Transcription:
Eating Disorders

Melanie Cole (Host): There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. Welcome to Kids Health Cast by Weill Cornell Medicine. I'm Melanie Cole. And joining me, we have a panel today with Dr. Melissa Klein, she's an Assistant Professor of Clinical Psychology and Psychiatry at Weill Cornell Medicine and she's an Assistant Attending Psychologist at New York Presbyterian Weill Cornell Medical Center; and Dr. Suzanne Straebler, she's a psychiatric nurse practitioner and a certified cognitive behavioral therapist at Weill Cornell Medicine.

Host: Doctors, thank you so much for joining us today. Dr. Straebler, I'd like to start with you, and if you could kind of set the table for us, what are the different types of eating disorders you see in your clinic? Tell us a little bit about what that term disordered eating even means.

Dr Suzanne Straebler: Absolutely. And thank you so much for having us, Melanie. We're really excited to be here, talking about these really important issues. I think the first thing really to highlight is that disordered eating occurs on a spectrum. And it's really not until individuals get to a point where their functioning is impaired. They're struggling to see friends. Maybe their schoolwork is starting to slide. It's at that point that they tend to come into our clinic.

Guest 1: And so, there are eight recognized feeding and eating disorders identified by the Diagnostic and Statistical Manual. Typically in our clinic, we really encounter about five main eating disorders. So, we're seeing anorexia nervosa both in those who are medically underweight and also those who are suppressing their weight. They exist in a body mass index that's considered a healthy body mass index; but actually, for their body, it's too low. We also see bulimia nervosa, binge eating disorder and we're seeing a newer eating disorder called avoidant restrictive food intake disorder or ARFID in many more individuals reaching out for treatment for this particular disorder.

Host: Well, Dr. Klein, how common are these? Are they more common in adolescent girls or are boys susceptible to them too? Tell us a little bit about the breadth of what you're seeing in the clinic?

Dr Melissa Klein: So, we're seeing eating disorders occur at all different ages. It seems like it's spreading out among the ages where we're seeing it start at a younger age, where on our unit we usually don't accept under 12. But we have been accepting patients as young as 11 on our unit, and I've been getting phone calls from parents with eight or nine-year-old children who are showing signs of eating disorders. And we see it go up into much higher ages, 50s, 60s. We've had a patient who was 80 on our unit recently. So, it happens with all different ages and it happens with females and males. So, we see it in both sexes. It is more common among females, but we're seeing it more commonly among males. We don't know, I think it's always been there in males, but I think people are more accepting that maybe their child who is a male has an eating disorder, where before it wasn't as widely accepted. And I think the numbers are increasing. These last few years, we've been seeing higher numbers of eating disorders in adolescents, where the actual percentage of patients with anorexia is fairly low, 1-2%. With bulimia, it is higher. But I think we're seeing a lot more disordered eating overall.

Guest 1: And to add to something Dr. Klein and I are always stressing is that eating disorders don't discriminate. So, there's this view historically eating disorders affected young, white female patients with high socioeconomic status. And that has really impacted the number of people who are properly diagnosed, who feel that they can come forward with an eating disorder, but really stressing that eating disorders affect all people, men, women, people of all genders, races, ethnicities, all socioeconomic status, all shapes, all sizes. And that we really need to shift our mindset on this so that we are listening out for eating disorder behaviors in all of the patients that we're meeting and that we aren't kind of struggling to see beyond what was the original conceptualization for eating disorders.

Guest 2: I just want to add to that, Suzanne, that often we'll have kids come in and they'll be overweight and they'll feel like they don't fit in because they're not underweight and what is expected to look like when you have an eating disorder. Or people may comment to them, "Oh, you don't have an eating disorder," just because their weight is a little bit higher. So, just to support what Suzanne was saying, eating disorders comes at all different weights. Someone doesn't have to be underweight to have a very serious eating disorder.

Host: Well, thank you both for that. Dr. Straebler, when you were talking about this really being the misconception that it used to be, girls of certain socioeconomic standing, that sort of thing; and now, it's a much broader problem, you know, children are coming up with this and we're seeing it so much more all around the country, do you have any theories? Because I know I have my own and, as an exercise physiologist, I've seen it for years when I've worked with kids and now, but it seems to me, and I have a 20-year-old daughter as well and a 23-year-old son, that social media influence, influencers, filters on TikTok. I mean, there's all of these things that contribute to the mental health epidemic that we are seeing in the country today. But along the disordered eating lines, do you have something, a theory, that you can look to that would signal why we're seeing this on the increase?

Guest 1: Yeah. I mean, it's complicated because of the pandemic. We know that during the pandemic, what we were all doing, the quarantine, the lockdown, the isolation that many mental health disorders increased, particularly eating disorders, they thrive in secrecy and hear where people locked away from their friends, unable to have control in other areas in their life. But to your point about social media, and I could go on and on about social media and the impact on eating disorder and eating disorder behavior, disordered eating, there is initial evidence really showing that the more time particularly young people spend consuming social media, the lower their body confidence, the lower their self-esteem. And it's a really complicated situation.

We are so concerned about social media usage that actually in our evaluations, we actually include it now. "Can you tell me a bit about how much time you're on social media? What are you using? Are you on TikTok or Snapchat?" And my younger patients, they keep track of it or their phone does and they'll show me. "I've been on for eight hours today total." And so, really helping to provide families and patients information about the best use of social media. Social media can be really helpful in terms of connecting people and keeping in contact with friends, but there's a lot of very unhelpful content out there. There's a lot of toxic content out there as well. But just in terms of helping someone to create their page so that they're not getting tons of information about dieting or what the best bathing suit look is for this season, and really helping people to reduce the amount of time they're consuming social media as well, I think, is hugely important.

Host: Yeah, I agree with you. That could be a conversation in itself. And Dr. Klein, I'd like you to differentiate anorexia, bulimia, two of the more common ones that we see and tell us how we can tell the difference. For parents listening, they may see that their child is turning away food. They may see that they're getting much thinner or that their negative self-talk is on the rise. But bulimia being a different deal because we can't always tell, and you don't always know, but there are certain signs. So, I'd like you to differentiate these two and speak to those signs and symptoms as you're differentiating, so that we can tell what it is we're looking for as parents, those red flags.

Guest 2: Sure. So with anorexia, one of the key differences between anorexia and bulimia is with anorexia, someone is lower in weight than what's expected. And it's very important that what's expected because sometimes you will have someone start at a higher weight and they lose a significant amount of weight, and maybe they're not considered to be low weight compared to maybe some of their friends. But for them, they're considered to be still very low in weight. So, it's something, that someone has to take into mind. There's also, just with anorexia, preoccupations with shape and weight. There is a form of anorexia called anorexia binge purge type. So, there are two forms, the restricting type and the binge-purge type.

So, someone with anorexia binge-purge type is binging and/or purging as well as being lower in weight than expected. And I just want to clarify, binging is eating much more than expected in a very short, discreet amount of time. So usually, it's more than like twice, maybe close to three times, as much as what's expected. And purging can take different forms. It could be vomiting, it could be use of laxatives, it could be overexercise, it could also be severe restricting. So for example, someone may have a binge and then the next day try not to eat at all, and that could be a form of compensating for their binge.

With bulimia, they're not underweight. They're binging and purging at least once a week. So, we talked about what binging is and the different forms of purging. And so yes, it is harder to know when someone is bulimic because often they do these behaviors in secret. It's something that they hide. But certainly within families, sometimes you'll hear parents, they'll say, "We noticed that there was a lot of food that was missing" or they'll find wrappers in their child's room, in their backpack. With binging and purging when someone purges, they don't get rid of everything that they take in. There's evidence that says they only get rid of about half of what they take in, so it's not uncommon for someone with bulimia to gain weight, because they're taking in such a large amount of calories.

So, other signs that someone is bulimic is maybe every time they eat, they go to the bathroom. They could just be feeling more tired, more moody, more irritable. Sometimes when someone's purging and they're using their fingers, there's some marks on the back of their hands, because they're doing it so frequently. Sometimes if they're purging very frequently, their salivary glands get very swollen, giving them a chipmunk appearance. Sometimes they go to the doctor and they get blood work done, and they see some electrolyte abnormalities. So, it is harder to know. But often if there is some secrecy around eating, if you see food missing, if you see some changes in weight or if you see someone is spending a lot of money on food, these could all be signs.

Host: That was a very comprehensive explanation. And for parents, listen to it again, because she just gave us all a lot to think about and things that we can be looking for as parents. And I think that's one of the main messages here is, as parents, we really want to watch and see what our kids are doing so that we can get them the help that they need if they need it.

Dr. Straebler, I'd like you to speak about treatments and tell us about your clinic at Weill Cornell Medicine, the services that you offer, both inpatient and outpatient, and tell us when it does become a point where treatment is required.

Guest 1: And I will start with outpatient and then I'm going to hand back over to Dr. Klein to speak about our inpatient services. But in our outpatient clinic, we are really trying hard to provide our patients and their families the most up-to-date evidence-based treatments that we can. So for our children and our adolescents with anorexia nervosa, bulimia nervosa, binge eating disorder, we're primarily using a therapy called family-based treatment, or many people have heard of it as the Maudsley method. And this is a treatment really involving heavy parental or whatever the adult in the household are to really become a part of the treatment team and helping us to re-feed their child. We're more of a coach in helping the parents to provide that therapy to their child.

For adults, we primarily use enhanced cognitive behavior therapy. And both of these therapies have a lot of evidence behind them. They're recommended treatments and we really try to strive as much as we can to provide these therapies to all individuals who come to our clinic. So, we're providing these therapies with sign language interpreters for patients who are deaf and hard of hearing. We're providing these therapies in different languages with either simultaneous translation or phone translation, but really making sure that we're expanding the reach of these effective therapies to as many individuals as we can. I will pass back to Melissa for thinking more about the inpatient services and what we're providing there.

Guest 2: Sure. Thanks, Suzanne. On the inpatient unit, we do treat both adolescents and adults. We have two kind of arms of our unit, which are kept separate. So, the adolescence side, usually 12 to 17, although we have been going as young as 11 these days. It is a very structured unit. It's a behavioral unit. Meals are provided. Everything is closely monitored. So, meals, bathroom use are all closely monitored. We do focus on cognitive behavioral treatments, helping patients to change behaviors and also working on helping them to challenge their thoughts around eating and shape and weight. So, they are receiving several groups during the day. We do have some individual treatment as well. And the patients I think often can be very supportive of each other. I think it's often hard for patients to talk about having an eating disorder with their friends, with their family. And I think it's helpful for them to see that other people are suffering from this and can relate to their issues.

Guest 1: And relating back to the therapies that we offer, but also the eating disorders that we encounter, really highlighting this avoidant restrictive food intake disorder or ARFID because we are really hearing from many more parents, adolescent medicine doctors, pediatricians looking for providers for this illness. And one of the first things that parents say when they call us is, "I don't know if you've heard of this, I don't know if you've heard of this illness called ARFID." And so, really reassuring families that we have heard of it. We are providing a different type of cognitive behavior therapy designed specifically for ARFID, but also a family-based version of that therapy for our younger patients. But there are effective treatments for ARFID.

And ARFID is different to some of the more traditional eating disorders that we may be more familiar with, in that there are about three kind of subcategories we see patients. Really, there's a lack of interest in eating, that may have been from when they were very little or it's kind of a newer onset or in combination with a lot of sensory concerns about eating. So, a child or an adolescent who's describing that they don't want to eat sharp foods or slimy foods, or patients who are trying to avoid something aversive happening. So, maybe they saw someone choke or they themselves experienced a choking episode and now they're restricting their eating for fear of choking themselves. And when we see that combination either of wanting to avoid a sensory component or an aversive consequence or a lack of interest combined with dramatic weight loss or nutritional deficiency, we really do want to get these individuals in for treatment because they often respond very well to treatment.

Host: That's encouraging for parents to hear that are so concerned. Now, as you speak about the treatments that are available, I'd like you to also speak about outcomes. Dr. Klein, tell us what you've seen when you work with these children and even some young adults. Please tell us what you see as they go on. What is their life like after treatment for disordered eating?

Guest 2: What we do see is that patients can be very responsive to treatment. So, eating disorders are a very difficult illness to treat. But for adolescents, especially if they're able to come for inpatient or get treatment right away. And the issues are addressed right away. And especially for anorexia, if they're able to get to a little bit of a higher weight, then they have a very, very good chance of doing very, very well in treatment. We see that they respond very well to cognitive behavioral therapy. And I just want to clarify, the inpatient unit, usually someone is there when they are not responding to outpatient treatment and they have some type of medical concerns often. And when they leave the unit, often they do need some type of transitional care. So by the time they leave the unit, usually they're at a healthier state and they're able to move on to the next level of treatment. But again, with adolescence when this disorder is caught early and they're given the help that they need, we do see a high rate of recovery. And I know with CBT and with FBT too, we've seen patients really fully recover from an eating disorder.

I think it's key though that this is something that is treated very early on. I think sometimes parents want to wait to see what happens. They don't want to get treatment for their child right away. They think they're going to grow out of it. And I just want to stress the importance that if you do get treatment earlier on, you have a much better chance of recovery.

Guest 1: I think that's such an important point, Melissa, that you're making that early detection is important, and then acting swiftly is important. And these treatments on the whole, for the majority of patients when they're implemented well, patients make a long and lasting recovery. Another thing Melissa and I are always stressing is that, for most people, eating disorders are treatable. And one of the most rewarding aspects of working with individuals and families, is that moment where either the parent comes in and says, "My child is themselves again. They're back to who they used to be" or the adolescent even says, "I feel like my old self." It's really just a wonderful moment in therapy and it really gives us momentum to finish out the therapy and to finish it well.

Guest 2: I just want to add to that too, with adolescents, often when they start treatment, they think that they can't change, they're afraid to gain weight. They think they're never going to feel comfortable again at a higher weight. And when they get there, they're quite surprised that it's not as bad as they expected and that they're happy again. And they look back to what their life was like before, and they think like, "Oh my, God. How was I living like that? How could I have been happy eating just like two things and I wasn't doing anything with my friends? And now, I'm able to do those things again." So, that is the great thing about our job, is actually seeing that change and seeing people get their lives back.

Host: That must be very rewarding. I mean, I'm encouraged even just listening to you both discuss these things and these outcomes and what you've seen with the kids that you're working with. I'd like to give you each a chance for a final thought here. Dr. Straebler, I'd like you to give some parents some healthy ways to talk about weight with their children. Because one of the things that, you know, we learned over the years is that negative self-talk, that negative looking in the mirror, but then as mothers, we sometimes do it to ourselves. "Oh God, look at my thighs. When did that happen?" And our kids hear that. So, I'd like you to speak to that particular thing and how we as parents can be role models to help our children so they don't think this way right out of the box.

Guest 1: Absolutely. And we talk a lot about this. Yes, we are the role models, our children see what we're doing, they hear what we're saying. And it's so important that we don't talk negatively about our bodies and our shapes and that we do our best not to engage on the latest fad diet each time they come around. And that we model for our children that we can eat a balanced and varied diet, and we can have ice cream and we can have other foods that maybe they're being told they shouldn't be eating. But it's so, so important that in the conversations we have with them, that we are modeling neutral language as best as possible. Try not to comment on your child's weight. If you want to encourage them to have balanced foods, really making it about energy. Calories are energy, so, "Yes, let's have this meal so we have the energy to go outside later and play some soccer or so we can do some rock climbing together," but shifting the language away from healthy eating or good eating or bad eating to just a much more neutral language that's really focused on providing our bodies with the energy that they need and modeling for our children and for those around us that we too eat a wide variety of foods and are not negatively commenting on our shape and weight.

Guest 2: I was just going to say in addition, we don't like to label food as good or bad. There's no good food or bad food. We don't want to cut out any type of food groups from our diets. We're not giving them a message that starches or fats are bad, that everything is okay in moderation.

Host: Well, that certainly applies to the obesity epidemic that we've seen as well, because that negative self-talk and good diets versus bad and restriction of certain foods, it all kind of comes together to make this whole issue with our kids go in either direction in such a big and dangerous way, and so scary for parents.

Dr. Klein, last word to you here, I'd like you to reiterate about the clinic at Weill Cornell Medicine and when you feel it's important that parents say, "Okay, you know, maybe the provider that they go to first will be their medical home, their pediatrician." But then, what happens when is it you feel that it's important that parents reach out?

Guest 2: Well, certainly if you go to your pediatrician and there's some medical concerns, if there are electrolyte abnormalities, if your kid hasn't grown as expected; if in between visits, they were 12 and 13 and they didn't gain any weight or they lost weight at the time that they should be gaining weight or they didn't gain in height, certainly those are huge red flags to consider and a time to ask for help. But also basically if you're seeing that your child is totally preoccupied with weight, shape, even if they haven't lost weight yet, that's a time that you might want to ask for help. If you see that your child has cut back significantly their food intake, is spending an excessive amount of time exercising or, in general, you see there's maybe a shift in eating and also a huge shift in mood, if your child starts to isolate, is avoiding social situations, if they're getting anxious when going to restaurants or going on vacations or holidays, you see their eating is not the same as it has been in the past, these are all red flags and a time that you should really consider asking for help.

Host: Thank you both so much for your expertise and for sharing it with parents. This is so important that we talk about it, that we get this information out there that we can trust, and it's quality information from the experts at Weill Cornell Medicine. It doesn't get better than that. So, thank you so much for joining us.

And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Kids Health Cast. We'd like to invite our audience to download, subscribe, rate, and review Kids Health Cast on Apple Podcast, Spotify, and Google Podcast. And for more health tips, please visit weillcornell.org and search podcasts. And don't forget to check out our Back to Health. I'm Melanie Cole. Thanks so much for joining us today.

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