May 23, 2024
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. Join us today for this conversation on eating disorders with Michael Manzano, doctoral intern in clinical psychology at Children’s Health Council and Lucile Packard Children’s Hospital at Stanford. We begin by talking about the behaviors you might see with disordered eating from picky eating to extreme dieting to binging and purging. We also discuss preventive measures that include fostering a positive relationship with food and body and early identification. Oh, and spoiler alert, one of the most important things you can do as a parent or caregiver is to model what you want to see in your child by promoting a healthy, neutral, not positive or negative, body image. So join us as we navigate this sensitive yet crucial topic, offering valuable insights and practical advice for promoting well-being and preventing disordered eating in children.
So Michael, thank you so much for joining us today and for talking to us on this subject about eating disorders. Can you just start by telling us a little bit more about yourself and why you think it’s so important for us to talk about this topic?
Michael Manzano: Absolutely. Very happy to talk about this topic, which is very near and dear to my heart. In terms of how I even got interested in this space, there’s a lot of places I could start, but I’ll start relatively recently in that, you know, in undergrad, I really became interested in the mind-body connection and understanding more about how physical and mental health are linked. For a variety of different reasons, society, medicine has made those very distinct. When in reality we know there’s very much a lot of connection there. So in my third year of undergrad, I actually changed majors pretty late in that trajectory to psychobiology. So after making that change I decided to go to grad school, and there I pursued an emphasis in behavioral medicine, again, really trying to understand more of this space of how the physical and the mental are very much connected in all of us.
And I thought I would be more in the health behavior change space. So more in this space of health promotion and you know, how movement, how sleep, how eating all affect children’s physical and mental health. And for a variety of just practical reasons being where I did most of my training in San Diego, there are some fantastic eating disorder experts. And I kind of dipped my toes into the field given I understood something about eating behavior, something about movement and it really just hooked me in. Ever since I started working with these populations, I have been fascinated ever since. And unfortunately with COVID, exacerbated really all youth mental health problems, eating disorders have been no exception. So I think the need is also there. So I think the practical and then just like the personal really just has drawn me to this space.
Cindy Lopez: I really like your reference to that mind body connection there so much, that we should be paying attention to, and you know our system is set up as you kind of alluded to, to consider things separately, to consider you go to the doctor for your physical health and you see another specialist for your mental health, and they’re treated differently, right?
So let’s define eating disorders. What are we talking about today when we reference eating disorders?
Michael Manzano: Absolutely. So when I’m referencing eating disorders or you also hear me make reference to disordered eating throughout our conversation, it’s really talking about anything that’s eating or movement related, body related, that is getting to the point that it’s causing distress and impairment in your life. And I’ll go into some of the specific behaviors that we’re looking out for, but broad strokes, it’s really when this process of eating or becoming, you know, focused, fixated on kind of our body shape and size when that’s taking up just so much time that it’s getting to the point that it’s really causing distress. And it’s really getting in the way of cultivating meaningful relationships, be able to focus on school, so on and so forth.
Cindy Lopez: As we talk about the behaviors that we see, that you see, that our listeners might be seeing, let’s talk about what are some of those behaviors associated with disordered eating. Can you talk about that a little bit?
Michael Manzano: Absolutely. So I think when a lot of people think of eating disorders, they really think of anorexia and the behavior that’s really characteristic of anorexia is restriction. And a lot of times when people think of restriction, they think of overt restriction, no food intake, complete starvation, and restriction does not necessarily need to be that level of severity for it to be concerning. So restriction can also look like eating minimal amounts of food. It’s not uncommon for the patients I’ve worked with to have very remarkably low kind of calorie goals of saying they won’t eat more than 200 calories a day or 400 or 600, where it’s not nothing, but it’s certainly not enough for anyone’s body, but I work in the child and adolescent young adult space, particularly a growing body, absolutely not enough nutrition, enough energy for just the basic aspects of development to be able to actually occur because there’s no energy for which to be able to have things grow. So restriction can look like that. It can also be restriction of the types of foods that we’ll eat. So some people will eliminate entire food groups. They will not eat any carbohydrates. They will not eat anything with added sugar. They will not eat anything that has a food label because processed food is quote unquote “bad.” So when I’m talking about restriction, it can certainly be that overt restriction, but it can also be these kind of less overt forms, which are absolutely still concerning and can be problematic.
Cindy Lopez: So Michael, just thinking about that restriction piece, thinking about autoimmune disorders and even autism, kids with autism, like they have a lot of sensory things going on and sometimes will eliminate food or don’t want to eat food because of how it feels or it could be how it tastes and also those with autoimmune issues, like, you know, eliminating gluten, eliminating dairy, all those kinds of things. When we talk about restriction today, are we talking about those things too?
Michael Manzano: That’s a great question. And my short answer is it absolutely can. So with those things, obviously, if you have celiac, if you have some sort of autoimmune condition where they’re trying to figure out like what things are maybe exacerbating symptoms, there is nothing inherently wrong with that. Where it can become problematic is if that level of restriction, it starts off coming from this place of healthfulness and then kind of takes on a life of its own. So I have unfortunately seen patients with, for example, diabetes, that it makes sense that they’re going to be mindful of what carbohydrate intake, what added sugar intake looks like, because they have a condition where insulin levels can get dysregulated. So it makes sense that you’re going to be mindful of the sugar that you’re going to put in your body. And that can take a life of its own and really start to, for lack of a better phrase, you could really overdo it. So it can start off from this place of, you’re following medical advice, and it can morph into this really treacherous thing that we call disordered eating or an eating disorder. So we started with restriction because that’s the behavior that most people think of. That is absolutely not the only eating disorder behavior.
So a behavior that some people don’t think of as related to restriction, which absolutely is in my experience, is binge eating. So that’s where eating a large amount of food while experiencing some sense of loss of control. So there’s some element with binge eating that once you start eating, you feel like you can’t stop. And that’s often accompanied by feelings of guilt or shame or wanting to eat in secret because you don’t want other people to see you. And oftentimes you will hear people in the eating disorder space talk about this restrict-binge cycle where it naturally follows that if you’re putting your body in this space of not giving it nourishment for an extended period of time the hunger signals are just going to increase, just going to ramp up. And for a lot of people that ends up resulting in binge eating, where you just, you feel like you need to get everything in, you absolutely lose control once you start.
So there’s restriction, there’s binge eating, purging. So a lot of people, when they hear purging, they think of vomiting, which is absolutely something we see all the time. And purging is really any form of compensatory behavior to, you know, quote, unquote, “make up for eating.” So I’m trying to stay away from diagnostic labels cause we can really just talk about the behaviors without talking about labels, but this is really characteristic in bulimia nervosa. It can also be things like exercise, which is something that takes a lot of parents by surprise. They’re like, “Oh, my kid just likes going for a walk after eating.” And then with some thought, they’re like, “Oh, they go for a three hour run after every single meal,” like maybe there’s something there. So I will say these compensatory behaviors, all of these behaviors can be tricky to identify and a little bit sneaky, but purging in particular can superficially, like it can either not be existent to the family or it seems like an okay behavior, but anything where you feel like you need to make up for the eating or you need to earn that eating that’s really where purging becomes problematic. And it can also take the form of certain over-the-counter medications, right, where it’s not uncommon, unfortunately, for my patients to be taking things like laxatives or other sort of over the counter supplements that they find on Amazon and whatnot that say they will kind of make you pee a lot, make you poop a lot, but it’s really like, they want to get rid of the actual food in their system, so to speak. So we have restriction, we have binge eating, we have purging, and a behavior that can absolutely be normative and can absolutely fall in the space of disordered eating is picky eating. So to your point about, you know, people with autoimmune diseases for people with little kids, everyone has had this experience of like, “Oh my gosh, my kid will only eat this brand of crackers. They will only eat these types of foods.” There is nothing inherently wrong with that. When it gets to the point where we become so picky that we can only eat at home because it is not safe to eat out in the world. When it becomes so picky that we’re only eating three, four or five different types of foods, that becomes a problem. I often see it with my young adult clients that if you’re so picky that you can’t eat dorm food, like, you’re unable to actually participate in the college experience because this is a barrier. So this is where the impairment piece comes in and why all of these behaviors connected with some sort of impairment in their life is key. Because being picky, not liking broccoli, not liking grilled chicken, not liking whatever, not inherently wrong. But when there’s a pattern that it becomes so picky that the variety is so limited that there might actually be, like, nutrient deficiencies, there might be some consequences for this, that’s where we definitely want to be paying more attention to that.
Cindy Lopez: What I hear you saying is there’s kind of normative behaviors, and there are more extreme behaviors. So, if you’re concerned about your child, your student, think about those things as you observe their behavior, what are the patterns? What are you seeing, and what’s extreme behavior? As you noted, Michael, the parent who said, “Oh my gosh, yeah, my child is running three hours after every meal,” like that’s a little extreme.
Let’s talk about age. Is there a typical age range that’s impacted around disordered eating?
Michael Manzano: So yes and no. So I think my short answer is eating disorders affect people of all ages. Unfortunately, they can happen very early in life, particularly with respect to picky eating, and we see these even in older adults. So that’s all to say, short answer is, eating disorders can affect anyone. In general, we do tend to see an onset in the kind of adolescent, young adulthood years. There are obviously exceptions to that. And being a child-adolescent person, I got into this space exactly because this is typically the age of onset where we see things like anorexia nervosa start to bud up, bulimia nervosa, binge eating behaviors. There’s a diagnostic label for kind of severe picky eating, that’s ARFID, so Avoidant Restrictive Food Intake Disorder. And I typically see that age of onset earlier in some time during their youth, so to speak. And it is absolutely the case for all of those conditions where I’ve seen the age of onset more in the age twenties and thirties. So that’s all to say, again, it can affect anyone, and we do tend to see some signs during that kind of adolescent young adult period for sure.
Cindy Lopez: So, is there more evidence of disordered eating now then there was previously? And if there is, why do you think that is?
Michael Manzano: So it’s a fantastic question, and it’s a loaded question. So I think some of it is an artifact of just broad strokes as a society, especially in Western culture, we on the whole have become more kind of accepting and more just aware that mental health is even a thing to begin with. And eating disorders absolutely fall under that realm of psychiatric conditions. So I think part of it is there’s more openness to talking about it. So people are able to be more honest about their experience and be honest if they’re struggling with feeling like they need to engage in compensatory behaviors or restriction or this, that or the other.
I think related specifically to eating as someone who’s been in the field now for almost a decade, which was interesting to reflect upon even before this conversation, is a lot of the stigma specifically around eating disorders it is still there, and there are still a lot of misconceptions around eating disorders, but on the whole, the education regarding the non-discriminant nature of eating disorder, so the fact that eating disorders affect everyone, regardless of your age, regardless of your gender, regardless of your socioeconomic status, where you live, it can affect anyone, which I think has made the net with which we throw out these questions more broad.
So I think before a lot of, you know, physicians tend to be the people that interact with kids on the whole, because they have well child visits, things like that. They might’ve only thought to ask follow up questions about disordered eating to the 15-year old white girl who is living in a smaller body, who is losing weight, like for them, okay, some signals might be going off, I’m going to ask some follow up questions, but for these things like binge eating and picky eating before they used to just happen. And they’d be like, “Oh, just keep living your life,” so to speak. And now there’s more awareness that that might be a problem, that might be something that is absolutely within the medical psychiatric realm. So there’s more openness to talking about that.
And less of a qualified answer is, post COVID, I think we are absolutely seeing an objective increase in the experiences, in the incidences of disordered eating and eating disorders, because if nothing else, COVID was just this remarkable stressor that everyone had to experience. So as with anything, stress, these kind of big triggers can do that. They can just trigger these underlying conditions. So I think some of it is, it was always there and now we’re more aware of it and more open to talking about it. And some of it is absolutely, the actual rates, the actual incidences of these behaviors of these disorders is increasing.
Cindy Lopez: So thinking about all that, how is it that eating disorders develop in kids?
Michael Manzano: Eating disorders have a very strong neurobiological underpinning, which is a complicated way of saying these are brain based disorders. There are neurobiological reasons that these disorders kind of manifest. I say that because a lot of people when they think of eating concerns, particularly with kids, they tend to place a lot of blame on parents or a lot of blame on society. And certainly there are societal issues that need to be addressed, certainly there are parental environments which might not be particularly validating of a child’s experience. And these are neurobiological conditions, right? These have a very clear biological component. So I think that’s one of the reasons they develop is there’s this predisposition to biologically developing that, and you can see that in the neuroscience space. Dr. Walter Kay has done a lot of work in that and in the genetic space, Dr. Cynthia Bulick is really a pioneer in exploring the genetic underpinnings of these eating disorders, which, the punchline is, there are pretty strong genetic components. It can depend on the condition, but there is something there. So that’s all to say there’s underlying conditions. And I think why I brought up COVID, is there’s this neurobiological underpinning and then there are these stressors, these triggers that allow that neurobiological underpinning to really manifest in the context of eating behaviors and body image disturbances, things like that. So it really develops as this intersection of, there’s usually some sort of underlying biological component, and there’s usually some trigger, whether that be a change in family structure, whether that be some just important life transition, whether that be a shared stressor of COVID, or it could be unfortunately things like body focused comments. I’ve heard it where families make well intentioned comments about their teen’s body when they’re on vacation, or they’re getting ready for a wedding and they need to, you know, quote, “fit into a dress” or this, that or the other, or at school the PE teacher you know, they think they’re being helpful, but they make a comment about someone’s stomach. Those are the type of triggers, which again, it’s not necessarily those people’s fault that this condition happened, but that is one of the things that pushed them over the edge, so to speak.
Cindy Lopez: Yeah. It’s interesting that you say it’s a brain based disorder, cause I had never connected that. Totally makes sense. Is there also an issue of control in this process?
Michael Manzano: Great question. Absolutely. And I think that’s the other piece. When we think about stressors, when we think about these triggers, when we think about the shared stressor of COVID, that was a space where we had no control, like literally no control. We didn’t have control over whether we could go into certain buildings or things like that. So it’s a level of taking our control, which most of us have not experienced in our lifetime. So we can see in the context specifically of eating disorders, focusing that control somewhere, and here that could be on eating, on movement, on anything else, it gives us some sort of, like, safety, some sort of comfort to know that we’re in control of something. So that control, that need for control can occur on a conscious level. And I’ve had patients say, “I have so much chaos in my life, this is something that I can control. This is something that I can really focus my attention on.” It can also happen on an unconscious level, but I think there is this absolute, that control is a piece of it for, for some people, not for all and that kind of conscious or unconscious need from control. Even that has a biological underpinning. So that’s where we tend to see certain clusters of behaviors tend to cluster with these eating disorder behaviors and that’s where the kind of transdiagnostic, that’s a fancy way of saying things that cut across disorders–control is one of those things. Control cuts across disorders, and it can absolutely be a part of eating disorders. Particularly, we talk about control a lot in the context of restrictive eating disorders, where, for example, in the context of anorexia nervosa, there is an entire treatment that’s starting to be explored called Radically Open DBT that is really trying to get people to be more flexible in the way they’re thinking because this rigidity, because this need to control things, has become problematic. So it is absolutely there for some people, not for others, and that’s where eating disorders can just look so many different ways.
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Cindy Lopez: So thinking about how eating disorders develop, so now we understand a little bit more about how they’re brain based, and the kinds of things that can trigger some disordered eating. What behaviors might parents, caregivers or others observe in youth that might raise red flags, so to speak?
Michael Manzano: So I think bottom line, if your child’s attention to food or their body image is taking up a notable amount of time or causing them significant distress, get help. So if you see that the focus on the body, the focus on the food is getting in the way of your child’s life, talk to your pediatrician, talk to someone.
So I think the specific things to look out for: isolation is one I hear a lot from families where I work primarily with adolescents, so it’s not uncommon that parents will be like, their teen just wanted to eat lunch in their room, they wanted to eat breakfast in their room, they just like to be by themself. I don’t think it’s a problem, they just eat dinner by themself. And it’s true, that can absolutely be a normative behavior, right? And particularly if it’s an uncharacteristic change in your teen, if as a family, you did have a lot of family meals and then all of a sudden they want to eat in their room, and they don’t want to eat what everyone else is eating. Eating disorders thrive on isolation. They thrive on being able to separate people from others because other people are going to support people. So eating disorders don’t want that. So isolation can be something to look out for, particularly in the context of isolating during meals, during snacks, things like that.
Overt weight loss is not something that is necessarily characteristic of all eating disorders, but particularly in the context of anorexia nervosa, and ARFID, again, Avoidant Restrictive Food Intake Disorder, if there’s notable weight loss from the restriction, that is absolutely something to keep in mind.
Weight is naturally meant to fluctuate, so a drop of a pound or two doesn’t mean you need to sound the alarm and drop everything, but if you’re noticing like this is a pattern that like I think they’re just eating typically, but they’re losing like a pound a week, some of these younger kids don’t have a lot of weight to lose, so them losing five, ten pounds over the course of a couple months is absolutely serious. So isolation, unexplained weight loss. Another thing, particularly in the context of compensatory behaviors or purging can be frequent visits to the bathroom, right around or right after meals. So if your teen is always eating with you, but then they disappear for 30 minutes, an hour after every single meal and you’re noticing this pattern, just, you know, get curious about what might be going on there cause that’s where sometimes teens are going into the bathroom to purge. I’ve also heard it where teens will go into their room and exercise for 30 minutes because they feel like they need to earn the food that they just ate. So I think isolation, unexplained weight loss and going to the bathroom or just isolating, particularly right after a meal are all things to be looking out for.
Cindy Lopez: Michael, you just said something that left an impression and that is “Get curious.” As a parent, a caregiver might be seeing some of these behaviors, isolating, weight loss, running to the bathroom before or after a meal. How can parents and caregivers get curious about this, like, should they talk to their kids about it? What does that look like?
Michael Manzano: So it’ll absolutely depend on the age and kind of developmental abilities of the kid, where, you know, asking a younger child might not get you anywhere, but particularly for adolescents, absolutely starting those conversations because parents know their kids better than anyone else. So that’s my stock phrase to parents is, “Be curious.” And one of the ways to do that is first off timing is everything, right. So in the middle of a teen engaging in a behavior is probably not the moment to put them on the spot about that sort of thing. So if they’re going off to their room and you can see they’re already frustrated or, you know, mad at you, grumbly, huffing and puffing as with anything, when any of us are upset, when any of us are doing something else, if someone asks us a question we are not ready to hear, we’re not going to respond particularly well. So when I say timing is everything, getting curious at the right time. So maybe it’s not right when you notice it, but you’ve noticed this pattern over two, three, four weeks. And then it’s nighttime, maybe, you know, between eight and nine o’clock as a family, you guys watch TV together or something. Maybe before that you sit with them at the dining table or on the couch or wherever. And you’re like, “Hey, I’ve noticed this, that, or the other. What’s going on for you?” And really coming from this place of concern and not from this place of feeling like it’s punitive, like they’re doing something wrong. Obviously, if they’re engaging in unsafe behaviors, we want to stop those behaviors, but, you know, just telling a kid, “Stop it!” is not the way it’s always going to work. Otherwise I wouldn’t have a job! So, really making sure that you’re getting curious at the right times.
So if your kid is someone who at the beginning of the day, they’re fresher, they have more energy, maybe on the car ride to school, especially if it’s just the two of you, it’s like one caregiver and the teen, you’ve noticed this stuff over a month, them not having to look you in the eyes makes the conversation seem more approachable, be like, “Hey, sweetie, I noticed that, you know, you haven’t been eating dinner with us, and I always kind of thought dinner time was like a fun time for all of us to see each other because now we’re all so busy, so like, what’s going on? Like, is there a reason you’re wanting to do that?” Again, you’re not putting judgment on it. You’re not doing anything other than I’m just trying to figure out what’s going on because oftentimes that’s what teens want. With one hand, they’re like, putting the hand up, being like, stop, stay away from me, I can do everything on my own, but on the other hand, they’re like gently calling you over and like, “I really do need help.” So this is one of those spaces where it can absolutely be uncomfortable for parents to bring it up. And I have seen it more times than not where that’s what the teen wants. They want someone to, to express their concern and to care.
Cindy Lopez: Many of our experts who have been on podcast episodes with us have said, “Listen, just listen,” more than trying to even ask questions or trying to tell them what you think they need to do, really listen to them. And I think that’s something for our listeners just to remember in general about your teens.
So if I’m a parent and I ask my son a question like you just said, “Hey, I was thinking that, you know, our evening dinners are a great time for us to touch base, and they’ve been kind of fun in the past, but I’ve noticed that you’re opting out, what’s going on?” What if you know as a parent there is something going on, but the child is not talking about it?
Michael Manzano: It’s a great question. And I think like with anything else, you know, parents have intuition, parents have that gut of like, uh, something seems off, and unfortunately if someone’s not ready, none of us can force someone to be ready to have that conversation. So to your point about listening, I absolutely want to reinforce that that is one of the most important things that in the context of throwing out these questions, it’s often more important to listen, then exactly the specific question that you asked. And something I will tell parents, explicitly when I’m trying to encourage them to have some of these conversations in this context or others is like counting to yourself in your head before you give a follow up question. It can feel like forever in the moment. And like, do not ask a follow up question until you’ve given at least 10 seconds for them to gather their thoughts and even have the opportunity to respond because sometimes it’s the case especially if the teen is not really sure if they’re really comfortable telling their parent, they’re going to need some time to just think about it of like, “What am I going to tell Mom, like, am I going to tell her a little bit of this?” And they might actively be trying to formulate their thoughts in their head, but you’re like, “Why aren’t you talking to me? I asked you a question.” And then they’re just going to completely shut down. So that point of listening is so critical. And they might not be fully transparent with you. I think this is the other really unfortunate part of eating disorders, particularly anorexia nervosa, is sometimes there’s really a lack of insight there. So they might not necessarily themselves be aware of how big of a problem it is, and that still gives you information. If you’re monitoring them and you’re like, okay, it looks like they’re wearing baggy clothes more, but I can tell that they’ve lost some weight and they’re isolating, like there’s something going on here sort of thing. And they’re not being honest with me. So that’s a clue for even if they’re not being forthcoming, that gives you information so that if you have to go to the primary care doc, if you have to go to their therapist, if you have to go to, you know, whoever, you’re like, not only am I thinking this is a problem, but I’ve asked them and they really don’t and that’s another reason I’m concerned.
Cindy Lopez: Yeah. So, are eating disorders lifelong? Is it like lifelong management, or can they be cured?
Michael Manzano: It’s a great question. And my short answer is it can be a little bit of both. I think my more helpful answer is, just like I want to impress that eating disorders have such a strong neurobiological component. I also want to stress that eating disorders are treatable. There is sometimes this misconception out there that, you know, once you have an eating disorder, you’re going to have it forever. And certainly that is the case for some people. I have seen particularly in the adult space there are people who have been struggling with anorexia or bulimia or binge eating disorder for decades of their life. And it really is this lifetime management of the disorder. I have also absolutely seen in the adolescent young adult space that this behavior happens, especially if we catch it early, we engage in some sort of evidence-based treatment, whether that be family based treatment or enhanced cognitive behavioral therapy.
So, I think all of that is to say, eating disorders can be chronic, and that is precisely why early intervention is so, so, so critical, because the longer these behaviors go on, the harder they are going to be to challenge. So they unfortunately can be chronic and lifelong for some people. And that is why I stress so much of when you see something, say something and get early intervention because it can absolutely be the case where this gets treated and it does get quote unquote, “cured.” And it’s not something that’s front of mind for them on a day to day basis.
Cindy Lopez: You know, most of us think eating disorders, you know, typically it’s going to be anorexia, bulimia, and we probably think about those kinds of conditions more likely happening with girls, but is that really the case? Does it affect girls more than boys?
Michael Manzano: So, especially in the case of anorexia nervosa and bulimia nervosa it is the case that we do see higher incidence rates in females over and above males. And all of these conditions occur in people of every and any gender identity. So while yes, it’s true that on the whole, on a population level, anorexia nervosa affects more girls than boys. I’ve worked in now two medical stabilization units for adolescent eating disorders. And there are times when half of the unit is filled with boys, because unfortunately, because people can have these stereotypes of this only affects girls, this only affects white rich girls, affluent girls that sometimes our boys and our gender diverse youth more broadly, they get sicker because nobody identified it. It’s like, oh, you can’t have this. So when they show up to the emergency room or to a higher level of care, they’re actually more severe. So I think the point I want to impress there is: it can affect anyone and everyone across the gender spectrum. Notably, just like we see a higher incidence rates of psychological concern, psychiatric conditions in gender diverse youth. We also see higher rates of disordered eating, but regardless of whether talking about gender diverse youth or cisgender males. It absolutely affects them and I’ve seen remarkably sick kids that fit that kind of criteria of being a boy or, trans or non-binary youth. So it can absolutely on the whole affect girls more. And that’s precisely one of the reasons I’m saying in the space is because these disorders affect boys. They affect men, they affect trans men, they affect people that identify as nonbinary and everyone, again, across this gender spectrum. So, so yes. Long-winded answer, but short answer is, you know, it’s absolutely the case that it affects girls more, and it still bottom line affects everyone.
Cindy Lopez: We’ve talked a lot about behavior and things that our listeners might be looking for or seeing in their youth, in their students, in their kids. Let’s switch gears for a minute and talk about preventive measures. So, say I’m not seeing any of this in my kids and I want to make sure this does not become an issue in the future. What preventive measures can be taken to support youth around eating?
Michael Manzano: Very much related to eating is this concept of body image, and I think even just our relationship to like body image, what it’s supposed to mean, I think a concept that has really stuck with me of late, working in the eating disorder space is this idea of body neutrality, right? So most people, especially, you know, in 2024, heard about body positivity, right? Like learning to love yourself and appreciate all the wonderful aspects of our body, and I am not discrediting that at all. I think for so many people that is so empowering. And if that is the case for you, more power to you. I have also seen the case that this idea of body neutrality really speaks to people more. And it’s really this idea that maybe our body is not some object to be admired and criticized, but it is this vessel that just houses us and our brain, and it allows us to like navigate this world. Just appreciating the functional aspects of our body. And maybe it’s not for everyone else to judge. So this idea that, it’s not necessarily about I need to love every aspect of myself, which if that works for you, great, but it might also be that you know, maybe my body isn’t something to be judged, and I can start by not judging it myself sort of thing. So I think for those interested, exploring this idea of body neutrality can be really helpful, and related to that concept can be the way parents are modeling, the way they talk about their eating behaviors and the way they talk about their body, right? So whether we like it or not, kids, teens, youth of all ages are sponges and they know and they hear what is going on around them.
So if they have a parent that is in the mirror, pinching their stomach, talking about how they need to lose the baby weight, or if they see a parent going shopping for a bathing suit, calling themselves some horrible, awful name, because they’re not happy with their body, whether we like it or not, we’re modeling for our children, for these youth that that’s an okay way of navigating the world. And again, it’s not about blaming parents. We live in a society where people focus on the external, people focus on the aesthetic all the time, and it’s probably not the path that most parents want their children to go down. Most parents do not want their kids to have the same body image issues that they have of not liking their stomach, or not liking their arms, or not liking their face, or this, that, or the other.
I think the other punchline here is, parents really modeling the way they want their children to be eating and to be talking about their body. So parents modeling talking about themselves in a kind, neutral way. Parents modeling that regular eating is important, that, like, I have to eat every few hours because my body needs it, sort of thing.
So it’s one of those things where I really will encourage parents don’t do the Do as I say and not as I do, space. So if you have a teen who is struggling with restrictive eating, and you yourself are doing time restrictive eating, and you’re only eating within a six hour window, that might not be modeling the behaviors you really want to see in your teen. So really trying to be the role model that you want your teen to see.
Cindy Lopez: Michael, before we go, what final advice do you want to leave with our listeners?
Michael Manzano: Well, first I’ll say, I also very much enjoyed this conversation and I hope that listeners have found it helpful. There’s a couple of things that stand out to me. So the first is really related to that point we just talked about in terms of body neutrality and parents modeling the way they want their youth to go about the world, moving away from body focused commentary whenever possible. So not having your child’s nickname be some aspect of their body sort of thing, which again, culturally can be very normative, inherently, not necessarily good or bad and focusing our attention on kids’ bodies. can have a lot of unintended consequences. And I bring that up first because I’ve heard it from so many teens. We talk about social media and societal pressures and this, that or the other. More often than not, I’ve heard kids and teens talk about comments from their siblings, from their parents, from their aunt, from their grandmother, because those comments from people that we care about sting the most and can be just so impactful. So really focusing away from body focused aesthetic commentary about kids bodies whenever possible, I think is broad strokes what I would love to see in society and parents start doing that in their own homes. And I think related to that and just bigger picture is don’t turn a blind eye because like I said, unfortunately, there are adults who have struggled with eating concerns for decades of their life, and that does not need to be your child’s story.
So early identification is so key and parents remembering that you are always going to be your child’s best and strongest advocate. So while I’ll always recommend that if you have concerns, go to your primary care doctor, go to your therapist, go to a trusted professional. Absolutely, there are times you’re going to go to your primary care doctor and they’re going to be like, “Oh, they’re fine.” And again, I’ve seen that happen so many times where they’re like, “Oh, I’m not concerned. Just make sure you’re eating three meals, a couple of snacks. I’ll see you back in a couple of months.” And they don’t make it to a couple of months because they end up in the hospital talking to me. So I think that’s all to say, trust your gut. If you notice something’s wrong, follow up with someone. And if someone’s saying, not a big deal. And you’re still having this feeling like something’s wrong, like they’re losing weight and we don’t know why, like they’re being so secretive or I can see like the food from their lunch and breakfast, like in the trash, trust your gut, trust the data, trust what you see in front of you and continue to advocate for your children. Because unfortunately, while the landscape is changing and there are so many professionals that can help now there are unfortunately a lot of people in the medical space, in the psychological space, that really are not informed about eating disorders. So, if you feel like something is wrong, making sure you’re getting the support you need. So bring it up, and if you’re again, still feel like you’re not being heard, continue to fight, which I hate that parents have put in the position that they have to feel like they’re fighting the system. And that’s your job, right? You don’t pick a thankless job for the thanks. So parents continue to just push and fight for your kids because they deserve it and giving up is just not an option. So just fight for your kids when you feel like something’s off because parents have a gut instinct for a reason.
Cindy Lopez: Just a few things that I’m remembering from our conversation as we wrap up. One is get curious, love that. And as parents it’s really good advice. Listen, try to listen more than you talk, and then trust your gut, especially as we consider this disordered eating and what’s happening with your child around food and body image and all that.
So thank you, Michael. Thank you to our listeners. And to our listeners, if you need some help, please feel free to reach out to us at chconline.org. You can reach our care team at careteam@chconline.org. And you can also call at 650-688-3625. Thank you all for joining us today. Visit us online at podcasts.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.
