Your Child’s Health Eating Disorders – Stanford Children’s Health

Your Child’s Health Eating Disorders – Stanford Children’s Health

March 9, 2020 1 By Kody Olson


So we’re really honored
to have Dr. Kathleen Kara Fitzpatrick here tonight. She is the Director of
Outpatient Eating Disorder Clinical Services at
Stanford Children’s Health and is a Clinical Assistant
Professor of Psychiatry in Behavioral Sciences. In real life, you
can find her working on clinical treatments of
eating disorders, researching treatment outcomes, working
with patients and families in the outpatient setting,
or teaching students. Her research interests focus
on novel treatment development and neuroscience informed
approaches to care. She loves animals, kids,
and feeding people. She is a terrific person
and an awesome speaker. And we’re really in
for a treat tonight. Thank you. Just want to make sure
Sandy has my volume on. Perfect. I’m loud. I actually really don’t
need a microphone. [LAUGHTER] But what I wanted to
do today is something a little bit different. And it’s really something
that my colleagues and I have been thinking about
for a long period of time. And that is that, for the most
part when we meet with families and when we meet people for
the first time struggling with eating disorders,
we feel like we often have to overcome certain myths
over and over and over again. And these are ideas that
we have about eating disorders and eating
disorder treatment and what exactly that entails. And hence, the Mythbusters
Eating Disorder Addition. Uh-oh. How do I move forward, Pablo? It should work. It should work. Or not. I can do it off
the top of my head. So why are there so many
myths about eating disorders? I think in part, it’s because
eating disorder research, treatment, training has
changed dramatically in the last 15 years. We’ve really gone from
having an understanding of eating disorders as
an individual disorder, as a psychiatric illness
that people don’t necessarily get better from, and we’ve
really turned the corner with that toward completely
different approaches that we might use. We’ve changed not just
our knowledge base about genetics and
environmental factors, as well as age and
developmental factors, but we’ve also changed
our understanding of– [CLEARS THROAT] Excuse me– the ways in which
these all come together– ha, ha– in order to change
the landscape. And one of the biggest
changes is actually in what the eating
disorders are. So how many people here
have heard of ARFID? Yeah. All right. So only about a third of
you raised your hands. How many people here have
heard of anorexia or anorexia nervosa? So you can see that there
are some real differences in the kind of knowledge
that people have. So when I’m talking about
the eating disorders, what I’m really going to be talking
about and focusing on tonight is anorexia nervosa, which
is characterized by a failure to maintain a healthy weight,
along with cognitive symptoms which are incredibly important
for this diagnosis, where people are tremendously
afraid of gaining weight and where body image
impacts the sense of self. What I mean by that is most
of us try to look good, right? I pulled out a
suit for you guys. That’s got to be
saying something. I even put on makeup, right? We try to dress
ourselves in ways that we feel both
comfortable with and feel reasonably attractive. But what we do is no matter
how we feel about our bodies, if we’re healthy,
we still go out and do things with our bodies. No matter how I feel about,
say, cellulite on my thighs, I still go swimming or I
still go to work every day. Body image unnaturally
influencing your ability to get out and do things is
part of anorexia nervosa. Bulimia nervosa is often
thought of as a disorder where people purge or throw up. And actually synonymously think
that purging and throwing up are the same thing
when actually there are multiple different
ways to purge. The main difference actually
between anorexia and bulimia is how much someone
weighs, where people with anorexia
nervosa are below weight or have fallen from
a higher weight to a weight that’s much lower
than their expected weight, while individuals
with bulimia nervosa are at or above a
normal weight actually, and engage in binging
and purging behaviors. So binging gets a bad
rap in our society. People talk about binging
and binging on everything. My son and I are currently
binge-watching The Office. And even then I’m not always
really sure when does it– how many episodes
constitutes a binge? And how many is just, hey,
they don’t have commercials and they start automatically
if you forget to do anything. I think that’s how I get conned
into watching as many as I do. In eating disorder terms, we
actually are pretty specific. Binge eating and a binge can
be objective or subjective. An objective binge
eating episode is where an individual– and this is very
important– loses control over their eating. They feel that they
can’t stop themselves, or they’re unable to shape their
behavior around food and eating and in an objective
binge eating episode, eat what we would
consider a gross– not gross as in disgusting,
but gross as in large amount of food in a very
short period of time– often 3,000 to 5,000
calories in 15 to 20 minutes. That would generally be an
accounting of a large binge. But you can also have
subjective binges. And that’s what
most of us have when we’re thinking about
binging or when we talk about it
in society, which is that same feeling
of loss of control. But the amount that you
eat might not actually be a large amount. In fact, it may be
quite a small amount. It may be even considered
an inadequate amount. But people can still feel that
loss of control that happens. And when you have
bulimia, you follow that with what we call
maladaptive or inappropriate compensatory behaviors,
which is just a fancy way of saying doing
something that you really shouldn’t do in order
to get rid of that food or to relieve the anxiety
around having eaten that food. Generally speaking,
that is thought of to be self-induced
vomiting, but can also be things like
excessively exercising or burning off
calories without ever engaging in any kind
of dieting behavior. It can mean fasting– simply not eating. So you might binge and then
fast for 24 hours and eat again. And if that sounds strangely
like the kinds of things that you hear in the
news that people actually suggest you do and have even
made the rather gross and kind of scary assumption
that doing so will actually
lengthen your life, that would be just
straight up wrong. But so things like
fasts and cleanses can also be part
of bulimia nervosa. And binge eating
is the same thing, but without the inappropriate
compensatory behaviors. ARFID, the new eating
disorder diagnosis, is Avoidant or Restrictive
Food Intake Disorder– possibly the least glamorous
name you will ever– I know. It’s not even descriptive. Like when I tell it
to you, you’re like, so what does that exactly mean? Can really be characterized
as two things– extreme picky eating. A lifetime habit of really
having very narrow taste preferences and
real difficulties in engaging around food. What’s really interesting
is kids with ARFID can look a lot like kids and
adults with anorexia nervosa, but the differences
is kids with ARFID don’t have body image concerns. They’re not driven by the same
sense of their own physicality, and rather they’re driven a
little bit more by anxiety. They’re worried
sometimes about how a food is going to
taste, what it’s going to be like, whether
they’re going to like it. And so a subset
of kids with ARFID will actually have
eaten regularly, but had a choking, vomiting,
or nausea experience that has then made
them pull back from regular food and eating. And so there’s this sort of
lifelong extreme picky eating– and when we say extreme,
we really do mean extreme. Not sort of just the parents of
toddlers who are annoyed that one day they ate a banana
and the next day they don’t. Kids with ARFID may
give up eating bananas and never eat
another banana again. These are also kids who may have
choking or vomiting phobias. So it can be induced by things. And so they’re pulling
back from that. And then of course
the largest category of eating disorders
as we know them are the people who don’t fit
neatly in any of those boxes. And we’ve worked really
hard to decrease that. But I’m really going to focus
on the general eating disorders for today. So the things that I just
talked about up here. And unfortunately, this
doesn’t look as good as it looks on my
computer screen. But the kinds of things
that people talk about associated with eating
disorders are often caught up in ideas or cultural
norms that actually aren’t necessarily helpful when
thinking about what to do or how to diagnose
an eating disorder. So I talked about
bulimia and binge eating. This is one of my favorite
ways of thinking about ARFID. It says, what I thought
feeding kids was like and what it’s really like. It’s almost like the
kids biting back. And this is the other
thing that parents tend to be reminded of when they
think about it, because kids with ARFID disproportionately
prefer beige foods, they tend to be carboholics. And the kinds of foods that they
often have a really hard time with are fruits and
vegetables and things like that, which kind
of makes sense if you’re an extreme picky eater. Fruits and veggies don’t
taste the same way each time you have one, right? If anybody here has ever
bought a bag of baby carrots, there’s always that
one baby carrot that’s like white and
kind of crusty and freaky. [LAUGHTER] Or you get a container of
blueberries and most of them are good, but one of them is
that like, just super bitter, nasty blueberry. And then you’re
like, these things just don’t taste the same. And that consistency is
really important for our kids with ARFID. So truth or myth. You can look at someone
and tell that they have an eating disorder. You should be able to know
based on how they appear, whether they’re skinny
or they’re heavy what– not only if they have one,
but what type they have. What do you guys think? Yes. No. I’m hearing a lot nuh, no. No. Not at all. In fact, a majority
of people who fall into the category of
having an eating disorder have a healthy or above
healthy body weight. It is only in extreme cases
and fairly infrequent cases, such as anorexia nervosa
when we have not caught it until someone reaches an extreme
weight that people actually look very, very thin. People can actually
be a healthy weight and be catastrophically ill. And so what you can– you can’t tell by
looking at someone. And even if someone has gained
weight from a low weight to a healthier
weight range does not mean that they
are not still ill. In fact, oftentimes, especially
with anorexia nervosa, as people gain weight,
they become more psychologically distressed. But it makes sense in
that context, right? We’ve removed the
strategy that’s been helping maintain their
mood and emotion regulation– restrictive eating–
and replaced it with behaviors that
are difficult for them, without having the time
to build up some of those coping skills and strategies. And so you can’t tell
by looking at someone. And weight is a very
poor predictor of how ill or who is ill. This is one that is definitely
pervasive in our society. And I think it’s probably
pervasive as either a truth or a myth because
we are very much an individualistic society. And so I put these two
together because they really do go together. Are families dangerous? Do they cause eating disorders? Can they be problematic? Maybe. But in our understanding of
whether or not families cause eating disorders and
whether treatment should be individually focused, the
answer to both of those groups is no. Why? What we found in the previous
research, decades of research, authors would
publish things saying that families of individuals
with eating disorders are overly enmeshed. They’re too connected
to each other, right? There’s no independence. These were also called
psychosomatic families, meaning that they were
families who communicated well around medical challenges, and
that over-controlling mothers– because it’s always
the mother’s, right? It’s like the dads
get off really easily, but over-controlling
mothers would result in eating disorder behaviors. In all of the research that’s
been done in about the last 30 years on that, we
can say definitively that that is not true. Now can families be challenging? Absolutely. I have one of my own–
both the one I came from and the one I’m building. Families are challenging, right? You may, as a parent,
or you may have been parented in a way that
made certain challenges more difficult. You may have been given ideas
about food and eating and body image, shape, and weight
that aren’t useful to you and may actually be dangerous. But that doesn’t actually
mean that families cause eating disorders. We now know that there is
a very resounding genetic and environmental influence
that are critically important for the development
of eating disorder behaviors. And it’s not genetics alone. And it’s not environment alone. And it’s actually
probably not even a choice in terms
of how things start, but rather a constellation
of these factors. In addition, we
know from working with children in
adolescence at least, that in children and
adolescence family therapy and
family-based treatment is actually the best way to help
bring people back to health. So while families may
have their difficulties, and certainly we all do, working
with those in a treatment context can actually be
tremendously beneficial, specifically because if
somebody is giving you messages that hold your
eating disorder in place or that make it harder
to reach recovery, don’t we want to help
them have the skills in order to begin
to overturn that? And we know that family
values around food and eating are actually deeply entrenched. Do you guys know that food is
the first independent skill we give kids? Before they can walk,
before they can talk, before they can even hold
their heads up straight, we’re allowing them– well,
not really allowing them. They choose how much
they’re going to eat and when they’re done. And anybody who’s ever nursed
a baby has had to live with the anxiety of having absolutely
no idea how much this kid has had to eat and having to
trust that that’s going OK, or to get help if they don’t. Toddlers may choose their
food even though they can’t– you would never trust
them to drive a car. You would never trust
them to actually really make any reasonable
or logical decisions. If anybody’s hung out with
any toddlers recently, that should be deeply
confirmed in your brain. And yet we ask them
what they’d like to eat. And then we serve it to
them as though that’s a normal type of interaction. And so we know that families
have really strong value systems around food and eating. And intervening in those
and helping families move away from illness
and toward things that maintain health is
actually critically important. Once an eating
disorder is in place, families have much
knowledge to bring about what helps people
stay well or get well or what wellness would
look like for them, but the way in which you
need to actually eat in order to overcome an
eating disorder may be something that has to
be learned in that family. So for example, anyone know
what one of the best strategies is for overcoming
bulimia and binge eating and relationship to food? Told you I wasn’t going to
pick specifically on anybody, but anybody know? Maudsley method. What’s that? The Maudsley method. That’s a treatment. The Maudsley method. But actually simply
normalizing your food intake– eating regular meals. In about 30% of
cases, just simply implementing regular
meals and snacks can help reduce
symptoms significantly. Not necessarily getting a cure,
but three meals and two snacks for children and adolescents–
sometimes three meals and three snacks, if you’re more active– is actually vitally important
for overcoming eating disorder behaviors. Kind of seems a little
bit counter-intuitive that it should be so
easy to just eat, right? But it’s not so easy
for those of us who work with eating disorder patients. That’s actually one of
the hardest things to do. Eating disorders
are health crises that disrupt personal
and familial functioning. True or false, guys? You’re like, that’s
why we came here. True. You knew it was
going to be true. I haven’t put up a true yet. Or you thought they were
all going to be false. Messing with you a little bit. I think one of the things
that I know my colleagues and I would love for
people to walk away with is this information. Eating disorders are the
most deadly mental illness that you can have. Anorexia, in particular
kills more people than depression
and schizophrenia combined when it is left
to be a long-term disorder. It can become a chronic
disorder, as they all can. And so not only is
intervention important, recovery is critical. We kinds of things can you
struggle with as a result of an eating disorder? Well, your body requires
food and nutrition. And whether you’re getting too
much of it or too little of it, or you’re getting rid of it
before your body can use it, it affects absolutely every
single cell in your body. Things that we know. Individuals presenting
with eating disorders, and this is true for both
anorexia and bulimia, can actually slow
their heart rates. They can actually what we
call bradycardic, up to and including needs
for hospitalization. And for both
anorexia and bulimia, increased risk of
maladaptive cardiac events or significant
cardiac events are one of the major outcomes
that we’re trying to reverse. And this can happen
from different pathways. When people are purging up
or vomiting up their food, they’re actually purging
up their potassium storage. You store potassium
in your stomach. And when you purge
that up, potassium– if you guys can
really like kind of go back to 10th grade
bio class right now. Everybody wants to go back
to 10th grade bio class, I’m sure, especially
on a Thursday night. You might remember potassium is
one of the things that actually makes your muscles twitch. It’s vital in cellular
communication. And so these eating disorders
can actually catastrophically impact the body. We also know that it
affects brain processing– not just what you are
thinking, cognitive content, but actually cognitive process– how your brain
actually develops, those changes that occur
during adolescence, and the aspects of cognitive
development that get set into place. And so we know that
these disorders can be incredibly disruptive. Bone health and
reproductive health are also at critical
risk in the face of all of the eating disorders. And you might be saying,
well, wait a minute– how does that
affect binge eating? How does binge eating
affect these risk factors? As much as I love food
and feeding people, eating too much in just
one short period of time actually puts tremendous
stress on the body. And we know that with
excessive binge eating, we can end up with things
like high cholesterol. We can end up with
aspects of heart disease. We can end up with risks for
catastrophic and fast weight gain. And that’s particularly
problematic for women and their hormonal systems,
where our fat cells are what produce estrogen, and
when estrogen is produced in too much or too
high of quantities, we can get physical
side effects. Binge eating increases your
risk for metabolic syndrome, which is a combination of
typically elevated blood sugar levels or pre-diabetes,
as well as high blood pressure and high cholesterol,
or dyslipidemia changes. So low good cholesterol
and high bad cholesterol. And so we know
that it’s not just the absence of food or
dysregulation of food. It can also be too
much of a good thing. And when we recognize that,
we have to also recognize that because you
can’t tell who’s ill, I can’t look at someone
and know this person needs to be in the hospital. In fact, after more than
a decade of doing my job, I am so bad at that that I’m
actually worse than chance. You would be better
off flipping a coin to determine who should go into
the hospital than to ask me. And that’s why we work so
closely with the medical team here is because a
true understanding of the physiological as well as
psychological and developmental impacts of eating disorders
is critical for helping overcome them. I think you guys already
kind of know this, because I sort of got a
little bit ahead of myself and I got all excited about the
fact that eating disorders– well, maybe– are
not choices, but are actually biological
illnesses with genetic as well as individual factors. Come on, guys. You all know the answer. True. But what do I mean
when I say that? We know that you can inherit
a genetic risk for developing anorexia and bulimia. With bulimia, it’s even less
clear than it is in anorexia. But having a family member
with an eating disorder does put you at greater
risk, but it does not confer direct risk. In other words,
you need something to pull that trigger
on your genetic risk. And the genetic risk
is not one single gene. It’s multiple genes. So what are we
really looking at? Well, we know that kids
who develop anorexia tend to be a little bit
more perfectionistic. They tend to be
more conscientious. In other words, they
like to do things right. They like to do things well. And I got to tell you, as
a parent, that’s fantastic. Who doesn’t want a kid who
wants to do things well or who’s driven? But these same sort of
rule-based behaviors can sometimes become
more catastrophic when they become related
to things like how to eat. We also know that
your genetic risk can have the trigger pulled by
activities that we almost all engage in– namely, dieting. And if we look at studies that
look at adolescent behavior around food and
eating, how many– or I’m trying to figure out how
to do this so you guys don’t feel picked on. How many of you, in your
lifetime as adolescents, skipped meals? Some of you guys are
like, nope, nope. I hear all the
time from the kids that I see with anorexia,
bulimia, and binge eating, I don’t have time for breakfast. I skipped breakfast. I don’t need breakfast. I’m not hungry for breakfast. If you have a healthy,
well-developing kid, you still want them
having breakfast. But if you have a kid
with an eating disorder, any meal skipping
is catastrophic. And that actually
increases the risk that those genes are
going to come into play, because your genes are not
like what you’re born with. They’re actually flipped on
and off by different behaviors and things that you engage in. The metaphor that was given
to me that I really love is you have to imagine your
genetic code like a room filled with pianos, and depending
on what’s happening, different keys on those
pianos are being played. So in people who are at
risk for eating disorder, even something as simple as
skipping meals or falling below that caloric threshold where
your energy intake is lower than your energy expenditure–
so you’re burning more than you’re taking in– can be enough to begin
to flip on aspects of that genetic
code that puts you at even greater risk
for an eating disorder. And that’s true even amongst
people who never intend to develop an eating disorder. We see so many
adolescents who start off and they think they’re doing
all of the right things. They want to eat clean. You guys heard this? Clean eating. To me, your food is clean
if it’s been washed. I’m hoping you’re not
eating carrots that you just pulled out of the ground. Well, and even
then, I’d probably prefer that to some other
things that you might be doing, like juice cleanses and fasts. We have a lot of information,
maybe too much information, about healthy eating. You can’t go online
without hearing that sugar is bad for you, but
carbs are also bad for you, but saturated fat
is terrible for you. What’s left? You can pretty much eat kale
and blueberries these days and feel like you’re
doing it right. These messages are typically
aimed at overweight, sedentary middle=aged people. In other words,
they’re aimed at me. They’re not aimed at
adolescents, who have far greater biological needs. And when I say adolescents,
I should be clear, I’m talking really up
until about age 25. So the good news, the takeaway
message, is that some of you might still be in
your adolescence. And if you’re not,
you’re closer to it than you thought you were. [LAUGHTER] But the fact is, is
because the body is still growing and changing
and developing until that period of time,
until about age 25 or 26, the biological need
for food and energy is far greater than it
is when you’re my age. I’m decomposing on the spot. I have hit my prime. And it is all
downhill from here. And so when you hear
things about like, I went on a 500
calorie diet, we know that that’s actually dreadfully
insufficient for children and adolescents. How dreadfully insufficient? Most need around 2,500 or
3,000 calories per day. 1,600 calories a day brings
kids into organ failure and starvation over time. That’s the number that we can
starve people with over time. So if you are
encouraging your kids to eat or know of kids who
are eating less than that and tracking their
calorie content, we know that the
ultimate outcome of that is going to be very dangerous–
changes in heart rate and blood pressure. The same thing happens
if people are engaging in purging or excessive eating. Worries that we might
have there would be things like 10 to 20
pounds of weight gain without a linear
height acceleration. In other words, you’re
not getting taller, you’re just gaining weight. That type of rapid weight
gain can actually be a signal that the body is not
only not processing food in the same way, but
may actually be having an inflammatory response. We see that in weight
clinic very often. And because I work all ends
of the spectrum, what I often see in my morbidly
obese patients and kids in families that I
work with is they’re eating the same amounts that my
kids with anorexia are eating. This group’s gaining
weight, and this group is catastrophic losing weight. What you put in
your body is not as important as making
sure that your body is getting what it needs. And as much as I think it
needs kale and blueberries, it needs a lot of
other things as well. Eating disorders are about
having or wanting control. Without a doubt,
this is the thing that I hear the most
often from family members, from kids themselves. So who wants to take a stab? Is this one true or
is this one false? It’s hard to say, right? So let me ask you guys–
how do you guys like having control over your life? Yeah? How many of you like picking
your own clothes to wear? Uh-huh. Choosing when you
shower or go to bed? Yeah. I’m still getting nods,
and you’re not nodding. I’m a little worried. [LAUGHTER] How many of you guys like
being able to kind of decide what you’re going to eat,
or where you’re going to go? Control freaks. You’re all control freaks. As people, we
exist and we thrive with consistency and structure. And I really want
to be quite clear that that’s different from
this sense of over-control. The idea that eating
disorders are about control is actually false. This one’s hard
for a lot of people because even people
who are struggling with an eating
disorder may say, well, I want to control my body. I want my body to
look a certain way. I want to feel a certain way. I’m not confident, or I don’t
feel good in this space. And when I don’t eat
or I eat too much or I purge after a
meal, I feel better. So I’ve got to ask you guys– how many people walk
through your day trying to make your life better? Yeah? People deliberately
move out of your way while you’re driving
on the freeway so you have a straight shot
to wherever you’re going? People make sure you’re happy
before they deliver news to you, or if they
give you bad news, they do something really awesome
to make up for it, right? No? So we’ve already decided that
you guys are control freaks. And now we’re adding to it
that other people don’t go out of their way to let
you get your way. These two things really
combine into an important thing about eating disorders. The development of
an eating disorder as often about wanting change. It’s about wanting
to feel different. And I’m using feel
instead of look differently, because
it’s really hard to change your physical
appearance too much. Like your nose is your
nose is your nose, and short of plastic surgery,
your nose– and a broken nose– your nose is your
nose is your nose. Well, your body is your body. And you can change your
weight to a certain degree, but you can’t actually usually
change your body habitus. And your body is driven
to maintain that. My body likes this weight. Now that it is this weight, it
would like to stay this weight, and it will do almost anything
in its power to do that. And that’s actually outside
of my psychological control. When we talk about
eating disorders being about control, what
we’re often really saying is these disordered
eating symptoms feel good to the person
who is engaging in them. And that has to be one of
the most challenging aspects of an eating disorder. Eating disorders, by and large,
are what we call egosyntonic. They feel good to have that’s
especially true of anorexia but it’s also true
of the behaviors that we see in binge
eating and bulimia nervosa. In other words, what I might
think about as the problem– eating too much, starving
yourself, purging behaviors, compulsive
or excessive exercise– people who are struggling
with an eating disorder look at as the cure
to what they are often struggling with, which are
feelings of incredible body dissatisfaction, maybe
feeling like they could be more confident, they
could have better self-esteem. Is any of this
resonating with you guys? How many of you in here
want to feel more confident? How many of you guys want
to have better self-esteem, feel better about yourselves? So now you’re all control freaks
and you have people who go out of the way to make
you feel better and you all have
an eating disorder? I don’t think so. What we have to move
away from is this idea that eating disorders
are choice behaviors. If anybody has ever
had an eating disorder or lived with someone
with an eating disorder or has worked with people
who have eating disorders, the one thing that should
be abundantly clear to you is that no one on
earth would choose to have an eating disorder. It is disruptive in every way
possible, and rarely, if ever, leads to the very behaviors
that people think it’s going to. In some ways, it’s
that definition of insanity of doing the
same thing again and again and expecting a
different outcome. And so it’s really
important that we recognize that what we often
think about as control is actually a symptom. It’s actually what
drives the disorders, rather than what will
solve the disorders. The other thing that’s
really important to remember about
eating disorders is that we don’t
know an actual cause. We actually have
very little, if any, idea what starts an eating
disorder for any individual. There are certain
risk factors, right? Energy imbalance or
dieting, engaging in behaviors like
vomiting after meals or exercising more
than you’re taking in. Maybe using laxatives
or things like that to help you
with weight loss. Restricting your
intake in any way so that you might later
binge or overcompensate. Those are all behaviors. And actually if we look at the
base rate of those behaviors, more of us in this society
engage in those behaviors than not. Did you know that some studies
suggest that as many as 60% of women on college
campuses are engaging in purging behaviors–
self-induced vomiting, in particular. So these behaviors
are not that unusual. Sad. Terrifying. Several of you are looking at
me kind of going, I had no idea. Dieting– any idea how
many women in America diet? 90%. What was that? 90%. About 90%. Really, really close. About 87% of American
women say that they have dieted in the last
year to year and a half. Sadly, 67% of middle school
students say the same thing. So these are behaviors that
we’re practicing over time. It’s not about having control. It’s about practicing
habits, right? These very habits
that are starting and then become
something bigger. And so while we don’t know
what causes eating disorders, we know how to disrupt
the symptoms of them in order to help bring
people back to health. Uh-oh. I did that in a bad way. Eating disorders affect
people of all ages, gender orientation, sexual– gender, sexual orientations,
weights, socioeconomic status. In other words, and since
it’s already up here, eating disorders look like
everybody in our nation. Do eating disorders affect boys? Yeah, actually. A lot more than we
thought, now that we’re better at identifying boys. So we used to think
it was about a half of a percent of boys suffered
from eating disorders. You know what really
they suffer from? Not being diagnosed with
eating disorders because they are boys. People used to say, well,
mostly eating disorders affect rich white girls, right? I don’t know about you,
but all the public service announcements that
I saw in high school all featured like really
cute tiny blond girls getting anorexia nervosa. That’s not what it looks like. In fact, eating disorders– and
all of them, except for ARFID, where we don’t have good data– are increasing the most in our
Hispanic female population. But you know who
else is at huge risk? Hispanic males, for all
of the eating disorders. We see these across
nationalities, ethnicities. But what’s really interesting
is that eating disorders tend to develop during adolescence. That’s one of the
reasons why I’m such a fan of developmentally
based treatments and the importance of
development, is that we know that the peak age of onset
for most of these disorders is between 12 and
24 years of age. You want me to be a
little bit more specific? For anorexia nervosa, there
are two peak ages for boys, actually– 13, 14, and 18. And those boys actually
can look very different from one another. So 13-year-old boys often
come in having that exercise physiological imbalance. And almost to a one, they
all say the same thing. I really want six pack abs. These are boys who are trying
to decrease their intake to give themselves a physical
look because if anything’s changed in last few years, it’s
not in that we’ve gotten easier with how women should look. It’s that we’ve gotten much,
much, much harder on boys. I really feel for them because
all these years we were like, you guys have unrealistic
body images for us. Well, we’ve just turned around
and done the same thing to them and it’s not good
for either of us. 18-year-old boys tend
to experience this sort of at that nascent age
of going off to college and learning how to do
things for themselves. And they often start
to get feedback or want to change how they’re eating. For girls, that peak age of
onset is 14 for anorexia. For bulimia, it’s
a little bit older. It’s closer to 18
for both groups. You kind of noticing something? What happens at 18? College for some of us,
for a lot more of us now than ever before. We’re supposed to be adults. I have to use that in air quotes
because like that whole notion of like being independent and
not relying on your family, like I am seriously middle aged
and I still rely on my mom. [LAUGHTER] My poor mom. But I think most
of us do, right? And especially in
this community. And so what we see
is that actually this rate of eating disorders
increases for people going off to college because often it’s
the first time that you’ve had widely available foods. Think about a
cafeteria at college. How do you make those choices? How do you engage with that? How do you know what to have? How do you know– I don’t know about
you guys, but I always slept through
breakfast at university because the cafeteria was
only open from 7:00 to 9:00. It was like, pshaw. So I skipped breakfast for the
whole time I lived in the dorm. And that meant that
lunch and dinner had to also be breakfast. And then there was also
scavenging snacks for later in case I got hungry
or stayed up late. So that dis-regulated
eating can sometimes be part and parcel of
actual healthy development. We know that these
disorders exist across different types
of sexual orientation, with our LGBTQ kids
being at greatest risk. And we especially see this in
our trans population, where the desire to
manipulate or to prevent that ongoing sexual
maturation is huge amongst a small
subset of our kids. Now let’s flip this around
to kids who might be overweight, who are
desperately trying to fit the norm
of losing weight, because if there’s one thing
that has made me sure that I will never lose a job
working with eating disordered patients,
it’s the war on obesity. The war on obesity has actually
probably created as many people with eating disorders as almost
anything else we could possibly do. When we give you the message
that your body is not only not OK, but a ticking time bomb,
and if you don’t do something about it you’re going
to die– sometimes the strategies that children
and adolescents adopt are those various strategies
that are actually going to put them at risk for death. We know everyone knows someone
with an eating disorder. This one is possibly one of
the saddest aspects to me. I don’t know that I have worked
with very many families who don’t believe this,
that this idea exists, that if you have an eating
disorder, especially anorexia nervosa, you
will never recover. I have to tell you,
that’s a big pill to swallow when you’re
telling somebody, I’m worried. I’m worried about your eating. I’m worried you might
have this disorder. People and parents
will often say to me, or young adults will
say to me, so I’m going to have this for
the rest of my life? What do you think my answer is? I hope, given that I
was smiling at you guys, that you know that
this isn’t true. I don’t know that I’d be able
to do my job if I didn’t believe that we could get people well. And fortunately, I’m
also a scientist, so this makes it really
awesome, because that means I get to study it. And guess what we find
when we really study it? Two things are really true. No matter what,
we can definitely decrease the impact of eating
disorder symptoms on people’s lives. We can improve
family functioning. And we can reach full cure. And that’s especially
true the younger you are when you get treatment. But that makes sense, because
your brain is more plastic and it’s moving and we can
create different structures. But we now know,
even in adulthood, people can reach for cure. The longer you were
ill, the harder that is. But actually you can
fully recover from all of the eating disorders. And in fact, full recovery
is where we end treatment. So don’t take this
idea that you have to suffer or
struggle, or take it with a grain of salt
I guess, because we know that not only
can we get people to a healthy weight or
healthy weight range– A little less so when we
come from a higher weight. Our overall BMI may
still remain high because that’s where
our set point is. But we can improve
the functioning on both ends of that system
from low weight to high weight. And we can also help
with the thinking. And that’s really
critical, right? It’s not that you walk around
and you’re eating healthy or have a semblance of
that, but you internally struggle against it every day. That’s not health for us. So we know we can get normal
thoughts and cognitions. And let me just say one thing
about that really quickly. How many people in here think
their body is a wonderland? [LAUGHTER] Right. It’s awesome. You can go into any
store and buy things. You never get a little anxious
about going bathing suit shopping, right? Everyone in here. When I say recovered
and I say cured, I really mean in the
context of how most of us are about these things. About the only time where
it’s really acceptable societally– not just
like, acceptable. I would love it if people walked
around loving their bodies. But about the last age
where you can do that without having a serious
clap back is about four. When you’re four, you
can be like, I’m awesome. And when you’re five
people go, don’t brag. We give each other
messages about what is and isn’t healthy. And that actually can help. That actually influences. Body image dissatisfaction,
which is– this is really sad– is the norm, not the exception. So one of the things that
we’re often looking at is how do we avoid the
limitations that body image dissatisfaction puts on us? How do we work around that? How do we feel the best in what
we have with what we’re given and in the way
that we want to be? And said very specifically,
my goal is always to reduce the distress, agitation,
and anxiety that comes with existing in a
physical space that, realistically y’all, you don’t
have that much control over. I don’t know about
you guys, but my body does all sorts of things
on its very own without me thinking about it. And I’m super happy about
that, because I’m not standing up here trying to
remind myself to breathe. My body’s just doing that. And when I get hungry– I don’t know about you guys,
but I get to that point where I’m hungry and
nothing else is going to help me other than eating. And that’s a good thing. You actually want that. The absence of that
is a bad thing. Eating disorders are
just about being thin and they’re just
about body image. And it’s hard to understand
this because I’ve been talking an awful lot
about body image and distress and things like that. But I think we just
put it out there. Most of us are somewhat
distressed by our bodies. So are eating
disorders about that? Is that what causes them? It’s kind of hard. A lot of you are saying no. And you would be
right about that. Anorexia nervosa
has actually been codified in the
medical literature for hundreds of years. And if we actually
look back, we can find historical case
reports of anorexia nervosa, especially binging and purging,
throughout human history– even when what was
an ideal body form was more like what I’ve got. I’m definitely like a 16th
century kind of chick. Like I would have been awesome. I can sing soprano. I can pack on weight. I’ve got like babies made for–
hip making baby hips, right? The fact is, is that yes–
our ideal body images have decreased over time. In fact, in the US right now,
what we consider attractive for females is anorexic. If you look at the
numbers that they give– and that they even give these
numbers should say something– on America’s Next Top
Model or Playboy models, most of those people actually
belong in the hospital for acute malnourishment. They fall below the 75th
percentile for median body weight for their height. Also people lie, but that’s OK. And so what we think of as
attractive is emaciated. And it’s really important
to remember that. Now it’s not just
about being thin and it’s not about
being in control. So what are eating
disorders about? The best way I can describe
it to you is this– eating disorders are a
set of habits or behaviors around food and eating
where we over-blow the expectation of how important
food, body image, shape, and weight are. And we change our behaviors
in ways that actually become replicating cycles. You know what’s really hard
is purging after you’ve eaten a large meal. It actually releases a lot
of the same neuro hormones and chemicals as
having an orgasm. And we’ve done studies in rats. We’ll never do these
studies in humans because when I tell you
what happens with rats, you’ll go, yeah. When we hook up electrodes
to a rat brain that allows them to have an
orgasm over and over and over again by
pushing a button, do you know what they do? Male rats. We studied this in male rats. That ought to shorten
the path to the answer. They actually push that button
so much they stop eating. They stop drinking. And they would push that
button until they died. If you could engage
in purging behavior and recognize that
it completely changes your emotional experience, if
you could hit that reset button on your mood, how
many of you would be able to keep your finger
away from that button? Had a bad day? Somebody pissed you off? You hit that button and you
feel totally differently. Restricting your
eating or dieting, if you do it long enough,
actually decreases or changes your mood state. It actually shrinks
your affective range. So your mood becomes a little
bit– well, not a little bit. Quite a bit flatter. Those of you who’ve been around
folks with anorexia nervosa will find that they
generally operate in a very kind of
flat sort of way. And their blinking
has slowed down. And their affective
range has slowed down. And also the humor muscle
wastes away really quickly. And so what you see is
that actually rigid dieting over a long period
of time can actually serve to regulate emotions. So can purging. And so can binge eating. So what we’re actually
doing is hitting on reward circuitry in
the brain and the body in ways that actually make
it more likely that you’re going to engage in
these maladaptive, inappropriate, super
dangerous, but also really satisfying behaviors. So we know that. I love this one. Not thin enough? You’re disgusting
and almost perfect. One of the things that
happens when people get on the trip of trying to
change their bodies– and let’s be real here. Most of us in this
room have done that. It’s kind of never good enough. You guys notice that? It doesn’t matter how
you thought you’d look. Once you learn how to
do that makeup trick that actually gives
you cheekbones– I’m still struggling
with that one– or you get your hair
to look really good, you can feel kind of
good about yourself. Who here does not
like a good hair day? They’re really great, right? And they’re also something that
then you want all the time. And when you don’t
have it, what happens? Do you feel OK, or do
you actually feel worse? Worse. For most of us, if we feel
like we’re achieving something and then that levels
out, we actually become distressed by where
that has leveled out. We can become distressed
with our new norm, even if our new norm is better
than what we had before. So you’ve heard me talk about
some of these challenges and some of these myths. What I really want to
also talk about are what are the truths
of eating disorder? The fact is, is that we
don’t know, or we can’t say, who’s going to be at risk
for an eating disorder before they develop one. The other thing we can say
is that one of the truths is that we are so bad at
catching them early that when we ran a study trying to
figure out whether or not we could help families- it
was called Parents Act Now. And it was for
family members who were concerned that their
adolescent daughters were developing eating disorders. 100% of the people
who contacted us about that study,
their child already had a diagnosable
eating disorder. We don’t know the signs
until they are too late. And so what are these truths? Anyone can have an
eating disorder. Eating disorders can start at
a very young age, particularly ARFID. We can generally pretty reliably
diagnose ARFID by age 5. Extreme picky eating. These are kids who,
instead of adding food, are getting rid of foods. So just in case you don’t know
this or you’re interested, language explosion
and dietary explosion should happen about
the same time. So between a year
and two years where kids are adding tons of
words to their vocabulary and really learning how
to speak and engage, they should be adding tons
of food to their diet. We know that kids who don’t get
that from the very beginning are at increased risk over time. We also know that eating
disorders and healthy behaviors overlap quite a bit. I would be crazy as a health
professional to say to you, I think that you should
never exercise again. You had trouble exercising. Exercising is off
the table for you. You can never ever do it again. Would anybody even hear and take
me seriously if I said that? But if I said, hey look–
your body is hurt right now. You have a stress
fracture in your leg and you need to stop for right
now until you are healthy and then go back to it. Could you guys get
on board with that? That’s the difference between
helping someone get back to health and
keeping someone ill. The other thing– dieting,
body image dissatisfaction. Do you know anybody
who doesn’t have it? No. We’ve already agreed
on that, right? So when somebody says, I
don’t like the way I look or I’m dieting, our
first response is often, let me help you. So I always joke that– I have a teenager
at home and I used to say, when my kid
comes home and says, mom, I want to join a gym
and I want to workout and I want six pack abs,
because he totally said that. I said, great. I’ll join the gym with you. Let’s do it. And he said, well, I didn’t
really want you to go with me. [LAUGHTER] And when he said I
want to eat healthier, I want to practice
good habits, and I want to give up junk food,
I was like, high five. You’ve discovered that we
don’t get to eat whatever we want whenever we want it. But if my child
then lost weight, I would be sitting there
going, wait a minute. Is this what I want? Maybe. Maybe not. And if he then got diagnosed
with an eating disorder, boy would I feel guilty. Boy, would I feel
responsible, because I was encouraging
those very behaviors that now seem like
they might have started an eating disorder. There’s not really
a situation on Earth where I would want
to teach my child how to engage in
self-induced vomiting, but we know that
this is something that teenagers talk about. We know that they
share this information. And I know personally that when
I was watching those videos about eating disorders, and
mine had a ballerina who was throwing up in order to
maintain her low weight– some of you are nodding, I know. We all saw the same videos. I was like, that’s a thing? You can do that? We’ve actually found that
teaching people and trying to prevent eating
disorders often initiates eating
disorder behavior. And so are the
very things that we would want to
protect our kids from may actually put them at risk. So what is healthy and
what is available to you. The first is, if you are worried
that your adolescent is losing weight, unless they are coming
from an extraordinarily high BMI, like the 99th
percentile, we don’t generally encourage kids to diet. What we encourage them to
do is become more active, to stop gaining weight, to
begin to move and maybe change the quality or the quantity
of what they’re eating. But actual dieting and cutting
out food, we rarely, if ever, recommend– except
for me, because I’m going to eat my hair tonight. If your child is experiencing
cold hands, cold feet, and has lost more than about
10 pounds, please come see us. Please come see us. Why? Because significant weight
loss, 10 or more pounds, especially in a short amount of
time, can be quite dangerous. And adolescents, because
they got that boost to grow, can sometimes maintain
their weight and get taller. And that’s also
really dangerous. So if your child is growing
and growing and growing and their weight’s
not catching up– sometimes it can
be a little slower, especially when kids have
a big strong growth spurt– but if their eating
isn’t increasing, you should be concerned. If they’re exercising more or
engaging in physical activity that they weren’t
engaging in before and, after four to six weeks,
their eating isn’t also increasing, you should
probably be worried. If your child is eating
food that you can’t see or they claim to not be
hungry or come to the table, you should be worried– about
any of the eating disorders, no matter what
size your child is. If you find food
hidden in their room, or worse, you find vomit
or syrup of ipecac, especially being particularly
dangerous, or laxatives or have any suggestion
that they may be using that in
their room, those are also huge risk factors. One of the things that’s
also really important is most people that I work with
think that eating disorders are a sign of something else. My daughter is really anxious
and that’s why she doesn’t eat and that’s what this
eating disorder is about. Or I know you want to help
her change her eating, but you really need to
address her depression. Or my son has OCD and this is
just one more aspect of that. So can I tell you? Eating disorders can
co-occur with other things, but nothing trumps
self-starvation in particular, or strong
maladaptive behaviors such as binging or purging. Nothing’s more
important than that, even if your child is depressed,
because believe it or not, anxiety happens when our
food is dysregulated. Come on. You guys kind of
know that, right? That’s why we have those
Snickers commercials where you hand something to somebody
and they become a much better version of themselves. That regular intake is
so important for driving actually emotion
regulation and the capacity to engage in a
healthy sort of way. So the other truths
about eating disorders is that they are treatable. And so I want to take
a minute and talk about what kinds of
treatments we have, because awesomely we have
several excellent treatments for eating disorders. And we have more all the time. For anorexia nervosa in
children in adolescence, we do have a strong
family based approach– really helping families disrupt
the maintaining symptoms of an eating disorder and
helping families begin to shape their child’s eating. We do the same thing
with bulimia nervosa, although the targets are also
not just normalizing meal, but disrupting some of
those other behaviors that may go along with that. For ARFID, we do the same
thing, but we actually help with food exposures–
actually adding new foods into your diet that
you might not otherwise be eating, which may mean doing
things like practicing eating different types of ice cream,
or experimenting with your food or doing actual exposures
where you cut up a tomato and you evaluate what it
looks like and smells like. We can teach coping strategies. So there are many individual
approaches as well, including cognitive behavioral
therapy, which interestingly also is the gold standard
for depression and anxiety. So when parents come
in and they’re like, I’m worried about
this, we can say we know these treatments
help with this as well. Family based treatment
also helps with depression and anxiety in kids. There are group treatments, such
as DBT, dialectical behavior therapy, where
families may engage in learning coping skills
and tools and strategies. And those seem to
be as useful as CBT, cognitive behavioral therapy,
for bulimia and binge eating. We also have neuroscience
based approaches now as well, where we’re actually
targeting cognitive process and cognitive content– in other words, how you think,
rather than what you think. And so increasingly,
the science is coming to help us understand
better how we can actually change your brain functioning
on a structural level or on a neurochemical level. And for binge
eating and bulimia, there are actually medications
that can help with treatment. Unfortunately, there
are no medications that are effective for the
treatment of anorexia nervosa. And generally,
unless we’re treating a co-morbid or
co-occurring condition, we don’t recommend
using medications. So those are some of the
basic truths and myths that occur around eating disorder. I would really love
for people to be able to engage a little bit
around asking some questions and things like that,
but we want to make sure that that’s fairly private. So if we can shut off the tape?