March 22, 2022
Cindy Lopez:
Welcome. My name is Cindy Lopez, the host of this CHC podcast, Voices of Compassion. We hope you find a little courage, feel connected and experience compassion every time you listen. Today’s podcast conversation focuses on eating disorders. It’s an important topic to discuss as data shows that calls alone to the helpline for the National Eating Disorders Association increased 40% in the first year of the pandemic. You know, sometimes the symptoms of eating disorders can fly under the radar or be dismissed as just a phase my child’s going through, but the shame and guilt that often accompanies eating disorders is something that should not be overlooked. Our guest today is Alexa Wilmarth, psychiatric mental health nurse practitioner at CHC. And prior to coming to CHC, Alexa worked at the center for discovery, a residential eating disorder treatment clinic for children and adolescents. So listen in as she shares her insights and experience on this timely topic.
Welcome Alexa.
Alexa Wilmarth:
Thank you, Cindy, for having me. It’s good to be here to talk about this important topic. So as you mentioned, my name’s Alexa, I’m a psychiatric nurse practitioner here at CHC, and I’ve been here for almost four years now, and I work with children and teens and young adults with a wide range of mental health disorders, and there’s been quite an overlap lately, especially during the pandemic of eating disorders and co-occurring mental health disorders. So I’m looking forward to talking about it today.
Cindy Lopez:
This topic of eating disorders is really interesting. Typically, I think the general public thinks about eating disorders like anorexia or bulimia, but as I’ve been reading, there’s so much more to it than that. Can you talk for a minute about the different types of eating disorders?
Alexa Wilmarth:
So the DSM-5 five actually lists seven major eating disorders. These include the well-known eating disorders of anorexia nervosa, bulimia nervosa, binge eating disorders, and there’s actually a few other eating disorders as well of restrictive food intake disorder, PICA and rumination disorder. There’s also a category of other specified feeding or eating disorders, which is kind of a catch all diagnosis for patients with significant features of eating disorders that don’t actually meet the criteria for anorexia or bulimia, but do have disordered eating and another common name for this disorder is atypical anorexia.
Cindy Lopez:
As I’ve read on the subject of eating disorders, I’ve come across disordered eating as well. I think disordered eating is different from eating disorders. So can you just talk about that for a minute too.
Alexa Wilmarth:
So I’ve worked with a lot of families who have this question, like when is it problematic eating disorder versus disordered eating? So with disordered eating sometimes I think of maybe cutting out food groups or eating or overeating when bored or having to have the same thing for lunch every single day. And it’s not quite an eating disorder, but maybe not quite problematic at that point, but when we’re thinking more about eating disorders, there’s much more strict or rigid food roles that cause significant mental distress, there’s constant eating disorder thoughts that are consuming some of these everyday thoughts to the point of obsession, and this causes a lot of anxiety. And then when there’s an eating disorder there’s also an element of the teen might be medically compromised, maybe experiencing some dizziness, and there also some functional impairment involved. So you want to think about the time and energy that they’re spending kind of planning out their meals or thinking about food or obsessing about weight loss or exercising. So it’s super important to get connected with a specialist to kind of tease it out.
Cindy Lopez:
Alexa, so going back to then eating disorders out of the ones that you talked about initially, what do you think you see the most of in your clinical practice?
Alexa Wilmarth:
Amongst teens, I see anorexia nervosa, bulimia nervosa and then binge eating disorders. So with anorexia the primary factor is actually restricting, there can also be purging or vomiting involved too, but with anorexia there’s an intense fear of weight gain, distorted body image, and then they can be underweight as well. Versus with bulimia, there’s like a cycling between binge eating and compensatory behavior. So that can be compensating with vomiting or using laxatives or overexercising, there’s still fear of weight gain, but oftentimes teens with bulimia are a normal weight, so they kind of can fly under the radar a little bit. With binge eating disorder, this is when teens are consuming large amounts of food rapidly until uncomfortably full, despite not feeling hungry, and then there’s typically a good amount of shame, guilt and emotional distress, but there’s no compensatory behavior as we see in bulimia.
Cindy Lopez:
Interesting cause you noted distorted body image with anorexia, but not the others. I typically think of eating disorders as related to like erroneous thinking about your body, right and distorted body image. Is that not accurate?
Alexa Wilmarth:
No Cindy that is accurate. There can be distorted body image, but I would say for anorexia, that’s like a hallmark feature of anorexia, but there is an element of dissatisfaction with body image, I would say with each of these, and then there could also be a good deal of shame that’s involved.
So, over the past two years, I think with the pandemic there’s been a kind of different emphasis on food, sometimes healthy sometimes not.
Cindy Lopez:
We’ve all felt some sort of loss, loss of control in the past couple of years. How is what we are currently experiencing or what we have experienced over the past couple of years contributed to eating disorders?
Alexa Wilmarth:
We all do find some sort of comfort in food, especially when we’re experiencing stress, but with a pandemic it really triggered teens with eating disorders. The world went on lockdown and there was a very strong, heightened anxiety around the pandemic. Specifically for kids there’s a huge feeling of lack of control. Plus, they were stuck at home from school. They couldn’t exercise or see their friends. All of this combined really fueled teens who struggle with eating disorders.
What we saw during this time was there was a significant increase in both new and relapsed eating disorders among teens and at the same time with the isolation not being in school or being able to see their friends or do extracurriculars, teens spent a ton of time on social media. There’s lots of influencers on different social media platforms that are posting content that can be actually potentially toxic specifically for teen girls. Content on these apps can range from the proverbial kind of clean eating to more severe pro anorexia extreme dieting, which they’re advising sometimes teens avoid certain foods or even labeling foods as good or bad. And I did a quick search on one social media app the other day, and I actually found a ton of accounts posting things like what I eat in a 24 hour period. While something like this could be well-intentioned, you know, maybe there are answering followers questions, but the problem is, is that over time, this can really fuel unhealthy eating habits. There’s even widely used filters that can alter your appearance and you can make a person look slimmer than they really are. Then there’s this unrealistic expectation to look perfect in our society, and of course this would be quite triggering for people who struggle with body image or eating disorders.
Cindy Lopez:
Yeah, that’s so interesting just thinking about how much diet and weight enter into to our conversation and as you think about this in your clinical practice, what are you seeing? What’s going on in terms of the problematic type of eating behavior?
Alexa Wilmarth:
I would say we’ve seen a big increase in problematic eating behavior during that time. Those that are prone to binging were binging more, and those prone to or having a history of restrictive eating were restricting calories. Another thing that worsened eating disorders over the pandemic is most outpatient clinics transitioned to a telehealth model. And with just a video and no other physical metrics or vitals, the weight loss and eating disorder itself became kind of easier to sort of fly under the radar. There was more weight loss, more disordered eating and actually a huge increase in hospitalizations.
Alexa Wilmarth:
So on that note, there was actually a recent large-scale cohort study done by JAMA, which is a peer reviewed medical journal, and it showed that hospitalization rates roughly doubled during this time for teens with eating disorders. Not only did they double, but teens were staying in the hospital longer, suggesting the severity of the malnourishment was particularly severe.
Cindy Lopez:
Yeah, that is really interesting. So you noted a study by JAMA. I’m wondering if you have any other data you might want to share?
Alexa Wilmarth:
Yeah, so calls alone to the National Eating Disorder Association helpline increased by 40% in the pandemic’s first year. So, and then another thing that was kind of alarming was people with anorexia who had been discharged from inpatient treatment, about 70% of them credited the pandemic for increasing weight concerns, loneliness, sadness and inner restlessness. And then another statistic that to me is just, has always been so concerning and alarming is, this is unrelated to the pandemic, eating disorders specifically, anorexia has the highest mortality rate of any mental health disorder.
Cindy Lopez:
Wow. I had no idea. It’s good information to know and referring to that high mortality rate is that because of suicide or other medical conditions that might come as a result of the eating disorder?
Alexa Wilmarth:
So most deaths associated with eating disorders are actually caused by the medical complications of the eating disorder itself rather than suicide. Suicide accounts for just one in five or 20% of the deaths, the most common serious medical complications associated with eating disorders are from the malnutrition itself and chronic malnutrition results in significant heart or cardiovascular issues and even multiple organ failure. So for teens, some of the common medical complications we see are anemia, blood pressure changes, which can cause dizziness or fainting, and we see electrolyte imbalances, especially in bulimia and we know electrolytes are essential for maintaining normal heartbeat. So with electrolyte imbalance, we see abnormal heart rhythms.
Another thing that happens when you restrict calories or if your body’s in a state of starvation, the metabolism slows down because it thinks it needs to conserve calories. So your body kind of goes into a hibernation mode. Everything just kind of slows down as if the body’s almost responding to a famine. The body does not want to waste a single extra calorie on anything. So we see slower metabolism, slow digestion, worse in cognitive ability and the heart rate slows as well. So what we see commonly in patients who are malnourished is bradycardia, which is an abnormally slow heartbeat. This combined with an abnormal heart rhythm is especially dangerous because it can lead to cardiac arrest and death. And then a few other medical issues worth mentioning is there’s also commonly osteoporosis that can happen due to the bone loss, which increases the risk of fractures. There’s atrophy or loss of muscle. Females lose their period. There can be hair loss. There’s decreased testosterone in men, kidney and liver damage and significant GI problems such as constipation, bloating or nausea. So eating disorders really take a huge toll on your body and your overall health.
Mike:
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Cindy Lopez:
So typically then Alexa, how would you say eating disorders start and what are some of the risk factors?
Alexa Wilmarth:
I think a lot of parents want to know, what should I be looking out for? What causes this? The tricky part is that eating disorders come from a range of factors. So it’s difficult to pinpoint exactly what started it or how it came to life. So first there’s genetic factors; genetics, DNA and family history are actually believed to be one of the largest contributors behind anorexia and then a lot of patients with eating disorders have a comorbid mental health disorder, which comorbid meaning a disorder that co-occurs along with another disorder. So in almost half of patients diagnosed with eating disorders have a comorbid disorder like generalized anxiety, social anxiety, depression or OCD. And at the same time, there’s all these society pressures with weight and fitting in, environmental factors, social media, where teens are constantly comparing themselves and their body images to others and this can really lead to low self-esteem. And with teens with eating disorders, sometimes there is a common personality trait of like a need for control or a need for perfectionism. And then finally, of course, the pandemic, we have the isolation, the loss of structure anxiety, and that kind of became the perfect storm situation for an eating disorder to begin or for one to relapse.
Cindy Lopez:
So, if I’m a parent, and I see my child like they’re eating too much or they’re not eating enough or I never see her eat, plus you just talked about some of the things that might be going on physically in the body, like slower metabolism, heart rate, those kinds of things. If those are happening, like what kinds of things would a parent be seeing? How would they know if there’s something that needs to be treated, maybe even talk about early warning signs?
Alexa Wilmarth:
From working with families, I can say I’ve had parents who come to me and say like my daughter is not eating. What can I do? And it can be a real challenge because they feel very helpless. You can’t really force your child to eat. That’s why it’s really important to intervene early.
So some more subtle signs to look for the teen might constantly be checking their weight, suggesting if you’re at weight gain maybe expressing guilt after eating. And then if your teen is spending a lot of time in the bathroom after meals could be a sign of possibly purging. And then you can also look out for some unusual eating rituals, such as organizing food on the plate in a certain way before eating, micro biding. So that’s having to cut food into tiny, tiny pieces before eating. Or maybe only eating in private or drinking like an excessive amount of fluids at meals to fill up on water instead of food. You could keep an eye out for excessive exercising or being overly obsessed with dieting or using substances to lose weight like laxatives or fasting of course, like not one of these alone means that you’re son or daughter has an eating disorder, but it’s really kind of the combination, and if there’s ever a concern it’s really important to meet with a specialist and kind of tease it out a bit and then another thing to look for, you know, without adequate nutrition, I would say teens often start having trouble concentrating on their schoolwork. It could even look like ADHD. So they can’t concentrate, their mood may decline and they may start having difficulty in school. So then they may also become more susceptible to depression, anxiety. So their self-esteem is declining and eating disorder thoughts can really be all consuming. So there’s definitely a bit of a triple effect.
Cindy Lopez:
So thinking about all of that, what advice do you have or what can you tell parents that they can do now?
Alexa Wilmarth:
I think it’s super important for parents to try to model healthy eating habits as a family, balanced meals, eating mindfully, encouraging to stop when they’re full, and for parents of younger kids try to not use food as a reward or a punishment. This can kind of interfere with the kid’s natural ability to recognize hunger cues, and it can also encourage them to eat when they’re not hungry to reward themselves. And then finally, just to avoid commenting on the child’s body size or shape. Sometimes if there is a weight loss even if they have the flu and lost of few pounds, they go to school and all of their friends are like, “you look great, you lost a few pounds” and that can be kind of positive reinforcement and can trigger sometimes eating disorder habits.
Cindy Lopez:
Thinking about eating disorders and if some of our listeners are thinking, wow, I wonder if my child is dealing with that or someone I know is dealing with that, and you’ve talked about the signs already. So what if I think oh maybe there is something going on here that needs to be treated. Let’s talk for a minute about what treatment looks like.
Alexa Wilmarth:
Eating disorders are super complex. So they’re typically treated with a multidisciplinary treatment team or approach, which includes a therapist who has experience with eating disorders. And then the therapist will often use a treatment model called family-based therapy or FBT, and this model seeks to avoid hospitalization. And so instead it engages the parents and the treatment to give them the skills to restore their child to a healthy weight at home, and then a registered dietician is typically included, sometimes psychiatry for medication and a medical provider to monitor vitals and all of the medical complications that we talked about that arise from eating disorders and the treatment goal generally focuses on a) weight restoration of course and being medically stable and b) guiding the teen towards having a healthy relationship with food.
So at CHC, we treat mild cases of eating disorders that are not medically compromised, and we always evaluate and determine if there needs to be like a higher level of care. And if so, we’ll place a referral. So there’s different levels of care for treatment. So the lowest level would be an outpatient program that would be like meeting weekly with a therapist or a dietician. And then up from there would be an individualized outpatient program or an IOP. That might be a program, an eating disorder specific that’s like a few days a week. And then from there, higher level of care would be PHB, which is partial hospitalization. So maybe five days a week, half day, so more hours, more intensive, more support. And then from there there’s residential treatment. So it’s kind of overnight support. I think similar sort of like a rehab program where the child may live there for 30 to 90 days and get really full support, which this type of program would be really helpful if the parent is having trouble managing the eating disorder at home and needs more hands-on care. And then finally the most intensive would be hospitalization, inpatient hospitalization, which is typically reserved when the teen is really medically compromised.
Cindy Lopez:
So going back to what you were talking about in terms of what the warning signs are, what parents might be seeing, if parents are seeing something, what does that conversation look like or should they not have that conversation?
Alexa Wilmarth:
I think going from just having a very gentle approach and starting off and asking what’s going on, maybe you’re noticing your teen has been skipping dinner every night. Is it anxiety? Are they trying to lose weight? So asking gentle but direct questions with your teen to kind of get a better understanding, what’s going on, using a really nonjudgmental approach. And, I think at times parents can feel like it’s beyond their control, and they don’t know what the right next step is. So getting connected with a therapist can be really helpful to either have that conversation as a family, or maybe the therapist can intervene and kind of figure out what’s going on.
Cindy Lopez:
For our listeners, a couple of resources for you. We do have some additional podcasts episodes from the past about connecting with your teen and listening to your teen. And those might be beneficial for you as parents, as you think about just how do you open up a conversation with your teen about something that might be awkward or uncomfortable, whether it’s eating disorders or anything else. And then of course, CHC is a resource for you. If you think something’s going on, as Alexa mentioned, it’s good to connect with a therapist who can help you figure out whether or not something’s going on. And then at CHC, we can do that. You can reach out chconline.org. You can reach out to our care team to make an appointment that’s careteam@chconline.org. We also have some free resources on our website, the podcast is one of them, and we also have a resource library. So please reach out to us if you think that there’s something that needs to be addressed.
So Alexa, as we wrap it up, what do you really hope that our listeners hear from you today on this topic?
Alexa Wilmarth:
Thanks for having me today Cindy, I think the biggest takeaway is if you notice early signs of disordered eating in your child or your teen don’t hesitate to reach out for an assessment. Early intervention can make a big difference in the treatment outcome. Another thing, and this is a simple thing that can be done, is to try to make sure to tailor your teen’s social media feeds. Encourage them to unfollow influencer accounts who may be overly focused on diet or exercise or thinness or even promoting kind of anorexia type behaviors and rather follow accounts that have a more body positive message that focuses more on mindful or intuitive eating. And then if you have concerns, definitely make sure it also raise the concern to your child’s pediatrician. They can do a basic medical workup to make sure your child’s medically stable and then they’ll make referrals if needed, therapy, dietitian or even more intensive levels of care. So if you’re listening to this now, you’re already doing a great job because you’re here. You’re trying to find resources for your child and so that they can be happy and thrive, and that’s what we want for your child here at CHC too.
Cindy Lopez:
Thank you Alexa, and to our listeners, thank you for joining us, and we hope that this episode has been helpful and it’s provided you with information, education, insights, and we hope you’ll listen again next week. Visit us online at podcast.chconline.org. Make sure to subscribe to Voices of Compassion so you never miss an episode and we’d love it if you’d leave us a rating and review. Have a question? Send us an email or a voice memo at podcasts@chconline.org. We’re here for you when you need us.
