 years ago. So it didn’t work. And it’s having all these unintended ripple effects, or sometimes, I would say, intended ripple effects.DeniseYes, exactly. Studies on nutrition curriculum have shown that over 11 years, teaching diet and exercise did not do anything, in two age groups. One was elementary/middle school, another one was a high school group. And they found no changes in body size or nutritional knowledge and and only the effects of what they call weight stigma. Which is just anti-fat bias. So it only causes harm. And these meta studies were from “obesity researchers,” right? So they are even acknowledging we don’t know how to prevent obesity.VirginiaSo you could see very clearly why the current landscape is harmful. How did you think about how to design a better curriculum?DeniseWe had been working on the back burner on an intuitive eating for students type of curriculum. Because the question I get from my teachers is, “What should I be teaching?” So we had been kind of working on an intuitive eating curriculum, and then one of my ambassadors, Selena Salfen, she works in Ramsey County Public Health in Minnesota, said, “Hey, we’re looking for a nutrition curriculum. Why don’t we do one together?”It really turned into how to eat, not what to eat. So we started working on body cues and building trust with your food. And then started really focusing on empowering the student as an authority on their own eating behavior, teaching them how to learn from their own eating experiences. Which is part of responsive feeding. And Ellyn Satter’s Division of Responsibility In Feeding. So we have pieces from all of these. We are empowering students to be experts on their own eating.VirginiaIt’s also so much more respectful of students’ cultural backgrounds, as opposed to the way we learned, like the food pyramid or MyPlate, saying “this is what your plate should look like.” And that doesn’t look like many plates around the world. That’s not what dinner is in lots of families. Your curriculum is saying, let’s empower students to be the experts is letting them own their own experience.DeniseAbsolutely, and trust their own experience. And trust themselves. And they don’t have to go outside of themselves. We want to teach them to act in their own best interests. That’s part of self-care, teaching them to take care of themselves. They need to learn it somewhere.So if you do what they’ve done for years and tell them you need to cut out sugar and you need to cut out carbs, or you need to get this this many grams of protein, it leaves off all of the wonderful parts of eating that we get to experience many times a day, which is the joy, the pleasure, the sharing of food. So in our curriculum, we ask the kids, what do you do in your culture around food? How do you celebrate in your culture with food? What do you eat?We get the discussion going with them and allowing them to feel pride in how their family celebrates. And so it’s really bringing in all these other aspects that we experience with food every day into talking about food. And we talk about pleasure, what do you like, what food do you like, what food do you enjoy? And we want them to be able to hold what foods they like, what their needs are that day.So you talked about MyPlate, MyPlate is stagnant. It always looks the same. But your nutritional needs change every day. If I’m sick, my needs around nourishment are different from if I’ve got a soccer match after school that day. So we’re trying to teach them to be flexible and really throw perfectionism out the window, because it’s unhelpful in any area of life, but especially around eating, especially around food.VirginiaI’m wondering what you’re hearing from school districts who are worrying about the federal guidelines. Because they do need to be in compliance with certain things. DeniseSo we spent a long time with the Food and Nutrition guidelines. The CDC food and nutrition guidelines, and we spent a long time with the HECAT standards, which are the health curriculum standards. We know that teachers are trying to match up what they’re teaching to the federal standards and the state standards. Because every state has their own discussion of this, and they write their own rules. Usually they look like the federal standards, but we find with food and nutrition, sometimes they go off. You’ll get somebody on the committee who hates soda, and will write 10 rules around soda. So every state has their own idiosyncratic rules around it as well.VirginiaI mean, on the flip side, that means there have been opportunities for advocacy. For example in Maryland, Sarah Ganginis was able to make real progress on her state standards. But yes, the downside is you’re gonna have the anti-soda committee showing up.DeniseTotally. And half of the country. We really tried to hit the big standards. I’m actually thumbing through the curriculum right now. We have two pages of the HECAT model food nutrition lessons and which ones this curriculum hits. And then if you’re interested in talking about some of the others — like some of them really want to talk about specifically sugary drinks— we give links in the curriculum to discussions that we agree with. So we may mention sugary drinks in a little piece of the curriculum, but if you want to get the article or the discussion on it that frames it the way we’d like to see it framed, we’ve got links in the curriculum for that.VirginiaSo tell me about the response so far. What are you hearing from teachers and districts?DeniseThe biggest response I’m getting is, “It’s a breath of fresh air.” It’s safe, as you say. And for the teachers out there that are familiar with all of the things that we’ve been teaching that haven’t been working, this is important. And I just want to say to all the health teachers who have been teaching nutrition out there because this is the way we’ve taught it for years: This is how it’s been done. But when you know better, you do better. And that’s the point we’re at now. I know people have been weighing and measuring kids and telling them to count calories for decades because that was best practices at the time. But we’re beyond that. The research has figured out that that’s not the best practices going forward.VirginiaThat’s right.DeniseWe had about 50 teachers and 250 students trial it. We get the experts to say everything we want to say in the curriculum, and we put it in there, and then let’s say that takes nine months. We have another nine months where we have expert teachers like Sarah weighing in on the curriculum. Telling us what happens when she teaches it in class with her and the students. What would you like to see different? Even down to activities. How would this activity work better? So we spent another nine months making sure that the teachers and the students like it, can relate to it, and that the activities are what are working in class.So that’s an extra step after some of the other research curriculum that we really want to make sure it’s user friendly and the students like it. We got a lot of feedback. We did two rounds of that.Now we released it to the public after we had a masters student write a thesis on all of the the data we collected, and felt very comfortable that it does no harm.VirginiaIt’s been tested.DeniseYeah, it’s been tested. It’s feasible and acceptable. Now we’re going to go and do the official feasibility and acceptability tests, like we’ve done on BodyKind with Let’s Eat and then take it to schools. We use the University of North Carolina’s IRB. We use the Mind Body Lab there, run by Dr. Jennifer Webb, and we are going to be doing research on Let’s Eat. We’ve got the Portland Public Schools, and then we’ve got a school district in Maryland, in Arundel County, that we’ve identified and that we’re working with to test students. And then, we’ll hopefully do an official test, write an official paper, as we’ve done with BodyKind.VirginiaAnd I should also mention, you’re making this resource free! Schools don’t have to pay for this, which I think everyone who’s ever tried to make any change in the school district of any kind knows, if it costs money, it’s harder to get done. So that’s great. DeniseYou know, it’s so funny. I’ve been speaking on this for years. I mean, we’ve been in curriculum development for five years, and I always forget to say that! I don’t know why. It’s a free curriculum! I’m a nonprofit. I’ve never been paid. This is such a passion project for me, and I continue to wake up every day energized by the work I’m doing.And the mission of our nonprofit is to get the best, well tested resources out to schools. And we want to remove barriers. And how we remove barriers is offering it for free.VirginiaA lot of our listeners are parents. They’re going to be listening to this thinking, “Okay, I want this in my kid’s school.” How do we do that? What do you recommend parents do? DeniseSo a couple things. We find the best advocate is the person at the school, the wellness professional, charged with curriculum decisions. So there are people in your district whose job it is to make sure that the teachers have the latest and greatest curriculum on nutrition.And they want these resources because they want to make sure that their students get the best resources out there. So it takes a little bit of sleuthing to call up the school, whether it’s the administrator or a health teacher, and figure out who’s that person, who’s the wellness coordinator. It could be a wellness coordinator. It could be a health teacher, who’s responsible for curriculum. Find that person and talk to them. They’re looking for this conversation. It’s part of their job. You could even say I heard about this new curriculum. It’s available for free. And you can hand them the postcard. That’s what I hand out when I speak at conferences. And it’s got a QR code. It describes what this curriculum does. We teach tuned in eating. It describes what tuned in eating does. VirginiaDownload that PDF above to QR code it right from this episode! DeniseYes. So you can send them as a PDF. You can write an email, figure out who the person is, send them the curriculum. Say “I was listening to a podcast, and there’s this great curriculum out there. I’d love you to check it out.”VirginiaI think that feels really doable, it’s a great starting point. What about when a kid comes home and tells a parent “Oh, we did calorie counting today?” Because that’s often how parents start to think about this issue. It kind of lands on their lap. Is it useful to engage directly with the teacher? How do you think about that piece of it? Because obviously, especially the school year is underway, asking a teacher like, hey, can you just change your whole curriculum right on a dime, they probably won’t appreciate that. So, what’s a, better way to think about this advocacy?DeniseI thought you did a great job in your book Fat Talk on giving them scripts, giving parents scripts to walk into the school. You want to be sensitive to how overloaded the health teacher is, the nutrition teacher is. They’re teaching 10 subjects in health that they need to be experts on so, you know, this is just one piece of what they’re teaching.The great thing about nutrition is, most health teachers are teaching nutrition so they’ve got some background in it, and you can just be as sensitive as possible to their time and do as you say in the book, you know, in a in a positive, collaborative way. “I heard about this research, I thought you might be interested,” rather than a critical way. And and again, your kid might not be taking health, they might just be in the school district. So maybe you have this discussion with an administrator, and ask them, who wants to talk to me about this? And ask them, who can I speak to? It could be a guidance counselor. Could be school social worker. You know, this is eating disorder and body dissatisfaction prevention, right? So who, who is interested in this topic?VirginiaWho in the district is working on that and wants to know about this? That’s super helpful.And I’ll also add: One thing I learned in reporting the book and thinking more about the school issue is we do, as parents, always have the right to opt our kids out of the assignments that we know to be harmful. So if you see a calorie counting assignment coming, you can ask for an alternative assignment. You can accept that your kid might get a lower grade because they don’t do it, but that might feel fair.Especially with older kids, I think it’s important to involve them. Like, don’t just swoop in. Never a good idea. They may want to talk to the teacher or you have do it. Work that out with your kid and figure out the best way forward. But I think it’s definitely worth doing that. If your kid’s like, no, don’t talk to the teacher. No, I’m not opting out. You can still have the conversation at home about why this assignment is not aligned with your values, and that’s yes important to do, too.DeniseI also wanted to say, we have an ambassador program at Be Real, and we have 135 ambassadors. What we’ve done with all of the materials we’ve been using for 10 years, which are presentations and worksheets for the presentations. We have frequently asked questions, where I quote you all the time. What do I do with my mother in law, who’s saying this thing? We give them scripts. What do I do when people equate body size with health? What do we do when people assume that everyone could be small if they tried hard enough? We have answers for all of these questions in our materials, frequently asked questions.I have templated the presentations I give. I use the notes, I give the talk track, so my ambassadors can give a talk with a teleprompter if they’re doing it on Zoom. Use the presentation as a teleprompter, and all the accompanying material we have on Canva that the ambassadors can create their own and add to it, and use their own name and picture to give talks and and things like that. We’ve got all of this so people are able to take this resource to their own local area,VirginiaSo they might give this talk to a PTA or a church group or any kind of community organization they’re affiliated with.DeniseAbsolutely. And we’ve been doing this for about seven years, and the last five years, it’s grown tremendously, and we have meetings every quarter. And at the meetings, people say, how do I get into my local school? And someone else will say, you know, I tried the principal and they didn’t answer my phone calls. And then I went and looked up so and so and and then I started out doing this for professional development for health teachers in the state of Illinois. So we also have ways to to be certified as a professional development trainer on this topic. So that’s how I initially got to health teachers. And then they also speak at conferences. So I speak at National SHAPE, which is the health teacher conference, but there are state SHAPE conferences out there that my Ambassadors will go speak at and it’s really how to get all of this material, another way to get it disseminated all throughout the world.VirginiaOh, I love that. Well, we will definitely link in the show notes for anyone who’s interested in becoming about an ambassador. ButterDeniseI am obsessed with Orna Guralnik, she is a psychotherapist who has a show on Showtime called Couples Therapy.VirginiaYes, I’ve been hearing about this.DeniseOh my God, it is so good. I don’t know why I like it so much, but I just binge watched the new season. And I say every time, I’ve got to string it out and enjoy it, but no, it’s impossible. And so I just binge watched the whole season, and as I was preparing for this interview, I just kept Googling what podcast she’s been on.VirginiaThat’s so satisfying. I love when you get a really good rabbit hole to dive down with the show. Another podcast I really enjoy, called Dire Straights , hosted by two writers, Amanda Montei and Tracy Clark-Flory, they just did an episode looking at the history of couples therapy and it actually has a pretty problematic history. Was not always great for women, very much developed as a way to help husbands control unruly wives—but has become other things. But you would enjoy that episode because they talk quite a bit about the show couples therapy and, she’s obviously doing something quite different.DeniseOkay, that’s my next one. Definitely going out and getting that.VirginiaI will also do a TV show butter, because they are so satisfying. I just started watching with my middle schooler a show that’s been off the air for a few years now. It’s called it’s Better Things, starring Pamela Adlon and created by her. It’s about a divorced mom with three daughters. She’s a working actor in LA but it’s just like about their life. It’s very funny. It’s very real and kind of gritty. My middle schooler and I have watched a lot of sitcoms together, and this is definitely a more adult show than we’ve watched before. But it’s still a family show, and it’s just, it’s so so good. It’s just a really incredible authentic portrayal of mothers and daughters. Which, you know, being a mother and a daughter, sometimes I’m like, is this making you like me more? Is this making you appreciate me? Probably not.DeniseHaving raised three kids, I don’t aspire to that anymore.VirginiaNot the goal, not the goal.DeniseJust never going to show up.VirginiaBut it is really sweet bonding in a way that I hadn’t expected. So that is my recommendation.DeniseLovely, lovely, lovely.VirginiaAll right, Denise. Tell folks again, just in case anyone missed it. Where do we find you? Where do we find the curriculums? How do we support your work?DeniseCome to berealusa.org—that’s our website. We have more information on everything I’ve mentioned, on all of the curriculum, on how to become an ambassador, and just more explanation. On the website, we have fact sheets on everything we do. So if you go in, I think on the homepage, you drop down, they’ll say fact sheets. And we also have probably have 10 fact sheets that will give you more information on this. We also talk about why you shouldn’t be taking BMI school. We had a “don’t weigh me in school” campaign about five years ago that kind of went viral. So anyway, that’s all good on our website.The Burnt Toast Podcast is produced and hosted by Virginia Sole-Smith (follow me on Instagram) and Corinne Fay, who runs @SellTradePlus, and Big Undies.The Burnt Toast logo is by Deanna Lowe.Our theme music is by Farideh.Tommy Harron is our audio engineer.Thanks for listening and for supporting anti-diet, body liberation journalism! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit virginiasolesmith.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit virginiasolesmith.substack.comYou’re listening to Burnt Toast!We are Virginia Sole-Smith and Corinne Fay, and it’s time for your September Indulgence Gospel!It’s time for a mailbag episode, so we’ll be diving into your questions about:⭐️ How to clap back when people say, “Wow, you’ve changed!” ⭐️ What to do with ageist grandparents? (We’re surprisingly…Team Grandparent on this one?)⭐️ Why it’s so hard to like photos of ourselves!!! ⭐️ Is Back To School (the hype, the myth, the culture)…a diet? And so much more!To hear the full story, you’ll need to be a paid Burnt Toast subscriber.

You’re listening to Burnt Toast! Today, my guest is Mara Gordon, MD.Dr. Mara is a family physician on the faculty of Cooper Medical School of Rowan University, as well as a writer, journalist and contributor to NPR. She also writes the newsletter Your Doctor Friend by Mara Gordon about her efforts to make medicine more fat friendly.Dr. Mara is back today with Part 2 of our conversation about weight, health, perimenopause and menopause! As we discussed last time, finding menopause advice that doesn’t come with a side of diet culture is really difficult. Dr Mara is here to help, and she will not sell you a supplement sign or make you wear a weighted vest.This episode is free but if you value this conversation, please consider supporting our work with a paid subscription. Burnt Toast is 100% reader- and listener-supported. We literally can’t do this without you.PS. You can always listen to this pod right here in your email, where you’ll also receive full transcripts (edited and condensed for clarity). But please also follow us in Apple Podcasts, Spotify, Stitcher, and/or Pocket Casts! And if you enjoy today’s conversation, please tap the heart on this post — likes are one of the biggest drivers of traffic from Substack’s Notes, so that’s a super easy, free way to support the show!And don’t miss these:Episode 209 TranscriptVirginiaSo today we’re going to move away from the weight stuff a little bit, into some of the other the wide constellation of things that can happen in menopause and perimenopause. Before we get into some nitty gritty stuff, I want to do Laurie’s question about hormone replacement therapy, since that is still one of those topics that people are like, Is it good? Is it bad? I don’t know.So Laurie asked: Is there a reason why a doctor would not want to prescribe hormone replacement therapy? My doctor seems more willing to treat individual symptoms instead of using HRT. Is that maybe because I’m still getting my period?MaraI love this question. Now my professor hat can nerd out about interpretation of scientific research! So first, I’ll just briefly say, Laurie, no big deal that you said HRT. But just so everyone’s aware, the preferred term is menopausal hormone therapy, MHT, or just hormone therapy, and it’s not a huge deal. But I think the North American Menopause Society now uses “menopausal hormone therapy.” The thinking is, hormones don’t necessarily need to be replaced. It comes back to that idea of, menopause is a natural part of life, and so the idea that they would need to be replaced is not totally accurate. VirginiaWe’re not trying to get you out of menopause, right? The goal isn’t to push you back into some pre-menopausal hormonal state. MaraBut again, not a big deal. You’ll see HRT still used, and a lot of doctors still use that term. So I graduated from medical school in 2015 and I remember one of the first times that a patient asked me about using menopausal hormone therapy, I was terrified. And I was still in training, so luckily, I had a mentor who guided me through it. But I had absorbed this very clear message from medical school, which is that menopausal hormone therapy will cause heart disease, cause pulmonary emboli, which are blood clots in the lungs, and cause breast cancer.And I was like, “Ahhh! I’m gonna cause harm to my patients. This is scary.” I had also learned that hot flashes–they weren’t life threatening. So a patient could just use a fan and she’d be fine, right? She didn’t need medicine for it.VirginiaCool.MaraI think the dismissal of symptoms here is just straight up misogyny. That message of, oh, you should just live with this You’re tough, you’re a woman, you can do it. This is just the next stage of it. Is just misogyny, right?But the fear of using menopausal hormone therapy has a specific historical context. There was a major study called the Women’s Health Initiative, and it was a randomized control trial, which is the gold standard in medical research. People were given estrogen and progestin to treat menopausal symptoms or they were given a placebo, and they didn’t know which pill they took. But WHI was actually halted early because they found an increased risk of breast cancer. This was on the front page of The New York Times. It was a really, really big deal. That was 2002 or 2003. So even 15 years later, when I was starting out as a doctor, I was still absorbing its message. And I think a lot of doctors who are still in practice have just deeply absorbed this message.But there’s a lot to consider here. The first issue is in the way that information about the Women’s Health Initiative was communicated. Nerd out with me for a second here: There is a big difference between absolute risk and relative risk. And this is a really subtle issue that’s often communicated poorly in the media.So I looked it up in the initial paper that came out of the Women’s Health Initiative. There was a relative risk of 26 percent of invasive breast cancer, right? So that meant that the people who got the estrogen and progestin, as opposed to a placebo, had a relative increased risk of 26 percent compared to the placebo arm.VirginiaWhich sounds scary,MaraSounds terrifying, right? But the absolute risk is the risk in comparison to one another. And they found that if you’re a patient taking the estrogen/progestin, your absolute risk was 8 people out of 10,000 women a year would get invasive breast cancer. So it’s very, very small.And this is an issue I see in medical journalism all the time. We talk about relative risk, like your risk compared to another group, but the absolute risk remains extremely low.And just to round it out: I looked all this up about cardiovascular events too. Things like a heart attack, a stroke. So the absolute risk was 19. So there were 19 cases of a cardiovascular event out of 10,000 women in a year. People just freaked out about this because of the way that it was covered in the media. VirginiaI was fresh out of college, doing women’s health journalism at the time. So I fully own having been part of that problem. We definitely reported on the relative risk, not the absolute risk. And I don’t understand why. I look back and I’m like, what were we all doing? We ended up taking this medication away from millions of women who could really benefit from it.MaraI found a paper that showed between 2002 and 2009 prescriptions for menopausal hormone therapy declined by more than 60 percent. VirginiaI’m not surprised. MaraAnd then even up until the time I started my training, right in 2015, we’re just seeing a huge decline in hormone therapy prescriptions.One other thing that’s also super important to acknowledge about the Women’s Health Initiative is that they enrolled women over 60, which is not really representative of women who want or need hormone therapy. So the average age of menopause is 51 and the vast majority of women who are experiencing symptoms that would respond well to hormone therapy are much younger. We’re talking here mostly about hot flashes. Which we call vasomotor symptoms of menopause, but it’s basically hot flashes. Women dealing with this are much younger, right? So they’re approaching menopause, late 40s, and right after the menopausal transition, early 50s, and then they don’t necessarily need it anymore, after their symptoms have improved.VirginiaAnd it will also be true that with women in their 60s, you’re going to see more incidence of cancer and heart disease in that age group than in women in their 40s anyway, right? MaraRightVirginiaSo even the 19 cases, the eight cases—they were looking at a higher risk population in general. MaraYeah. And so there have been all these subsequent analyses, which is why now we’re seeing menopausal hormone therapy sort of on the upswing. There’s a lot of increased interest in it. The American College of Obstetricians and Gynecologists recommends it, the North American Menopause Society, the British Menopause Society; here’s a full run-down. It’s not that everybody needs it, and we’ll get to that in a second, but it is a totally safe and appropriate treatment for—specifically and most importantly—for vasomotor symptoms of menopause. Like hot flashes. There’s been all these further analyses of the Women’s Health Initiative data and and then from other studies, too. And basically, it shows that when the hormone therapy is initiated before age 60, or within 10 years of menopause, there’s a reduced risk of heart disease and reduced mortality.VirginiaWow! MaraSo the timing matters. Isn’t that so interesting? The timing matters.Also, the route of administration matters. So what that means in English is that an estrogen patch seems to have a lower risk of blood clots. So one of those fears of the, you know, initial Women’s Health Initiative data was that you might have an increased risk of blood clots. But it’s something about the way that the estrogen is metabolized. It’s not metabolized through the liver when it’s absorbed through the skin, and something about that process seems to decrease the risk of blood clots.So that’s why your doctor, if you’re interested in menopausal hormone therapy, might recommend an estrogen patch rather than a pill.VirginiaGot it. MaraThere’s a lot of ambiguity in all of this data, because, you know, we’re talking about just huge numbers of people, and it’s hard to sort of isolate variables when you’re studying just like massive cohorts of people and trying to understand what you know, what factors affect your risk for which diseases. It’s not clear that taking hormones prevents heart disease. And that’s one of the big claims I see with menopause influencers, that every single person needs this.The data don’t support it at this point in time, and the major menopause organizations do not recommend it as a universal preventative treatment for everybody. But it seems like there might be some sort of association that may become clearer as research continues. That said, now it seems like the pendulum is swinging in the opposite direction. I learned, “be afraid of menopausal hormone treatment.” And now all these menopause influencers are saying everyone should be on hormone therapy.I don’t know the answer. And so the way that I try to parse through all of this noise is, you know, go to trusted sources, right? So I stick to society guidelines, like the North American menopause society, the British menopause society, they’re run by world experts in menopause.VirginiaOkay, so we don’t need to be terrified of hormone therapy, and you can be on it if you’re still getting your period right? Just to finish Laurie’s question.MaraIf you’re still getting a period regularly, you’re more in perimenopause than past the menopausal transition. And we will often use contraception to help and that you can have a lot of the same benefits from using contraception in that stage. It’s also useful just because unintended pregnancy still can be totally a thing in your 40s. But yes, you can absolutely use traditional regimens of menopausal hormone therapy while you’re still getting a period too. Just know it won’t prevent pregnancy. VirginiaSince we talked a little bit about hot flashes, I’m gonna jump to Judy’s question so we can kind of round that piece out: One of the things I am really struggling with is the way I have lost all ability to regulate temperature. I am boiling hot almost all the time, and the slightest thing makes me break out into a full sweat, which makes me not want to move at all.My doctor has not been super helpful in navigating this. What can I do to mitigate this issue? If anything, it is so very hard for me not to blame the size of my body for this, since the correlation seems so clear, smaller body less sweating, larger body sweating all the dang time.MaraJudy, I empathize first of all. Just one caveat I can’t really give medical advice to Judy. There are a lot of things that could be going on, and it’s really important that you see a doctor and get a full history and physical exam. But I will say that this is one of the things that menopausal hormone therapy is extremely helpful for, is hot flashes.VirginiaThat was my first thought! MaraThere are a lot of influencers who really overstate the benefits of hormone therapy, right? Hormone therapy is not really going to cause significant weight loss or prevent weight gain. It’s not totally clear that it helps with mood symptoms or even sleep is a little more ambiguous. But the one thing it really works for is hot flashes. So that would be my thought: Start there. VirginiaAnd on the feeling like you want to blame your body for it: I don’t know if Judy identifies as fat, but as someone who identifies as fat, I often feel like I’m sweatier now than when I was thinner. I run warmer. All my skinny friends will be bundled up in coats, and I still won’t be wearing one in October. I do notice that. And I think that this is a situation where that is, even if those two things correlate— you’re larger and you’re sweatier—is that worth putting yourself through the hell of weight loss? You may decide yes, it is, if hormone therapy doesn’t work for you.But that’s one of those times where I bring it back to “What would actually make my daily life miserable?” I can drink water, I can be in AC, I’m gonna find a link to this nighttime cooling bed thing that my friend Claire Zulkey really loves. MaraI’ve heard of those!VirginiaI think there are options to mitigate your suffering with this. Medicine is definitely an option. Before you go to “okay, my body size has to be the thing that changes.”MaraI totally agree. I just deal with this all the time where people tell me in my clinic that they want to lose weight. And when I sort of gently ask, what are you hoping to achieve? What are your goals? They’re often things that can be achieved through other means. Like, people say my clothes don’t fit, right? And most of my patients are low-income, right? I’m not trying to be flippant about the idea that everyone can just go and purchase a new, you know, multi $1,000 wardrobe at the drop of a hat. But it is possible to get new clothes in affordable ways. Don’t torture yourself with clothes that don’t fit because you feel like weight gain is a moral failing. And I think that there are things that we can do to help keep us at a comfortable temperature, right wear clothes that feel, you know, that feel good. Air conditioning is an amazing modern invention. And, you know, cool beverages, ice cream. VirginiaPopsicle O’Clock is very important in my summer right now, very important. MaraWait, what’s a popsicle clock?VirginiaOh, Popsicle O’Clock. It’s just the time of day where you eat popsicles. It could be 9am it could be 4pm just whenever I feel like we need to add popsicles to a situation.MaraI think we all need more popsicles in our life, that is absolutely for sure.So I think what I’m hearing from Judy’s question is once again, shame about body size, and also this myopic zooming in on weight loss as the only possible solution. Which I blame doctors for in many ways! Some people do benefit from weight loss, right? I’m not opposed to the idea that anybody would ever want to lose weight. I don’t think that that’s a betrayal of fat solidarity, necessarily. But that there are other things you can do just to make your life feel better in the meantime, or even if you choose to never pursue weight loss. There are things you can do to feel better, and we shouldn’t deprive ourselves of those things.VirginiaAnd you don’t know that it is the weight gain. It could be age and hormones, and those coincided with the weight gain for you personally. But there are lots of thin women getting hot flashes all the time too.Okay, this next question is from Michaela: I am super curious about the connection between perimenopause, menopause and mental health symptoms, specifically, an uptick in anxiety and depression. Is this a thing?We also got many questions about whether perimenopause and menopause exacerbate ADHD symptoms. MaraSo this is a question I get a lot from my patients, and I’ve seen a lot of discourse about online. And the short answer is: There is probably a connection between the hormonal changes of perimenopause and the menopausal transition and mental health. Do we understand it? No. So I mean, with ADHD specifically, I will say: This is really not my area of expertise. It’s a very complex mental health condition, and our medical understanding of it is really rapidly evolving. I have many patients who have a diagnosis of ADHD but I’m typically not the one who diagnoses them. That being said: Estrogen affects neurotransmitters. Neurotransmitters are implicated in ADHD. Declining estrogen does seem to affect dopamine, in particular, which is implicated in ADHD. And anecdotally, I’ve had many of my patients say that they feel like their ability to focus and sustain attention decreases. And they experience brain fog as they enter perimenopause and menopause. So it’s there’s probably something going on, and a lot of researchers are really actively studying it, but we don’t know yet.VirginiaDo we know if this is something that hormone therapy can help with?MaraSo I think the answer is, I don’t know.VirginiaWhat about anxiety and depression?MaraI don’t think the data are there, right? Hormone therapy is usually not considered a first line treatment for the mental health conditions that are often associated with the menopausal transition. But we have great medicines for those conditions. We have good treatments for ADHD, we have good treatments for anxiety and depression. And sometimes during the menopausal transition, patients might need an increase of those treatments. And that could mean going back into therapy, if you’ve been out of therapy, increasing your medications or restarting a med that you may have stopped years ago. Those are all totally valid approaches during this phase.And I guess what I’d say, is that it’s okay to trust your body. And if you notice changes in your mental health associated with perimenopause or menopause itself, ask about it. Don’t be afraid to advocate for yourself. And while hormone therapy doesn’t look like it is an effective treatment specifically for those symptoms, there are other treatments, and you should feel empowered to ask about them.VirginiaThe next question goes back to some of the diet and exercise stuff we’ve touched on. This person writes: Since recently reaching menopause, my cholesterol has become high. I understand there is a proven link between menopause and increased cholesterol, and that weight is part of the picture. I’m trying to lower my cholesterol with focus on nutrition and exercise. But it is f*****g with my head because it feels like a very restrictive diet. I’d love any thoughts on the menopause cholesterol connection and keeping cholesterol low with nutrition and exercise without falling into the abyss of obsessing about how many almonds I’ve eaten.MaraOh, that is such a good question!VirginiaThe almond of it all. MaraAlmonds are really good in some scenarios, but also just like, kind of a sad snack. I always think about President Obama eating those, like, eight almonds, or whatever.VirginiaIt turns out that was a joke and he wasn’t doing that. But just the fact that everybody assumed he would says a lot! MaraThat is hilarious, and I didn’t know! And it just shows how with information online, the initial story sticks. Like to this day, 10 years later, I still thought that Barack Obama ate eight almonds as his indulgent midnight snack every single night. I hope the man is eating some ice cream and living his best life. Okay, so there is absolutely a link between menopause and elevated risk of cardiovascular disease. But even within the term cholesterol, there are different types. I wouldn’t really say to a patient, “Your cholesterol is high.” One thing you might hear is “your LDL cholesterol is high,” which is known popularly as, the “bad” cholesterol. Which, again, moral language alert. But LDL cholesterol is a proxy for risk of cardiovascular disease. I will say it’s not a great one; it’s kind of a blunt instrument. We measure and we treat it, because we don’t have other great ways of predicting cardiovascular risk. But it is not the full portrait, although it’s certainly a risk factor for developing cardiovascular disease. And the transition of menopause seems to impact LDL, cholesterol, other biomarkers of cardiovascular disease, and increases your risk for cardiovascular disease.And what’s interesting–I think we talked about this a little bit already, is that this happens, this this risk happens independent of normal aging.So, for example, women who go through menopause early start developing this increased risk earlier than women who go through menopause slightly later. And overall, we see that women develop cardiovascular disease, at rates lower than men, and at later in life than men. And there’s a hypothesis that this has to do with menopause, right? That there’s a protective effect of estrogen, but then when your estrogen starts to decline in menopause, it puts women at an increased risk compared to where they were pre-menopause.There’s also some data to suggest that the severity of menopause symptoms—particularly vasomotor symptoms like hot flashes or sleep disturbances—may indicate risk for developing cardiovascular disease. So this is not to scare everyone, but it’s good to have knowledge. If you’re having really severe hot flashes, it may indicate that you are at slightly higher risk for developing cardiovascular disease than somebody who is not. The intention of having this knowledge is not to make you feel shame, and not to berate you for your belly fat or whatever. It’s to have knowledge so that you can help mitigate risk factors in ways that feel aligned with your values and ways that feel aligned with the way that you want to pursue health in your life.And so I would approach this reader’s or this listener’s question with smy same approach to all of my patients questions. “I have hypertension, does that mean I need to lose weight?” “I have diabetes, does that mean I need to lose weight?” The answer is that we have many treatments that can help you address these concerns independent of weight loss. But this is not to say that you cannot pursue weight loss too, right? And if using a GLP-1 agonist to reduce your visceral adiposity is aligned with your values, and you can tolerate the side effects, and you feel good about it, and it’s covered by your insurance….that’s totally a reasonable approach. But it’s not the only one. So I think what I’m hearing from this patient is the menopause flavor of what I do every single day in my work as a size inclusive doctor. Which is: How can we disentangle weight stigma and body shame from these questions of how to lead a healthy life? And the idea of giving you more information, I hope, is not to shame you or make you feel guilt for the relationship between body size and risk of cardiovascular disease, but instead, to give you information that might help you take proactive care of your body, right?And proactive care might mean committing to an exercise routine. Proactive care might mean taking a statin. A statin is a very common cholesterol medicine like Lipitor. It might mean getting your blood pressure under control and taking an antihypertensive.VirginiaI also want to say on cholesterol, specifically, I did a piece that I’ll link to digging into the connection between nutrition and cholesterol. And the data is not as strong as I think a lot of doctors are telling folks.And I think the benefit of making dietary changes—the amount it could lower cholesterol—was not huge. It was like three points or six points or something in one of the studies we looked at. So if it’s making you crazy to count almonds, it’s possible that medication might be a more health promoting strategy for you. Because it will be less stressful and it will have a bigger benefit on your cholesterol than just trying to control it through diet and exercise.MaraYeah, I totally agree. I think there’s a really strong genetic component that we haven’t fully understood and medication is a totally reasonable approach and very safe approach. Honestly, statins are pretty benign medications. They’re pretty inexpensive, pretty minimal side effects, which is not to say– nobody’s paying me from the statin companies, I swear to God!–but yeah, like they’re, they’re pretty benign as medications go. And I think it’s a totally reasonable way to approach this issue.VirginiaI just think it’s one of those times where this is shame coming in, where it’s like, “You should be able to fix this with how you eat and exercise, and so you don’t get the medication unless you fail at that!” This is a framing that I’ve encountered from doctors. But what if we gave the medication, what if we also consider diet and exercise, but don’t make that a pass/fail situation in order to earn the medication? MaraYeah, that’s really interesting.And even the language you’re using Virginia is what we use in the medical record, and I’ve tried to stop it. But the way we’re taught to describe patients, is “patient failed XYZ treatment,” right? And I feel like we’re both at once, overly invested in pharmaceutical treatments, right and underinvested. They’re a very useful tool. And we moralize it, both pro and con? Sometimes, like, we moralize in favor of it. So if your BMI is 26 or above, you need to be on a GLP one agonist, which is just false, right?But on the other hand, I think we often underutilize medications because there’s this sense that you’re getting at —that you have to exhaust all of your like willpower options first, and it’s somehow failing to use a med. And that is really false too. They’re really useful tools. Science is really useful, and we shouldn’t feel ashamed to use it.VirginiaAll right. And our last question, I like because it just will give us a chance to kind of sum up some key points: As a post menopausal woman, I feel like I’m swimming in information, and I’m overwhelmed by it all. What are Dr Gordon’s top three pieces of advice out of all of the WHO meaning, if women at this time only did these three things, it would make the biggest difference, and then they just had it. You know, is, does it need to be different for perimenopause versus post menopause? Or maybe not.So what are your top three? Top three tips for surviving this life stage?MaraOh, my God, if only I knew! I’m flattered that you’re asking, and I will do my best to answer, but I don’t think there’s a right answer at all.So I’ve thought about a couple things. I will say that, you know, longevity and wellness and health span is extremely complicated, but it’s also kind of simple, right?So sometimes the advice that we’ve just heard over and over again is actually really, really good, right? So, sleep. Are we sleeping enough?Staying engaged with social relationships, that seems to be extremely important for longevity. And it’s kind of amazing, actually. When they do these long-term studies on people who are thriving into old age, like they have really strong relationships. And that is so important.Moving our bodies and it does not need to be punishing. Workouts can be gardening. I know Virginia, I love receiving your gardening content online. Gardening is an amazing form of exercise, and can be very life affirming, and does not need to feel like punishment. Just getting up, moving our bodies, sleeping enough, maintaining relationships, cultivating a sense of purpose and meaning in our lives. It’s actually been really studied right, that people who have a sense of meaning and have a sense of purpose in their lives tend to live longer and live longer, healthier lives.So all of this is to say that like it’s complicated, but sometimes it’s not. And there are a million people on the Internet who want to sell you a miracle drug, a miracle supplement, a miracle weighted vest, whatever. But sometimes simple, Simple is good. Easier said than done, right?VirginiaYeah, but start simple. That’s wonderful.MaraCan I ask? Virginia, what would your advice be? VirginiaI love the three areas you hit on: Sleep, social relations and exercise or moving your body. None of those are about weight loss or dieting. I think that’s really helpful for us to keep in mind that the things that might protect our health the most can also be very joyful as well. The idea that doing things that makes you happy and reduce your stress can be health-promoting is great. And I think that’s something especially in midlife. We are all incredibly busy. We’re holding a lot of things together. A lot of us are caregivers, maybe sandwich generation caregivers. So prioritizing your own joy in that feels really wonderful.ButterVirginiaAll right, so speaking of joy, let’s do some Butter! Dr. Mara, what do you have forus?MaraI have a Philadelphia-specific one, but hopefully it can be extrapolated to our listeners in different locations. So I have recently been really craving soft serve ice cream. And so I googled best soft serve in Philadelphia, and I found this Vietnamese coffee shop called Càphê Roasters, which is in North Philly. In a neighborhood called Kensington. And it has condensed milk soft serve ice cream. So good.And so I recently, I had to give a lecture at a medical school in the north part of the city early in the morning. It was like, 8am and I was like, “Oh, I’m never up in this neighborhood. I gotta get over there.” And I went after I gave my lecture, and I bought myself ice cream at 10:30 in the morning. And I ate it in my car, and it was so good. Condensed milk. So good. But soft serve in general, is my Butter. But for those of you in Philly, go to Càphê Roasters in Kensington and get the condensed milk. It is chef’s kiss, delicious.VirginiaAmazing. I’m gonna double your Butter and say ice cream in general is my Butter right now. We have a spare fridge freezer that I have just been loading up with all of the popsicles to get us through summer. But also: Ice cream dates. Something that comes up a lot for me as a co-parent is figuring out how to have one on one time with my kids. Since we have joint custody, they move as a package. So I get kid-free time, which is wonderful, but when they’re with me, it’s just me. So one thing I’ve been figuring out is pockets of time when I can take one kid out for ice cream. It’s usually when a sibling is at another activity, and so we have an hour to kill, and often we would just like, wait for the activity, or go home and come back, and then you’re just driving.And now I’m like, No, that will be our ice cream break!MaraI love that.VirginiaSo one kid’s at the library doing her book trivia team stuff, and the other kid and I are getting ice cream while we wait for her. And it’s great one on one time with kids. Obviously, the ice cream is delicious. The other thing I’ve realized, especially if you have younger kids who are still building restaurant skills, ice cream is a great practice run at being a person in a restaurant, which is really hard for kids understandably. It is one food thing that they’re excited to go do. And you do have to sit and practice eating it somewhat neatly. There’s a high mess potential. My pro-move for that is, always have wipes in your car, bring a pack of wipes in. MaraI love that, and it’s so intentional about sort of creating traditions with kids. That feels really special. But I will say I had my ice cream solo, and that was also really good solo ice cream too.The Burnt Toast Podcast is produced and hosted by Virginia Sole-Smith (follow me on Instagram) and Corinne Fay, who runs @SellTradePlus, and Big Undies.The Burnt Toast logo is by Deanna Lowe.Our theme music is by Farideh.Tommy Harron is our audio engineer.Thanks for listening and for supporting anti-diet, body liberation journalism! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit virginiasolesmith.substack.com/subscribe

You’re listening to Burnt Toast! Today, my guest is Ash Brandin of Screen Time Strategies, also know as The Gamer Educator on Instagram. Ash is also the author of a fantastic new book, Power On: Managing Screen Time to Benefit the Whole Family. Ash joined us last year to talk about how our attitudes towards screen time can be…diet-adjacent. I asked them to come back on the podcast this week because a lot of us are heading into back-to-school mode, which in my experience can mean feelingsss about screen routines. There are A LOT of really powerful reframings in this episode that might blow your mind—and make your parenting just a little bit easier. So give this one a listen and share it with anyone in your life who’s also struggling with kids and screen time.Today’s episode is free but if you value this conversation, please consider supporting our work with a paid subscription. Burnt Toast is 100% reader- and listener-supported. We literally can’t do this without you! PS. You can take 10 percent off Power On, or any book we talk about on the podcast, if you order it from the Burnt Toast Bookshop, along with a copy of Fat Talk! (This also applies if you’ve previously bought Fat Talk from them. Just use the code FATTALK at checkout.)Episode 208 TranscriptVirginiaFor anyone who missed your last episode, can you just quickly tell us who you are and what you do?AshI’m Ash Brandin. I use they/them pronouns.I am a middle school teacher by day, and then with my online presence, I help families and caregivers better understand and manage all things technology—screen time, screens. My goal is to reframe the way that we look at them as caregivers, to find a balance between freaking out about them and allowing total access. To find a way that works for us. VirginiaWe are here today to talk about your brilliant new book, which is called Power On: Managing Screen Time to Benefit the Whole Family. I can’t underscore enough how much everybody needs a copy of this book. I have already turned back to it multiple times since reading it a few months ago. It just really helps ground us in so many aspects of this conversation that we don’t usually have.AshI’m so glad to hear that it’s helpful! If people are new to who I am, I have sort of three central tenets of the work that I do: * Screen time is a social inequity issue. * Screens can be part of our lives without being the center of our lives. * Screens and screen time should benefit whole families.Especially in the last few years, we have seen a trend toward panic around technology and screens and smartphones and social media. I think that there are many reasons to be concerned around technology and its influence, especially with kids. But what’s missing in a lot of those conversations is a sense of empowerment about what families can reasonably do. When we focus solely on the fear, it ends up just putting caregivers in a place of feeling bad.VirginiaYou feel like you’re getting it wrong all the time.AshShame isn’t empowering. No one is like, “Well, I feel terrible about myself, so now I feel equipped to go make a change,” right?Empowerment is what’s missing in so many of those conversations and other books and things that have come out, because it’s way harder. It’s so much harder to talk about what you can really do and reasonably control in a sustainable way. But I’m an educator, and I really firmly believe that if anyone’s in this sort of advice type space, be it online or elsewhere, that they need to be trying to empower and help families instead of just capitalizing on fear.VirginiaWhat I found most powerful is that you really give us permission to say: What need is screen time meeting right now? And this includes caregivers’ needs. So not just “what need is this meeting for my child,” but what need is this meeting for me? I am here recording with you right now because iPads are meeting the need of children have a day off school on a day when I need to work. We won’t be interrupted unless I have to approve a screen time request, which I might in 20 minutes.I got divorced a couple years ago, and my kids get a lot more screen time now. Because they move back and forth between two homes, and each only has one adult in it. Giving myself permission to recognize that I have needs really got me through a lot of adjusting to this new rhythm of our family.AshAbsolutely. And when we’re thinking about what the need is, we also need to know that it’s going to change. So often in parenting, it feels like we have to come up with one set of rules and they have to work for everything in perpetuity without adjustment. That just sets us up for a sense of failure if we’re like, well, I had this magical plan that someone told me was going to work, and it didn’t. So I must be the problem, right? It all comes back to that “well, it’s my fault” place.VirginiaWhich is screens as diet culture.AshAll over again. We’re back at it. It’s just not helpful. If instead, we’re thinking about what is my need right now? Sometimes it’s “I have to work.” And sometimes it’s “my kid is sick and they just need to relax.” Sometimes it’s, as you were alluding to earlier, it’s we’ve all just had a day, right? We’ve been run ragged, and we just need a break, and that need is going to dictate very different things. If my kid is laid up on the couch and throwing up, then what screen time is going to be doing for them is very different than If I’m trying to work and I want them to be reasonably engaged in content and trying to maybe learn something. And that’s fine. Being able to center “this is what I need right now,” or “this is what we need right now,” puts us in a place of feeling like we’re making it work for us. Instead of feeling like we’re always coming up against some rule that we’re not going to quite live up to.VirginiaI’d love to talk about the inequity piece a little more too. As I said, going from a two parent household to a one parent household, which is still a highly privileged environment—but even just that small shift made me realize, wait a second. I think all the screen time guidance is just for typical American nuclear families. Ideally, with a stay at home parent.So can you talk about why so much of the standard guidance doesn’t apply to most of our families?AshIt’s not even just a stay at home parent. It’s assuming that there is always at least one caregiver who is fully able to be present. Mom, default parent, is making dinner, and Dad is relaxing after work and is monitoring what the kids are doing, right? And it’s one of those times where I’m like, have you met a family?VirginiaPeople are seven different places at once. It’s just not that simple.AshIt’s not that simple, right? It’s like, have you spent five minutes in a typical household in the last 10 years? This is not how it’s going, right?So the beginning of the book helps people unlearn and relearn what we may have heard around screens, including what research really does or doesn’t say around screens, and this social inequity piece. Because especially since the onset of COVID, screens are filling in systemic gaps for the vast majority of families.I’m a family with two caregivers in the home. We both work, but we’re both very present caregivers. So we’re definitely kind of a rarity, that we’re very privileged. We’re both around a lot of the time. And we are still using screens to fill some of those gaps.So whether it’s we don’t really have a backyard, or people are in a neighborhood where they can’t send their kids outside, or they don’t have a park or a playground. They don’t have other kids in the neighborhood, or it’s not a safe climate. Or you live in an apartment and you can’t have your neighbors complain for the fifth time that your kids are stomping around and being loud. Whatever it is—a lack of daycare, affordable after school care —those are all gaps. They all have to be filled. And we used to have different ways of filling those gaps, and they’ve slowly become less accessible or less available. So something has to fill them. What ends up often filling them is screens. And I’m not saying that that’s necessarily a good thing. I’d rather live in a world in which everyone is having their needs met accessibly and equitably. But that’s a much harder conversation, and is one that we don’t have very much say in. We participate in that, and we might vote for certain people, but that’s about all we can really do reasonably. So, in the meantime, we have to fill that in with something and so screens are often going to fill that in.Especially if you look at caregivers who have less privilege, who are maybe single caregivers, caregivers of color, people living in poverty—all of those aspects of scarcity impacts their bandwidth. Their capacity as a caregiver is less and spread thinner, and all of that takes away from a caregiver’s ability to be present. And there were some really interesting studies that were done around just the way that having less capacity affects you as a caregiver.And when I saw that data, I thought, well, of course. Of course people are turning to screens because they have nothing else to give from. And when we think of it that way, it’s hard to see that as some sort of personal failure, right? When we see it instead as, oh, this is out of necessity. It reframes the question as “How do I make screens work for me,” as opposed to, “I’m bad for using screens.”VirginiaRight. How do I use screen time to meet these needs and to hopefully build up my capacity so that I can be more present with my kids? I think people think if you’re using a lot of screens, you’re really never present. It’s that stereotype of the parent on the playground staring at their phone, instead of watching the kid play. When maybe the reason we’re at the playground is so my kid can play and I can answer some work emails. That doesn’t mean I’m not present at other points of the day.AshOf course. You’re seeing one moment. I always find that so frustrating. It just really feels like you you cannot win. If I were sitting there staring at my child’s every move in the park, someone would be like, “you’re being a helicopter,” right? And if I look at my phone because I’m trying to make the grocery pickup order—because I would rather my child have time at the playground than we spend our only free hour in the grocery store and having to manage a kid in the grocery store and not having fun together, right? Instead I’m placing a pickup order and they’re getting to run around on the playground. Now also somehow I’m failing because I’m looking at my phone instead of my kid. But also, we want kids to have independent time, and not need constant input. It really feels like you just can’t win sometimes. And being able to take a step back and really focus on what need is this meeting? And if it’s ours, and if it is helping me be more present and connected, that’s a win. When I make dinner in the evening, my kid is often having screen time, and I will put in an AirPod and listen to a podcast, often Burnt Toast, and that’s my decompression. Because I come home straight from work and other things. I’m not getting much time to really decompress.VirginiaYou need that airlock time, where you can decompress and then be ready to be present at dinner.I’m sure I’ve told you this before, but I reported a piece on screen time for Parents Magazine, probably almost 10 years ago at this point, because I think my older child was three or four. And I interviewed this Harvard researcher, this older white man, and I gave him this the dinner time example. I said, I’m cooking dinner. My kid is watching Peppa Pig so that I can cook dinner, and take a breath. And then we eat dinner together. And he said, “Why don’t you involve her in cooking dinner? Why don’t you give her a bag of flour to play with while you cook dinner?”AshOf all the things!VirginiaAnd I said to him: Because it’s 5pm on a Wednesday and who’s coming to clean the flour off the ceiling?AshA bag of flour. Of all the things to go to! VirginiaHe was like, “kids love to make a happy mess in the kitchen!” I was like, well I don’t love that. And it was just exactly that. My need didn’t matter to him at all. He was like, “h, well, if you just want to pacify your children…” I was like, I do, yes, in that moment.AshWell, and I think that’s another part of it is that someone says it to us like that, and we’re like, “well, I can’t say yes,” right? But in the moment, yeah, there are times where it’s like, I need you to be quiet. And as hard as this can be to think, sometimes it’s like right now, I need you to be quiet and convenient because of the situation we’re in. And that doesn’t mean we’re constantly expecting that of them, and hopefully that’s not something we’re doing all the time. But if the need is, oh my God, we’re all melting down, and if we don’t eat in the next 15 minutes, we’re going to have a two hour DEFCON1 emergency on our hands, then, yeah, I’m gonna throw Peppa Pig on so that we can all become better regulated humans in the next 15 minutes and not have a hungry meltdown. And that sounds like a much better alternative to me!VirginiaThan flour all over my kitchen on a Wednesday, right? I mean, I’ll never not be mad about it. It’s truly the worst parenting advice I’ve ever received. So thank you for giving us all more space as caregivers to be able to articulate our own needs and articulate what we need to be present. It’s what we can do in the face of gaps in the care system that leave us holding so much.That said: I think there are some nitty gritty aspects of this that we all struggle wit, so I want to talk about some of the nuts and bolts pieces. One of my biggest struggles is still the question of how much time is too much time? But you argue that time really isn’t the measure we should be using. As you’re saying, that need is going to vary day to day, and all the guidance that’s been telling us, like, 30 minutes at this age, an hour at this age, all of that is not particularly germane to our lives. So can you explain both why time is less what we should fixate on? And then how do I release myself? How do I divest from the screen time diet culture?AshOh man, I wish I had a magic bullet for that one. We’ll see what I can do.When I was writing this and thinking about it and making content about it, I kept thinking about you. Because the original time guidelines that everyone speaks back to—they’re from the AAP. And they have not actually been used in about 10 years, but people still bring them up all the time. The “no time under two” and “up to an hour up to age five” and “one to two hours, five to 12.” And if you really dig in, I was following footnote after footnote for a while, trying to really find where did this actually come from? It’s not based on some study that found that that’s the ideal amount of time. It really came from a desire to find this middle ground of time spent being physically idle. These guidelines are about wanting to avoid childhood obesity.VirginiaOf course.AshIt all comes back, right?VirginiaI should have guessed it.AshAnd so in their original recommendations, the AAP note that partially this is to encourage a balance with physical movement. Which, of course, assumes that if you are not sitting watching TV or using an iPad, that you will be playing volleyball or something.VirginiaYou’ll automatically be outside running around.AshExactly, of course, those are the only options.VirginiaIt also assumes that screen time is never physical. But a lot of kids are very physical when they’re watching screens.AshExactly. And it, of course, immediately also imposes a morality of one of these things is better—moving your body is always better than a screen, which is not always going to be true, right? All these things have nuance in them. But I thought that was so interesting, and it shouldn’t have surprised me, and yet somehow it still did. And of course it is good to find movement that is helpful for you and to give your kids an enjoyment of being outside or moving their bodies, or playing a sport. And putting all of that in opposition to something else they may enjoy, like a screen, really quickly goes to that diet culture piece of “well, how many minutes have you been doing that?” Because now we have to offset it with however many minutes you should be running laps or whatever.So those original recommendations are coming from a place of already trying to mitigate the negatives of sitting and doing something sort of passively leisurely. And in the last 10 years, they’ve moved away from that, and they now recommend what’s called making a family media plan. Which actually I think is way better, because it is much more prioritizing what are you using this for? Can you be doing it together? What can you do? It’s much more reasonable, I think. But many people still go back to those original recommendations, because like you said, it’s a number. It’s simple. Just tell me.VirginiaWe love to grab onto a number and grade ourselves.AshJust tell me how much time so that I can tell myself I’m I’m doing a good job, right? But you know, time is just one piece of information. It can be so specific with what am I using that time to do? If I’m sitting on my computer and doing work for an hour and a half, technically, that is screen time, but it is going to affect me a lot differently than if I’m watching Netflix or scrolling my phone for an hour and a half. I will feel very different after those things. And I think it’s really important to be aware of that, and to make our kids aware of that from an early age, so that they are thinking about more than just, oh, it’s been X amount of minutes. And therefore this is okay or not okay.Because all brains and all screens are different. And so one kid can watch 20 minutes of Paw Patrol, and they’re going to be bouncing off the walls, because, for whatever reason, that’s just a show that’s really stimulating for them. And somebody else can sit and watch an hour and a half of something, and they’ll be completely fine. So if you have a kid that is the first kid, and after 20 minutes, you’re like, oh my god, it’s not even half an hour. This is supposed to be an okay amount. This is how they’re acting. We’re right back to that “something’s wrong. I’m wrong. They’re bad,” as opposed to, “What is this telling me? What’s something we could do differently? Could we try a different show? Could we try maybe having some physical movement before or after, see if that makes a difference?” It just puts us more in a place of being curious to figure out again, how do I make this work for me? What is my need? How do I make it work for us?And not to rattle on too long, but there was a big study done in the UK, involving over 120,000 kids. And they were trying to find what they called “the Goldilocks amount of time.”VirginiaYes. This is fascinating.AshSo it’s the amount of time where benefit starts to wane. Where we are in that “just right”amount. Before that, might still be okay, but after that we’re going to start seeing some negative impacts, particularly when it comes to behavior, for example.What they found in general was that the Goldilocks number tended to be around, I think, an hour and 40 minutes a day. Something around an hour and a half a day. But if you looked at certain types of screens, for computers or TV, it was much higher than that. It was closer to three hours a day before you started seeing some negative impacts. And even for things like smartphones, it was over an hour a day. But what I found so so interesting, is that they looked at both statistical significance, but also what they called “minimally important difference,” which was when you would actually notice these negative changes, subjectively, as a caregiver.So this meant how much would a kid have to be on a screen for their adult at home to actually notice “this is having an impact on you,” regularly. And that amount was over four and a half hours a day on screens.VirginiaBefore caregivers were like, “Okay, this is too much!” And the fact that the statistically significant findings for the minutia of what the researchers looking at is so different from what you as a caregiver are going to actually be thrown by. That was really mind blowing to me.AshRight, And that doesn’t mean that statistical significance isn’t important, necessarily. But we’re talking about real minutiae. And that doesn’t always mean that you will notice any difference in your actual life.Of course, some people are going to hear this and go, “But I don’t want my kid on a screen for four and a half hours.” Sure. That’s completely reasonable. And if your kid is having a hard time after an hour, still reasonable, still important. That’s why we can think less about how many minutes has it been exactly, and more, what am I noticing? Because if I’m coming back to the need and you’re like, okay, I have a meeting and I need an hour, right? If you know, “I cannot have them use their iPad for an hour, because they tend to become a dysregulated mess in 25 minutes,” that’s much more useful information than “Well, it says they’re allowed to have an hour of screen time per day so this should be fine because it’s an hour.”VirginiaRight.AshIt sets you up for more success.VirginiaAnd if you know your kid can handle that hour fine and can, in fact, handle more fine, it doesn’t mean, “well you had an hour of screen time while I was in a meeting so now we can’t watch a show together later to relax together.” You don’t have to take away and be that granular with the math of the screens. You can be like, yeah, we needed an extra hour for this meeting, and we’ll still be able to watch our show later. Because that’s what I notice with my kids. If I start to try to take away from some other screen time, then it’s like, “Oh, god, wait, but that’s the routine I’m used to!” You can’t change it, and that’s fair.AshYes, absolutely. And I would feel that way too, right? If someone were giving me something extra because it was a convenience to them, but then later was like, “oh, well, I have to take that from somewhere.” But they didn’t tell me that. I would be like, Excuse me, that’s weird. That’s not how that works, right? This was a favor to you, right?VirginiaYeah, exactly. I didn’t interrupt your meeting. You’re welcome, Mom.Where the time anxiety does tend to kick in, though, is that so often it’s hard for kids to transition off screens. So then parents think, “Well, it was too much time,” or, “The screen is bad.” This is another very powerful reframing in your work. So walk us through why just because a kid is having a hard time getting off screens doesn’t mean it was too much and it doesn’t mean that screens are evil? AshSo an example I use many times that you can tweak to be whatever thing would come up for your kid is bath time. I think especially when kids are in that sort of toddler, three, four age. When my kid was that age, we had a phase where transitioning to and from the bathtub was very hard. Getting into it was hard. But then getting out of it was hard.VirginiaThey don’t ever want to get in. And then they never want to leave.AshThey never want to get out, right? And in those moments when my kid was really struggling to get out of the bathtub, imagine how it would sound if I was like, “Well, it it’s the bathtub’s fault.” Like it’s the bath’s fault that they are having such a hard time, it’s because of the bubbles, and it smells too good, and I’ve made it too appealing and the water’s too warm. Like, I mean, I sound unhinged, right?Virginia“We’re going to stop bathing you.”AshExactly. We would not say, “Well, we can’t have baths anymore.” Or when we go to the fun playground, and it’s really hard to leave the fun playground, we don’t blame the playground. When we’re in the grocery store and they don’t want to leave whichever aisle, we don’t blame the grocery store. And we also don’t stop taking them to the grocery store. We don’t stop going to playgrounds. We don’t stop having baths. Instead, we make different decisions, right? We try different things. We start a timer. We have a different transition. We talk about it beforehand. We strategize, we try things.VirginiaGive a “Hey, we’re leaving in a few minutes!” so they’re not caught off guard.AshExactly. We talk about it. Hey, last time it was really hard to leave here, we kind of let them know ahead of time, or we race them to the car. We find some way to make it more fun, to make the transition easier, right? We get creative, because we know that, hey, they’re going to have to leave the grocery store. They’re going to have to take baths in a reasonable amount of time as they grow up into their lives. We recognize the skill that’s happening underneath it.And I think with screens, we don’t always see those underlying skills, because we see it as this sort of superfluous thing, right? It’s not needed. It’s not necessary. Well, neither is going to a playground, technically.A lot of what we do is not technically required, but the skill underneath is still there. So when they are struggling with ending screen time, is it really the screen, or is it that it’s hard to stop doing something fun. It’s hard to stop in the middle of something. It’s hard to stop if you have been playing for 20 minutes and you’ve lost every single race and you don’t want to stop when you’ve just felt like you’ve lost over and over again, right? You want one more shot to one more shot, right?People are going to think, “Well, but screens are so much different than those other things.” Yes, a screen is designed differently than a playground or a bath. But we are going to have kids who are navigating a technological and digital world that we are struggle to even imagine, right? We’re seeing glimpses of it, but it’s going to be different than what we’re experiencing now, and we want our kids to be able to navigate that with success. And that comes back to seeing the skills underneath. So when they’re struggling with something like that, taking the screen out of it, and asking yourself, how would I handle this if it were anything else. How would I handle this if it were they’re struggling to leave a friend’s house? I probably wouldn’t blame the friend, and I wouldn’t blame their house, and I wouldn’t blame their boys.VirginiaWe’re never seeing that child again! Ash I would validate and I would tell them, it’s hard. And I would still tell them “we’re ending,” and we would talk about strategies to make it easier next time. And we would get curious and try something, and we would be showing our kids that, “hey, it’s it’s okay to have a hard time doing that thing. It’s okay to have feelings about it. And we’re still gonna do it. We’re still going to end that thing.”Most of the time, the things that we are struggling with when it comes to screens actually boil down to one of three things, I call them the ABCs. It’s either Access, which could be time, or when they’re having it, or how much. Behavior, which you’re kind of bringing up here. And Content, what’s on the screen, what they’re playing, what they what they have access to.And so sometimes we might think that the problem we’re seeing in front of us is a behavior problem, right? I told them to put the screen away. They’re not putting the screen away. That’s a behavior problem. But sometimes it actually could be because it’s an access issue, right? It’s more time than they can really handle at that given moment. Or it could be content, because it’s content that makes it harder to start and stop. So a big part of the book is really figuring out, how do I know what problem I’m even really dealing with here? And then what are some potential things that I can do about it? To try to problem solve, try to make changes and see if this helps, and if it helps, great, keep it. And if not, I can get curious and try something else. And so a lot of it is strategies to try and ways to kind of, you know, backwards engineer what might be going on, to figure out how to make it work for you, how to make it better.VirginiaIt’s so helpful to feel like, okay, there’s always one more thing I can tweak and adjust. Versus “it’s all a failure. We have to throw it out.” That kind of all or nothing thinking that really is never productive. The reason I think it’s so helpful that you draw that parallel with the bath or the play date is it reminds us that there are some kids for whom transitions are just always very difficult—like across the board. So you’re not just seeing a screen time problem. You’re being reminded “My kid is really building skills around transitions. We don’t have them yet.” We hope we will have them at some point. But this is actually an opportunity to work on that, as opposed to a problem. We can actually practice some of these transition skills.AshAnd I really like coming back to the skill, because if we’re thinking of it as a skill, then we’re probably more likely to tell our kids that it’s a skill, too. Because if we’re just thinking of it as like, well, it’s a screen. It’s the screen’s fault, it’s the screen’s fault. Then we might not say those literal words to our kids, but we might say, like, it’s always so hard to turn off the TV. Why is that, right? We’re talking about it as if it’s this sort of amorphous, like it’s only about the television, or it’s only about the iPad, and we’re missing the part of making it clear to our kids that, hey, this is a skill that you’re working on, and we work on this skill in different ways.VirginiaI did some good repair with my kids after reading your book. Because I was definitely falling into the trap of talking about screen addiction. I thought I was saying to them, “It’s not your fault. The screens are programmed to be bad for us in this way” So I thought, I was like at least not blaming them, but being like, we need less screens because they’re so dangerous.But then I read your book, and I was like, oh, that’s not helpful either. And I did have one of my kids saying, “Am I bad because I want to watch screens all the time?” And I was like, oh, that’s too concrete and scary.And again, to draw the parallel with diet culture: It’s just like telling kids sugar is bad, and then they think they’re bad because they like sugar. So I did do some repair. I was like, “I read this book and now I’ve learned that that was not right.” They were like, oh, okay. We’re healing in my house from that, so thank you.AshOh, you’re very welcome, and I’m glad to hear that!I think about those parallels with food all the time, because sometimes it just helps me think, like, wait, would I be wanting to send this message about food or exercise or whatever? And if the answer is no, then how can I tweak it so that I’m sending a message I’d be okay with applying to other things. And I like being able to make those parallels with my kid. In my household right now, we’re practicing flexibility. Flexibility is a skill that we’re working on in so many parts of our lives. And when I say we, I do mean we. Me, everybody is working on this.VirginiaParents can use more flexibility, for sure.AshAbsolutely. And so like, when those moments are coming up, you know, I’m trying to say, like, hey, like, what skill is this right now? Who’s having to be flexible right now? Flexible can be a good thing, right? We might be flexible by saying yes to eating dinner on the couch and watching a TV show. That’s flexibility. Flexibility isn’t just adjust your plans to be more convenient to me, child, so that I can go do something as an adult. And coming back to those skills so they can see, oh, okay, this isn’t actually just about screens. This applies to every part of these of my life, or these different parts of my life, and if I’m working on it here, oh, wow, it feels easier over there. And so they can see that this applies throughout their life, and kind of feel more of that buy in of like, oh, I’m getting better at that. Or that was easier. That was harder. We want them to see that across the board.VirginiaOh, my God, absolutely.Let’s talk about screens and neurodivergence a little bit. So one of my kiddos is neurodivergent, and I can both see how screens are wonderful for them at the end of a school day, when they come home and they’re really depleted. Screen time is the thing they need to rest and regulate. And they love the world building games, which gives them this whole world to control and explore. And there’s so much there that’s wonderful.And, they definitely struggle more than their sibling with this transition piece, with getting off it. One kid will naturally put down the iPad at some point and go outside for a bit, and this kid will not. And it creates more anxiety for parents. Because neurodivergent kids may both need screens—in ways that maybe we’re not totally comfortable with, but need to get comfortable with—and then struggle with the transition piece. So how do you think about this question differently with neurodivergence? Or or is it really the same thing you’re just having to drill in differently?AshI think it is ultimately the same thing, but it certainly is going to feel quite more heightened. And I think especially for certain aspects of neurodivergence, especially, I think it feels really heightened because of some of the ways that they might be discussed, particularly online, when it comes to how they relate to technology. I think about ADHD, we’ll see that a lot. Where I’ll see many things online about, like, “kids with ADHD should never be on a screen. They should never be on a device, because they are so dopamine-seeking.” And I have to just say that I find that to be such an ableist framing. Because with ADHD, we’re talking about a dopamine deficient brain. And I don’t think that we would be having that same conversation about someone needing insulin, right? Like, we wouldn’t be saying, like, oh yeah, nope, they can’t take that insulin. VirginiaThey’re just craving that insulin they need to stay alive.AshA kid seeking a thing that they’re that they are somehow deficient in—that’s not some sort of defiant behavior. VirginiaNo, it’s a pretty adaptive strategy.AshAbsolutely, it is. And we want kids to know that nobody’s brain is good or bad, right? There’s not a good brain or a bad brain. There are all brains are going to have things that are easier or harder. And it’s about learning the brain that you’re in, and what works or doesn’t work for the brain that you’re in.And all brains are different, right? Neurotypical brains and neurodivergent brains within those categories are obviously going to be vastly different. What works for one won’t work for another, and being able to figure out what works for them, instead of just, “because you have this kind of brain, you shouldn’t ever do this thing,” that’s going to set them up for more success. And I think it’s great that you mentioned both how a screen can be so regulating, particularly for neurodivergent brains, and then the double-edged sword of that is that then you have to stop. VirginiaTransition off back into the world.AshSo if the pain point is a transition, what is it really coming from? Is it coming from the executive function piece of “I don’t know how to find a place to stop?” A lot of people, particularly kids ADHD, they often like games that are more open-ended. So they might like something like a Minecraft or an Animal Crossing or the Sims where you can hyperfocus and deep dive into something. But what’s difficult about that is that, you know, if I play Mario Kart, the level ends, it’s a very obvious ending.VirginiaRight? And you can say, “One more level, and we’re done.”AshExactly. We’ve reached the end of the championship. I’m on the podium. I quit now, right?But there’s a never ending series of of tasks with a more open-ended game. And especially if I’m in my hyper focus zone, right? I can just be thinking, like, well, then I can do this and this and this and this and this, right?And I’m adding on to my list, and the last thing I want to do in that moment is get pulled out of it when I’m really feeling like I’m in the zone. So if that’s the kind of transition that’s difficult. And it’s much less about games and more about “how do I stop in the middle of a project?” Because that’s essentially what that is.And that would apply if I’m at school and I’m in the middle of an essay and we’re finishing it up tomorrow. Or I’m trying to decorate a cake, and we’re trying to walk out the door and I have to stop what I’m doing and come back later. So one of the tricks that I have found really helpful is to ask the question of, “How will you know when you’re done?” Or how will you know you’re at a stopping point? What would a stopping point be today? And getting them to sort of even visualize it, or say it out loud, so that they can think about, “Oh, here’s how I basically break down a giant task into smaller pieces,” because that’s essentially what that is.VirginiaThat’s a great tip. Ash“Okay, you have five minutes. What is the last thing you’re going to do today?” Because then it’s concrete in terms of, like, I’m not asking the last thing, and it will take you half an hour, right? I’m at, we have five minutes. What’s the last thing you’re wrapping up? What are you going to do?Then, if it’s someone who’s very focused in this world, and they’re very into that world, then that last thing can also be our transition out of it. As they’re turning it off, the very first thing we’re saying to them is, “So what was that last thing you were doing?”VirginiaOh, that’s nice.AshThen they’re telling it to us, and then we can get curious. We can ask questions. We can get a little into their world to help them transition out of that world. That doesn’t mean that we have to understand what they’re telling us, frankly. It doesn’t mean we have to know all the nuance. But we can show that interest. I think this is also really, really important, because then we are showing them it’s not us versus the screen. We’re not opposing the screen, like it’s the enemy or something. And we’re showing them, “Hey, I can tell you’re interested in this, so I’m interested in it because you are.” Like, I care about you, so I want to know more.VirginiaAnd then they can invite you into their world, which what a lot of neurodivergent kids need. We’re asking them to be part of the larger world all the time. And how nice we can meet them where they are a little more.AshAbsolutely. The other thing I would say is that something I think people don’t always realize, especially if they don’t play games as much, or if they are not neurodivergent and playing games, is they might miss that video games actually are extremely well-accommodated worlds, in terms of accommodating neurodivergence.So thinking about something like ADHD, to go back to that example, it’s like, okay, some really common classroom accommodations for ADHD, from the educator perspective, the accommodations I see a lot are frequent check ins, having a checklist, breaking down a large task into smaller chunks, objectives, having a visual organizer.Well, I think about a video game, and it’s like, okay, if I want to know what I have available to me, I can press the pause menu and see my inventory at any time. If I want to know what I should be doing, because I have forgotten, I can look at a menu and see, like, what’s my objective right now? Or I can bring up the map and it will show me where I supposed to be going. If I start to deviate from what I’m supposed to be doing, the game will often be like, “Hey, don’t forget, you’re supposed to be going over there!” It’ll get me back on task. If I’m trying to make a potion that has eight ingredients, the game will list them all out for me, and it will check them off as I go, so I can visually see how I’m how I’m achieving this task. It does a lot of that accommodation for me. And those accommodations are not as common in the real world, or at least not as easily achieved.And so a lot of neurodivergent kids will succeed easily in these game worlds. And we might think “oh because it’s addicting, or the algorithm, or it’s just because they love it” But there are often these structural design differences that actually make it more accessible to them.And if we notice, oh, wow, they have no problem knowing what to do when they’re playing Zelda, because they just keep checking their objective list all the time or whatever—that’s great information.VirginiaAnd helps us think, how can we do that in real life? AshExactly. We can go to them and say, hey, I noticed you, you seem to check your inventory a lot when you’re playing that game. How do we make it so that when you look in your closet, you can just as easily see what shirts you own. Whatever the thing may be, so that we’re showing them, “hey, bring that into the rest of your world that works for you here.” Let’s make it work for you elsewhere, instead of thinking of it as a reason they’re obsessed with screens, and now we resent the screens for that. Bring that in so that it can benefit the rest of their lives.VirginiaI’m now like, okay, that just reframes something else very important for me. You have such a helpful way of helping us divest from the guilt and the shame and actually look at this in a positive and empowering way for us and our kids. And I’m just so grateful for it. It really is a game changer for me.AshOh, thank you so much. I’m so glad to hear that it was helpful and empowering for you, and I just hope that it can be that for others as well.ButterAshSo my family and I have been lucky enough to spend quite a lot of time in Japan. And one of the wonderful things about Japan is they have a very huge bike culture. I think people think of the Netherlands as Bike cCentral, but Japan kind of rivals them.And they have a particular kind of bike that you cannot get in the United States. It’s called a Mamachari, which is like a portmanteau of mom and chariot. And it’s sort of like a cargo bike, but they are constructed a little differently and have some features that I love. And so when I’ve been in Japan, we are on those bikes. I’m always like, I love this kind of bike. I want this kind of bike for me forever. And my recent Butter has been trying to find something like that that I can have in my day to day life. And I found something recently, and got a lovely step through bike on Facebook Marketplace. VirginiaSo cool! That’s exciting to find on marketplace, too.AshOh yes, having a bike that like I actually enjoy riding, I had my old bike from being a teenager, and it just was not functional. I was like, “This is not fun.” And now having one that I enjoy, I’m like, oh yes. I feel like a kid again. It’s lovely.VirginiaThat’s a great Butter. My Butter is something both my kids and my pets and I are all really enjoying. I’m gonna drop a link in the chat for you. It is called a floof, and it is basically a human-sized dog bed that I found on Etsy. It’s like, lined with fake fur.AshMy God. I’m looking at it right now.VirginiaIsn’t it hilarious?AshWow. I’m so glad you sent a picture, because that is not what I was picturing?Virginia I can’t describe it accurately. It’s like a cross between a human-sized dog bed and a shopping bag? Sort of? AshYes, yes, wow. It’s like a hot tub.VirginiaIt’s like a hot tub, but no water. You just sit in it. I think they call it a cuddle cave. I don’t understand how to explain it, but it’s the floof. And it’s in our family room. And it’s not inexpensive, but it does basically replace a chair. So if you think of it as a furniture purchase, it’s not so bad. There’s always at least a cat or a dog sleeping in it. Frequently a child is in it. My boyfriend likes to be in it. Everyone gravitates towards it. And you can put pillows in it or a blanket.Neurodivergent people, in particular, really love it, because I think it provides a lot of sensory feedback? And it’s very enclosed and cozy. It’s great for the day we’re having today, which is a very laid back, low demand, watch as much screen as you want, kind of day. So I’ve got one kid bundled into the floof right now with a bunch of blankets in her iPad, and she’s so happy. AshOh my gosh. Also, it kind of looks like the person is sitting in a giant pita, which I also love.VirginiaThat’s what it is! It’s like a giant pita, but soft and cozy. It’s like being in a pita pocket. And I’m sure there are less expensive versions, this was like, 300 something dollars, so it is an investment. But they’re handmade by some delightful person in the Netherlands.Whenever we have play dates, there are always two or three kids, snuggled up in it together. There’s something extremely addictive about it. I don’t know. I don’t really know how to explain why it’s great, but it’s great.AshOh, that is lovely.VirginiaAll right, well tell obviously, everyone needs to go to their bookstore and get Power On: Managing Screen Time to Benefit the Whole Family. Where else can we find you, Ash? How can we support your work?AshYou can find me on Instagram at the gamer educator, and I also cross post my Instagram posts to Substack, and I’m on Substack as Screen Time Strategies. It’s all the same content, just that way you’re getting it in your inbox without, without having to go to Instagram. So if that’s something that you are trying to maybe move away from, get it via Substack. And my book Power On: Managing Screen Time to Benefit the Whole Family is available starting August 26 is when it fully releases.VirginiaAmazing. Thank you so much. This was really great.AshThank you so much for having me back.The Burnt Toast Podcast is produced and hosted by Virginia Sole-Smith (follow me on Instagram) and Corinne Fay, who runs @SellTradePlus, and Big Undies.The Burnt Toast logo is by Deanna Lowe.Our theme music is by Farideh.Tommy Harron is our audio engineer.Thanks for listening and for supporting anti-diet, body liberation journalism! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit virginiasolesmith.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit virginiasolesmith.substack.comYou’re listening to Burnt Toast! We are Virginia Sole-Smith and Corinne Fay. For our last August hiatus episode, we’re looking back at a conversation we ran back in February of this year — exploring the work of attorney turned self-help guru Mel Robbins.Did Mel steal the concept of “let them?” Is she just Andrew Huberman for the “We Can Do Hard Things” crowd? Is high-fiving yourself in the mirror every morning a diet? As you’ll hear, Corinne and I didn’t totally agree… until we did. Let’s get into it.To hear our discussion, you’ll need to be a paid Burnt Toast subscriber. Subscriptions are $7 per month or $70 for the year.

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit virginiasolesmith.substack.com/subscribeWelcome to Indulgence Gospel After Dark! First up: Please take our listener survey here: https://bit.ly/3HwYVhT Today, we’re going to revisit our conversation about Emily Oster, and her evolving views on kids, weight and health.This episode first aired in November 2024, right after the presidential election. We’re now 8 months into Trump’s second term, and continuing to grapple with how America has slid to the right. So the story of a public health advocate and scholar who is now aligned with conservative media feels incredibly timely—especially because many of you are starting back at school this month, and Emily’s take on school lunches is particularly complex. That said, we also want to hold space for how much Emily’s work has meant to so many of us (including Virginia!).This is a complicated conversation. To hear the whole thing, read the full transcript, and join us in the comments, you’ll need to join Extra Butter, our premium subscription tier: https://virginiasolesmith.substack.com/subscribeExtra Butter costs just $99 per year. (Regular paid subscribers, the remaining value of your subscription will be deducted from that total!)In these monthly episodes we get into the GOOD stuff like:Dating While FatWhat to do when you miss your smaller bodyIs Kids Eat In Color anti-diet?And did Virginia really get divorced over butter?Extra Butters also get exclusive weekly chats, DM access, and a monthly bonus essay or thread. And Extra Butter ensures that the Burnt Toast community can always stay an ad- and sponsor-free space—which is crucial for body liberation journalism. Join us here!(Questions? Glitches? Email me all the details, and cc [email protected].)PS. If Extra Butter isn’t the right tier for you, remember that you still get access behind almost every other paywall with a regular paid subscription.

Today Virginia is chatting with Anna Maltby. Anna is a health journalist, editor, content strategist, personal trainer, and author of the newsletter How to Move. Anna also created Pilates For Abortion Funds, a monthly online class that has raised about $30,000 for abortion funds since July 2022. She has been an ACE-certified personal trainer since 2015, and a certified mat pilates instructor since 2021. She’s also a certified prenatal and postpartum exercise specialist. Anna lives in Brooklyn with her husband, two kids, and two extremely cute cats.Anna was previously a guest on one of Burnt Toast’s most popular ever episodes, The Myth of Visible Abs. What’s so great about Anna—and what makes her different from a lot of fitness writers and personal trainers out there—is that she’s so smart about bodies, she’s truly anti-diet and size neutral as a fitness professional…and, she’s been in the belly of the beast. Anna worked in women’s magazines with me long enough to know all the diet culture tricks. So she’s one of my favorite people to talk fitness with, because she can dissect what is marketing, what is diet culture, and what is actually maybe useful for your body.Two content warnings for today:1. We are going to talk about specific forms of exercise. This will always be through a weight neutral lens, but if you’re recovering from an eating disorder or just otherwise in a place where exercise is not serving you, please take care.2. CW for Butter, because we ended up talking quite a lot about toilets! And while I feel it’s all incredibly practical information and you’re going to thank me for my great Butter recommendation this week, I do realize that toilet conversation is not for everyone. It’s usually not for me! So I get it! You’ve been warned.To tell us YOUR thoughts, and to get all of the links and resources mentioned in this episode, as well as a complete transcript, visit our show page.If you want more conversations like this one, please rate and review us in your podcast player! And become a paid Burnt Toast subscriber — subscriptions are just $7 per month! —to get all of Virginia's reporting and bonus subscriber-only episodes. And don’t forget to check out our Burnt Toast Podcast Bonus Content! Disclaimer: You’re listening to this episode because you value my input as a journalist who reports on these issues and therefore has a lot of informed opinions. Neither my guest today nor I are healthcare providers, and this conversation is not meant to substitute for medical or therapeutic advice.FAT TALK is out in paperback! Order your signed copy from Virginia's favorite independent bookstore, Split Rock Books (they ship anywhere in the US!). Or order it from your independent bookstore, or from Barnes & Noble, Amazon, Target, or Kobo or anywhere else you like to buy books. You can also order the audio book from Libro.fm or Audible.CREDITSThe Burnt Toast Podcast is produced and hosted by Virginia Sole-Smith and Corinne Fay. Follow Virginia on Instagram, Follow Corinne  @SellTradePlus, an Instagram account where you can buy and sell plus size clothing and subscribe to Big Undies.Our theme music is by Farideh.Tommy Harron is our audio engineer.Thanks for listening and for supporting anti-diet, body liberation journalism.  This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit virginiasolesmith.substack.com/subscribe

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit virginiasolesmith.substack.com/subscribeWelcome to Indulgence Gospel After Dark! We are Corinne Fay and Virginia Sole-Smith, and this month we’re discussing… Things Thin People Say. 👀 The list includes: ⭐️ The most bananas comment about swimsuit shopping⭐️ That thing where they think their boyfriend’s clothes will fit you ⭐️ How Caroline Chambers’ thin privilege shows up⭐️ Our thoughts on Haley Nahman’s sugar addict essay. ⭐️ And more! To hear the whole thing, read the full transcript, and join us in the comments, you’ll need to join Extra Butter, our premium subscription tier.Extra Butter costs just $99 per year. (Regular paid subscribers, the remaining value of your subscription will be deducted from that total!)Extra Butter subscribers also get access to posts like:Is weight loss surgery the new Ozempic? Does Dr. Becky have a privilege problem? Is Kids Eat In Color anti-diet?And did Virginia really get divorced over butter?And Extra Butters also get DM access and other perks. Plus Extra Butter ensures that the Burnt Toast community can always stay an ad- and sponsor-free space—which is crucial for body liberation journalism. Join us here!(Questions? Glitches? Email me all the details, and cc [email protected].)PS. If Extra Butter isn’t the right tier for you, remember that you still get access behind almost every other paywall with a regular paid subscription.Episode 204 TranscriptCorinneSo, today we’re going to talk about the fatphobic things that people say without realizing it. And I think any fat person you talk to probably has an example of this.VirginiaOr a dozen examples of this.CorinneOr a dozen examples of this.We asked Burnt Toast readers to share stories. And we’re going to talk about a couple of examples that we stumbled across recently…VirginiaOn the Internet.CorinneIn the course of our jobs.VirginiaWe are going to talk about Caroline Chambers. We are going to talk about Haley Nahman. We’re going to get into some stuff that’s been happening with the thin folks.

You’re listening to Burnt Toast! Today, my guest isMara Gordon, MD. Dr. Mara is a family physician on the faculty of Cooper Medical School of Rowan University, as well as a writer, journalist and contributor to NPR. She also writes the newsletter Your Doctor Friend by Mara Gordon about her efforts to make medicine more fat friendly. And she was previously on the podcast last November, answering your questions on how to take a weight inclusive approach to conditions like diabetes, acid reflux, and sleep apnea.Dr. Mara is back today to tackle all your questions about perimenopause and menopause! Actually, half your questions—there were so many, and the answers are so detailed, we’re going to be breaking this one into a two parter. So stay tuned for the second half, coming in September! As we discussed in our recent episode with Cole Kazdin, finding menopause advice that doesn’t come with a side of diet culture is really difficult. Dr Mara is here to help, and she will not sell you a supplement sign or make you wear a weighted vest. This episode is free but if you value this conversation, please consider supporting our work with a paid subscription. Burnt Toast is 100% reader- and listener-supported. We literally can’t do this without you.PS. You can always listen to this pod right here in your email, where you’ll also receive full transcripts (edited and condensed for clarity). But please also follow us in Apple Podcasts, Spotify, Stitcher, and/or Pocket Casts! And if you enjoy today’s conversation, please tap the heart on this post — likes are one of the biggest drivers of traffic from Substack’s Notes, so that’s a super easy, free way to support the show!And don’t miss these: Episode 203 TranscriptVirginiaWhen I put up the call out for listener questions for this, we were immediately inundated with, like, 50 questions in an hour. People have thoughts and feelings and need information! So I’m very excited you’re here. Before we dive into the listener questions, let’s establish some big picture framing on how we are going to approach this conversation around perimenopause and menopause.MaraI should start just by introducing myself. I’m a family doctor and I have a very general practice, which means I take care of infants and I have a couple patients who are over 100. It’s amazing. And families, which is such an honor, to care for multiple generations of families. So, perimenopause and menopause is one chunk of my practice, but it is not all of it.I come from the perspective of a generalist, right? Lots of my patients have questions about perimenopause and menopause. Many of my patients are women in that age group. And I have been learning a lot over the last couple of years. The science is emerging, and I think a lot of practice patterns amongst doctors have really changed, even in the time that I have been in practice, which is about 10 years. There has been a huge shift in the way we physicians think about menopause and think about perimenopause, which I think is mostly for the better, which is really exciting.There’s an increased focus on doctors taking menopause seriously, approaching it with deep care and concern and professionalism. And that is excellent. But this menopause advocacy is taking place in a world that’s really steeped in fatphobia and diet culture. Our culture is just so susceptible to corporate influence. There are tons of influencers who call themselves menopause experts selling supplements online, just selling stuff. Sort of cashing in on this. And I will note, a lot of them are medical doctors, too, so it can be really hard to sort through.VirginiaYour instinct is to trust, because you see the MD.MaraTotally. There’s a lot of diet talk wrapped up in all of it, and there’s a lot of fear-mongering, which I would argue often has fatphobia at its core. It’s a fear of fatness, a fear of aging, a fear of our bodies not being ultra thin, ultra sexualized bodies of adolescents or women in their 20s, right? This is all to say that I think it’s really exciting that there’s an increased cultural focus on women’s health, particularly health in midlife. But we also need to be careful about the ways that diet culture sneaks into some of this talk, and who might be profiting from it. So we do have some hearty skepticism, but also some enthusiasm for the culture moving towards taking women’s concerns and midlife seriously.VirginiaThe cultural discourse around this is really tricky. Part of why I wanted you to come on to answer listener questions is because you approach healthcare from a weight inclusive lens, which is not every doctor. It is certainly not every doctor in the menopause space. And you’re not selling us a supplement line or a weighted vest, so that’s really helpful. So that’s a good objective place for us to start! Here’s our first question, from Julie: It’s my understanding that the body naturally puts on weight in menopause, especially around the torso, and that this fat helps to replace declining estrogen, because fat produces estrogen. I don’t know where I’ve heard this, but I think it’s true? But I would like to know a doctor’s explanation of this, just because I think it’s just more evidence that our bodies know what they’re doing and we can trust them, and that menopause and the possible related weight gain is nothing to fear or dread or fight.MaraOof, okay, so we are just diving right in. Thank you so much for this question. It’s one I get from many of my patients, too. So I looked into some of the literature on this, and it is thought that declining estrogen—which happens in the menopausal transition—does contribute to what we call visceral adiposity, which is basically fatty tissue around the internal organs. And in clinical practice, we approximate this by assessing waist circumference. This is really spotty! But we tend to think of it as “belly fat,” which is a fatphobic term. I prefer the term “visceral adiposity” even though it sounds really medical, it gets more specifically at what the issue is, which is that this particular adipose tissue around internal organs can be pathologic. It can be associated with insulin resistance, increasing risk of cardiovascular disease, and risk of what we call metabolic—here’s a mouthful—metabolic dysfunction associated steatotic liver disease, which is what fatty liver disease has been renamed.So I don’t think we totally understand why this happens in the menopausal transition. There is a hypothesis that torso fatty tissue does help increase estrogen, and it’s the body’s response to declining estrogen and attempts to preserve estrogen. But in our modern lives, where people live much longer than midlife, it can create pathology. VirginiaI just want to pause there to make sure folks get it. So it could be that this extra fat in our torsos develops for a protective reason —possibly replacing estrogen levels—but because we now live longer, there’s a scenario where it doesn’t stay protective, or it has other impacts besides its initial protective purpose.MaraRight? And this is just a theory. It’s kind of impossible to prove something like that, but many menopause researchers have this working theory about, quote—we’ve got to find a better term for it—belly fat. What should we call it, Virginia? Virginia. I mean, or can we reclaim belly fat? But that’s like a whole project. There is a lot of great work reclaiming bellies, but we’ll go with visceral adiposity right now.MaraAnyway, this is an active area of menopause research, and I’m not sure we totally understand the phenomenon. That being said, Julie asks, “Should we just trust our bodies?” Do our bodies know what they’re doing? And I think that’s a really philosophical question, and that is the heart of what you’re asking, Julie, rather than what’s the state of the research on visceral adiposity in the menopause transition.It’s how much do we trust our bodies versus how much do we use modern medicine to intervene, to try to change the natural course of our bodies? And it’s a question about the role that modern medicine plays in our lives. So obviously, I’m a fan of modern medicine, right? I’m a medical doctor. But I also have a lot of skepticism about it. I can see firsthand that we pathologize a lot of normal physiologic processes, and I see the way that our healthcare system profits off of this pathology.So this is all to say: Most people do tend to gain weight over time. That’s been well-described in the literature. Both men and women gain weight with age, and women tend to gain mid-section weight specifically during the menopausal transition, which seems to be independent of age. So people who go through menopause earlier might see this happen earlier. This weight gain is happening in unique ways that are affected by the hormone changes in the menopausal transition, and I think it can be totally reasonable to want to prevent insulin resistance or prevent metabolic dysfunction in the liver using medications. Or can you decide that you don’t want to use medications to do that; diet and exercise also absolutely play a role. But I think it’s a deep question. I don’t know, what do you think? Virginia, what’s your take?VirginiaI think it can be a both/and. If everybody gains weight as we age, and particularly as we go through menopause transition, then we shouldn’t be pathologizing that at baseline. Because if everybody does it, then it’s a normal fact of having a human body. And why are we making that into something that we’re so terrified of?And I think this is what we’re going to get more into with these questions: It’s also possible to say, can we improve quality of life? Can we extend life? Can we use medicine to help with those things in a way that makes it not about the weight gain, but about managing the symptoms that may or may not be caused by the weight gain? If the weight gain correlates with insulin resistance, of course you’re going to treat the insulin resistance, because the insulin resistance is the concern. Does that mean weight loss is the thing we have to do? Not necessarily.MaraTotally. I define size inclusive medicine—which is the way that I practice medicine—as basically not yelling at my patients to lose weight. And it’s quite revolutionary, even though it shouldn’t be. I typically don’t initiate conversations about weight loss with my patients. If my patients have evidence of metabolic dysfunction in the liver, if they have evidence of diabetes or pre-diabetes, if they have high blood pressure, we absolutely tackle those issues. There’s good medications and non-medication treatments for those conditions.And if my patients want to talk about weight loss, I’m always willing to engage in those conversations. I do not practice from a framework of refusing to talk with my patients about weight loss because I feel that’s not centering my patients’ bodily autonomy. So let’s talk about these more objective and less stigmatized medical conditions that we can quantify. Let’s target those. And weight loss may be a side effect of targeting those. Weight loss may not be a side effect of targeting those. And there are ways to target those conditions that often don’t result in dramatic or clinically significant weight loss, and that’s okay.One other thing I’ll note that it’s not totally clear that menopausal weight gain is causing those sort of metabolic dysfunctions. This is a really interesting area of research. Again, I’m not a researcher, but I follow it with interest, because as a size-inclusive doctor, this is important to the way that I practice. So there’s some school of thought that the metabolic dysfunction causes the weight gain, rather than the weight gain causing the metabolic dysfunction. And this is important because of the way we blame people for weight gain. We think if you gain weight, you’ve caused diabetes or whatever. This flips thta narrative on its head. Diabetes is a really complex disease with many, many factors affecting it. It’s possible that having a genetic predisposition to cardiometabolic disease may end up causing weight gain, and specifically this visceral adiposity. So this is all to say there’s a lot we don’t understand. And I think at the core is trying to center my patients values, and de-stigmatize all of these conversations.VirginiaI love how Julie phrased it: “The possible related weight gain in menopause is maybe nothing to fear, dread, or fight.” I think anytime we can approach health without a mindset of fear and dread and not be fighting our bodies, that seems like it’s going to be more health promoting than if we’re going in like, “Oh my God, this is happening. It’s terrible. I have to stop it.”And this is every life stage we go through, especially as women. Our bodies change, and usually our bodies get bigger. And we’re always told we have to fight through puberty. You have a baby, you have to get your body back as quickly as possible. I do think there’s something really powerful in saying: “I am going through a big life change right now so my body is supposed to change. I can focus on managing the health conditions that might come along with that, and I can also let my body do what it needs to do.” I think we can have both.MaraYeah, that’s so beautifully said. And Julie, thank you for saying it that way.VirginiaOkay, so now let’s get into some related weight questions.I was just told by my OB/GYN that excess abdominal weight can contribute to urinary incontinence in menopause. How true is this, and how much of a factor do you think weight is in this situation? And I think the you know, the unsaid question in this and in so many of these questions, is, so do I have to lose weight to solve this issue?MaraYes. So this is a very common refrain I hear from patients about the relationship between BMI and sort of different processes in the body, right? I think what the listeners’ OB/GYN is getting at is the idea that mass in the abdomen and torso might put pressure on the pelvic floor. And more mass in the torso, more pressure on the pelvic floor.But urinary incontinence is extremely complicated and it can be caused by lots of different things. So I think what the OB/GYN is alluding to is pelvic floor weakness, which is one common cause. The muscles in the pelvic floor, which is all those muscles that basically hold up your uterus, your bladder, your rectum—all of those muscles can get weak over time. But other things can cause urinary incontinence, too. Neurological changes, hormonal changes in menopause, can contribute.Part of my size inclusive approach to primary care is I often ask myself: How would I treat a thin person with this condition? Because we always have other treatment options other than weight loss, and thin people have urinary incontinence all the time.VirginiaA lot of skinny grandmas are buying Depends. No shame!MaraTotally, right? And so we have treatments for urinary incontinence. And urinary incontinence often requires a multifactorial treatment approach.I will often recommend my patients do pelvic floor physical therapy. What that does is strengthen the pelvic floor muscles particularly if the person has been pregnant and had a vaginal delivery, those muscles can really weaken, and people might be having what we call genitourinary symptoms of menopause. Basically, as estrogen declines in the tissue of the vulva, it can make the tissue what we call friable.VirginiaI don’t want a friable vulva! All of the language is bad.MaraI know, isn’t it? I just get so used to it. And then when I talk to non-medical people, I’m like, whoa. Where did we come up with this term? It just means sort of like irritable.VirginiaOk, I’m fine having an irritable vulva. I’m frequently irritable.MaraAnd so that can cause a sensation of having to pee all the time. And that we can treat with topical estrogen, which is an estrogen cream that goes inside the vagina and is an amazing, underutilized treatment that is extremely low risk. I just prescribe it with glee and abandon to all of my patients, because it can really help with urinary symptoms. It can help with discomfort during sex in the menopausal transition. It is great treatment.VirginiaItchiness, dryness…MaraExactly, yeah! So I was doing a list of causes of urinary incontinence: Another one is overactive bladder, which we often use oral medications to treat. That helps decrease bladder spasticity. So this is all to say that it’s multifactorial. It’s rare that there’s sort of one specific issue. And it is possible that for some people, weight loss might help decrease symptoms. If somebody loses weight in their abdomen, it might put less pressure on the pelvic floor, and that might ease up. But it’s not the only treatment. So since we know that weight loss can be really challenging to maintain over time for many, many reasons, I think it’s important to offer our patients other treatment options. But I don’t want to discount the idea that it’s inherently unrelated. It’s possible that it’s one factor of many that contributes to urinary incontinence.VirginiaThis is, like, the drumbeat I want us to keep coming back to with all these issues. As you said, how would I treat this in a thin person? It is much easier to start using an estrogen cream—like you said, low risk, easy to use—and see if that helps, before you put yourself through some draconian diet plan to try to lose weight.So for the doctor to start from this place of, “well, you’ve got excess abdominal fat, and that’s why you’re having this problem,” that’s such a shaming place to start when that’s very unlikely to be the full story or the full solution.MaraTotally. And pelvic PT is also underutilized and amazing. Everyone should get it after childbirth, but many people who’ve never had children might benefit from it, too.VirginiaOkay, another weight related question. This is from Ellen, who wrote in our thread in response to Julie’s question. So in related to Julie’s question about the role of declining estrogen in gaining abdominal fat:If that’s the case, why does hormone replacement therapy not mitigate that weight gain? I take estrogen largely to support my bone health due to having a genetic disorder leading to fragile bones, but to be honest I had hoped that the estrogen would also help address the weight I’ve put on over the past five years despite stable eating and exercise habits. That hasn’t happened, and I understand that it generally doesn’t happen with HRT, but I don’t understand why. I guess I’d just like to understand better why we tend to gain abdominal fat in menopause and what if anything can help mitigate that weight gain. I’m working on self acceptance for the body I have now, and I get frustrated when clothes I love no longer fit, or when my doctor tells me one minute to watch portion sizes to avoid weight gain, and the next tells me to ingest 1000 milligrams of calcium per day, which would account for about half of the calories I’m supposed to eat daily in order to lose weight or not gain more weight. It just feels like a lot of competing messages! Eat more protein and calcium, but have a calorie deficit. And it’s all about your changing hormones, but hormone replacement therapy won’t change anything.Ellen, relatable. So many mixed messages. Dr. Mara, you spoke to what we do and don’t know about the abdominal fat piece a little bit already in Julie’s question, so I think we can set that aside. But yes, if estrogen is playing a role, why does hormone replacement therapy not necessarily impact weight? And what do we do with the protein of it all? Because, let me tell you, we got like 50 other questions about protein.MaraI will answer the first part first: I don’t think we know why menopausal hormone therapy does not affect abdominal fat. You’re totally right. It makes intuitive sense, but that’s not what we see clinically. There’s some evidence that menopausal hormone therapy can decrease the rate of muscle mass loss. But we consider it a weight neutral treatment. Lots of researchers are studying these questions. But I don’t think anybody knows.So those messages feel like they’re competing because they are competing. And I don’t think we understand why all these things go on in the human body and how to approach them. So maybe I’ll turn the question back to you, Virginia. How do you think about it when you are seeking expertise and you get not a clear answer?VirginiaI mean, I’m an irritable vulva when it happens, that’s for sure. My vulva and I are very irritated by conflicting messages. And I think we’re right to be. I think Ellen is articulating a real frustration point.The other thing Ellen is articulating is how vulnerable we are in these moments. Because, as she’s saying, she’s working on self-acceptance for the body she has. And I think a lot of us are like, “We don’t want weight loss to be the prescription. We don’t want to feel pressured to go in that direction.” And then the doctor comes in and says, “1000 milligrams of calcium a day, an infinity number of protein grams a day. Also lose weight.” And then you do find yourself on that roller coaster or hamster wheel—choose your metaphor. Again, because we’re so programmed to think “well, the only option I have is to try to control my weight, control my weight, control my weight.” And you get back in that space.What I usually try to do is phone a friend, have a plan to step myself out of that. Whether it’s texting my best friend or texting Corinne, so they can be that voice of reason. And I would do this for them, too! You need help remembering: You don’t want to pursue intentional weight loss. You’re doing all this work on self-acceptance. Dieting is not going to be helpful. So what can you take from this advice that does feel doable and useful? And maybe it’s not 1000 milligrams of calcium a day, but maybe it’s like, a little more yogurt in your week. Is there a way you can translate this to your life that feels manageable? I think it’s what you do a great job of. But I think in general, doctors don’t do a great job with that part.MaraYeah, I bet you Ellen’s doctor had 15 minutes with her. And was like, “Well, eat all this calcium and definitely try to lose weight,” right? And then was rushing out the door because she has 30 other patients to see that day.I think doctors are trying to offer what maybe they think patients want to hear, which is certainty and one correct answer. And it can feel hard to find the space to sort of sit in the uncertainty of medicine and health and the uncertainty of like our bodies. And corporate medicine is not conducive to that, let’s put it that way.VirginiaBut so how much protein do we need to be eating?MaraI have no idea. Virginia, I don’t think anybody knows. I think exercise is good for you. It’s not good for every single body at every single moment in time. If you just broke your foot, running is not a healthy activity, right? If you’re recovering from a disordered relationship with exercise, it’s not healthy.But, movement in general prolongs our health span. And I’m reluctant to even say this, but, the Mediterranean diet—I hate even calling it a diet, right? But vegetables, protein—I don’t even want to call them healthy fats, it’s just so ambiguous what that means. But olive oil. All those things seem to be good for you. With the caveat that it’s really hard to study the effects of diet. And this is general diet, not meaning a restrictive diet, but your diet over time. But I don’t think we know how much, how much protein one needs to eat. It is unknowable.VirginiaAnd that’s why, I think what we’ve been saying about figure out how to translate this into something that feels doable in your life. It’s not like, Oh, olive oil forever. Never butter again. MaraOf course not. I love butter. Oh, my God. Extra butter!VirginiaRight. Butter is core to the Burnt Toast philosophy. I know you wouldn’t be coming here with an anti-butter agenda.MaraOh, of course not. Kerry Gold forever.VirginiaBut it’s, how can you take this and think about what makes sense in your life and would add value and not feel restrictive? And that’s hard to do that when you’re feeling vulnerable and worried and menopause feels like this big, scary unknown. But you still have the right to do that, because it’s still your body.MaraBeautifully said.ButterVirginiaWell, this has all been incredibly helpful. Let’s chat about things that are bringing us joy. Dr Mara, do you have some Butter for us? MaraI had to think about this a lot. The Butter question is obviously the most important question of the whole conversation.We have been in a heat wave in Philly, where I live, and it’s really, really hot, and we have a public pool that is four blocks from our house. Philly actually has tons of public pools. Don’t quote me on this, but I’ve heard through the grapevine—I have not fact-checked this—that it is one of the highest per capita free public pools in the country. I don’t know where I heard that from. I know I should probably look that up, but anyway, we’ve got a lot of pools in Philly. And there’s one four blocks from my house.So I used to think of pool time as a full day, like a Saturday activity. Like you bring snacks, you bring a book, you lounge for hours. But our city pool is very bare bones. There’s no shade. And so, I have come to approach it as an after work palate cleanser. We rush there after I get my kid from daycare, and just pop in, pop out. It’s so nice. And pools are so democratic. Everybody is there cooling off. There’s no body shame. I mean, I feel like it’s actually been quite freeing for my experience of a body shame in a bathing suit, because there’s no opportunity to even contemplate it. Like you have to hustle in there to get there before it closes. There’s no place to put your stuff. So you can’t do all those body shielding techniques. You have to leave your stuff outside of the pool. So you have to go in in a bathing suit. And it’s just like, all shapes and sizes there. I love it. So public pools are my Butter.VirginiaWe don’t have a good public pool in my area, and I wish we did. I’m so jealous. That’s magical. Since we’re talking about being in midlife, I’m going to recommend the memoir, Actress of a Certain Age: My Twenty-Year Trail to Overnight Success by Jeff Hiller, which I just listened to on audiobook. Definitely listen to it on audiobook. Obviously, Jeff Hiller is a man and not in menopause, but he is in his late 40s, possibly turned 50. He’s an actress of a certain age, as he says. If you watched “Somebody Somewhere” with Bridget Everett, he plays her best friend Joel. And the show was wonderful. Everyone needs to watch that.But Jeff Hiller is someone who had his big breakout role on an HBO show at the age of, like, 47 or something. And so it’s his memoir of growing up as a closeted gay kid in Texas, in the church, and then moving to New York and pursuing acting and all that. It’s hilarious. It’s really moving. It made me teary several times. He is a beautiful writer, and it just makes you realize the potential of this life stage. And one of his frequent refrains in the book, and it’s a quote from Bridget Everett, is Dreams Don’t have Deadlines, and realizing what potential there is in the second half of our lives, or however you want to define it. Oh my gosh, I loved it so much. There’s also a great, great interview with Jeff on Sam Sanders podcast that I’ll link to as well. That’s just like a great entry point, and it will definitely make you want to go listen to the whole book.MaraI love it.I will briefly say one thing I’ve been thinking about during this whole conversation is a piece by the amazing Anne Helen Petersen who writes Culture Study, which is one of my favorites of course, in addition to Burnt Toast. She wrote a piece about going through the portal. That was what she calls it. And she writes about how she’s talking with her mom, I think, who says, “Oh, you’re starting to portal!” to Anne. And I just love it.What she’s getting at is this sort of surge of creativity and self confidence and self actualization that happens in midlife for women in particular. And I just love that image. Whenever I think of doing something that would have scared me a few years ago, or acting confident, appropriately confident in situations. I’m like, I’m going into the portal. I just, I love it, it’s so powerful, and I think about it all the time.VirginiaWell, thank you so much for doing this. This was really wonderful. Tell folks where they can find you and how we can support your work.MaraThank you so much, Virginia. I’m such a fan of your work. It has been so meaningful, meaningful to me, both personally and professionally. So it’s such an honor to be here again. You can find me on Substack. I write Your Doctor Friend by Mara Gordon . And I’m on Instagram at Mara Gordon MD, too. And you can find a lot of my writing on NPR as well. And I’m writing a book called, tentatively, How to Take Up Space, and it’s about body shame and health care and the pursuit of health and wellness. So lots of issues like we touched on today, and hopefully that will be coming into the world in a couple of years. But yeah, thanks so much for having me, Virginia.The Burnt Toast Podcast is produced and hosted by Virginia Sole-Smith (follow me on Instagram) and Corinne Fay, who runs @SellTradePlus, and Big Undies.The Burnt Toast logo is by Deanna Lowe.Our theme music is by Farideh.Tommy Harron is our audio engineer.Thanks for listening and for supporting anti-diet, body liberation journalism! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit virginiasolesmith.substack.com/subscribe

This is a free preview of a paid episode. To hear more, visit virginiasolesmith.substack.comYou’re listening to Burnt Toast!We are Virginia Sole-Smith and Corinne Fay, and it’s time for… part 2 of our 200th episode!We are continuing to revisit favorite moments from the podcast archives. Coming up:🔥We have feelings about aging!🔥What’s our current take on heterosexual marriage?🔥How do you set boundaries when you’re in eating disorder recovery but your partner is…on a diet?And so much more!To hear the full story, you’ll need to be a paid Burnt Toast subscriber. Subscriptions are ON SALE THIS WEEK ONLY for 20% off to celebrate 200 episodes!