Podcast: Understanding the Mind-Body Connection of Eating Disorders

Jenn talks to Dr. Holly Peek about eating disorders and their impact on both physical and mental health. Holly shares insights into how we can better understand the role emotion can play on our eating habits, and provides advice on how we can navigate a stressful world while staying true to ourselves.

Holly S. Peek, MD, MPH, is an instructor in psychiatry at Harvard Medical School and the assistant medical director for the Klarman Eating Disorders Center at McLean Hospital. Dr. Peek is board certified in both adult and child and adolescent psychiatry by the American Board of Psychiatry and Neurology. She also has a private practice specializing in child, adolescent, and adult psychotherapy and medication evaluation and management.

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Thanks so much for joining today. Wherever you’re joining us from, thank you for joining us. I would like to formally introduce myself. I’m Jenn Kearney, and I am a digital communications manager for McLean Hospital.

And if you joined us before I clicked the record button I’ve been talking really enthusiastically to Holly about how I’m super excited for today’s session.

So our recording of the session is actually happening during Eating Disorder Awareness Week where a lot of organizations are raising awareness, and challenging systemic biases on eating disorders.

Eating disorders are super complicated in a lot of ways. They’re one of the deadliest mental illnesses, really second only to opioid overdoses, and impact at least 9% of the population worldwide.

And I say at least because we might not actually have a true snapshot of those of us with eating disorders because so many of us still believe that having an eating disorder constitutes simply being underweight, but, in fact, not even 6% of folks with an eating disorder are medically diagnosed as being underweight.

So that’s why Holly and I are here today. We’re going to unearth and debunk misconceptions, and myths about eating disorders, and have a candid conversation around the impact of eating disorders on our minds, bodies, and relationships both with ourselves and one other.

So if you are unfamiliar with Holly you’re in for a treat. She is my guest today. Dr. Holly Peek is an instructor in psychiatry at Harvard Medical School, and also serves as the assistant medical director for the Klarman Eating Disorders Center at McLean hospital. She is also a staff psychiatrist.

Sorry, I said psychologist before, psychiatrist for the Pediatric Neurogastroenterology Program at MGH. Alright, so Holly, first and foremost, can you explain how eating disorders impact both our physical and our mental health?

Holly: Of course, yes. So I often think of eating disorders as a psychological condition that can have really severe and grave medical consequences.

So an eating disorder like anorexia, bulimia, binge eating disorder is in the DSM-5, a psychiatric diagnosis, but what we all so often see as the results of malnutrition if someone is restricting, or changes in all sorts of organs from binging and purging, or people who may be overweight from binge eating disorder.

It can affect someone medically in so many different ways. And, actually, anorexia, I think you mentioned earlier, Jenn, is one of the most deadly, or is the most deadly psychiatric illness, and many die from suicide, but also many die from starvation, and consequences of that as well.

So there is a big connection between the psychological piece, and the medical piece, when we think about eating disorders.

Jenn: So does the mental health impact of an eating disorder differ based on the person’s age, or onset of the condition?

Holly: Yeah, it really depends. I think research shows that someone has the best prognosis for recovery from their eating disorder if there’s a shorter time between onset and diagnosis.

So, for instance, if someone has an onset of their eating disorder and is diagnosed pretty quickly maybe like three months later, their prognosis is pretty good, no matter what age they might be.

However, let’s say someone’s onset is age 15, and they don’t get treatment ‘til age 25 they may have a more difficult course because they’ve lived with their eating disorder for so long, but that’s not to say they can’t recover.

It’s just like statistically, a more difficult road. I think that it’s so, so important for everyone in the mental health field, in the medical field to screen for eating disorders in both men and women.

I think men often fly under the radar, which is problematic, but when I think about the prognosis and age of onset, that’s kind of what I think about, that shorter distance between onset and diagnosis.

Jenn: You’ve actually just teed me up beautifully for my next question. Do eating disorders present differently in those who identify as male and female, and if yes, how?

Holly: Yeah, yeah. So interestingly, and this is research of people who are biologically male. 15% of people with anorexia, bulimia, and binge eating disorder are actually men. And interestingly, we don’t often see them seeking treatment.

And I think it’s problematic because that duration of illness that impacts prognosis I think can be really detrimental for men who are often not screened for it.

There can be a lot of guilt and shame among men who have eating disorders because of the stereotypes of an eating disorder being a female disease.

Men can certainly have anorexia, and bulimia, and binge eating disorder, but often when we think about body image, and this ideal male body image of bulking up, or being muscular that may not actually fall in the DSM.

It would be more of an other specified eating disorder, but you see a lot of that in men who might be taking supplements to bulk up muscular, the way their muscles are, or altering the way they eat.

And so I think it can look the same, and it could look different, but the biggest problem is that men often fly under the radar, and can have less treatment options as well because so many centers can be female only.

Jenn: So are there any ways that we can be more self-aware of how our emotions are affecting both our appetites and our eating habits?

Holly: I think that a person needs to ask themselves, if they find themselves restricting their food intake, or overexercising, or altering the times and day in which they eat, or what sort of supplements they are taking the why of that, if it’s depression, anxiety, OCD, psychologically driving how and what you allow yourself to eat.

I think that could be a sign of disordered eating, and a potential eating disorder. And when you start seeing those sort of behaviors really dictate a person’s life, and what they allow themselves to eat I think that’s when someone needs to question.

I mean, ideally people should be eating to nourish themselves to make sure their body, and their brain are working appropriately, so that they can live their best life, but then if other things start influencing that that’s when I think seeking help is appropriate.

Jenn: Do you find that there’s a connection between body image issues, and binge eating disorder?

Holly: Yes, I mean, I think if you looked strictly at the DSM there is not a body image component of the criteria for binge eating disorder in the DSM. Strictly speaking for the diagnosis of a binge eating disorder, you might not necessarily see the body image piece driving the behaviors.

That being said, I think clinically we often do see a body image piece with binge eating disorder because, I mean, oftentimes people with that disorder might try to diet, or restrict their food intake at some point in time to alter their bodies because they might not feel great about themselves.

So although it might not be a main criteria, strictly speaking, I think that we often do see it.

Jenn: More recently we’ve been talking so much about social media, and how people are feeling ultimately worse about themselves, the longer that they spend on the platforms.

Do you know if there’s any correlation or relationship between the increase in social media use, and particularly like image altering apps, and onsets in eating disorders?

Holly: I don’t know the exact statistics, or studies relating to this, but I can speak from my experience that absolutely.

I think that particularly young adults and adolescents, and even younger kids now who are on these social media apps are often looking at things where people are altered.

It kind of influences what people think of as this thin ideal, or an ideal body type which then can feed into other behaviors that the person might engage in, or make them feel worse about themselves because they’re not what they see in that picture.

Just like we’ve always seen when we think of television, and movies and magazines, those can certainly we know impact body image, but now here we are with social media when kids are always having their phone and always on it.

So it’s like a constant bombarding of these messages, and this ideal body image. And then, of course, now we have all these apps that can allow people to alter the way they look themselves, and so that can make it so, so much worse.

I think that in social media there are people who are spreading good things. I don’t think everything is bad in social media, but there can also be just as many good things as there are bad things, and people not giving good messages on there.

So it’s important, I think, to teach media awareness to kids, and how to really critically think about messages that they’re seeing in the media and how it influences them.

Jenn: I think it’s also super important to note that apps like Instagram and Pinterest when you look for eating disorder related hashtags, and things that are tagged that way there’s actually a call to action that says, if you think that you need help, here is contact information to do so prior to actually being able to access those tags.

Holly: Right, and I think that’s an improvement from the corporate of these social media apps that are really trying to dissuade people from coming to problematic platforms that find their way in there.

Jenn: There was, I know in like in terms of the social diaries so like LiveJournal, Tumblr, all of those, there was a rise in folks who were using it as fuel for eating disorders and encouraging one another.

And I know they buckled down on that probably about five or six years ago, but it’s good to see that everybody is still trying to make strides. And, of course, it’s baby steps along the way.

Holly: Right, right, absolutely.

Jenn: So can you share a little bit of your perspective on food tracking apps like MyFitnessPal, and Lose It?

Holly: Yeah, I think these food tracking apps are created with good intentions for people to be aware of what they’re eating to live a healthier lifestyle. However, I think oftentimes, it can draw attention to the wrong thing.

And if there are other pieces of a person’s behavior, or psychologically it could be a recipe for disaster. I’ll give an example. I’ve certainly met adolescents with an eating disorder, and you ask them how it started.

Well, they were introduced to MyFitnessPal in their PE class, and they were asked to track their calories for a week, and they were comparing it with each other.

And then it was a habit gone haywire because on these apps it will say, oh, you’re supposed to stay below 1,200 calories a day, which is actually inappropriate for a 16-year-old person who might be in that PE class.

So I think that for certain people under an appropriate medical guidance, and nutritional guidance, those apps can have some good intentions, but in the hands of someone with an eating disorder, or who are susceptible to the development of an eating disorder I think it’s a recipe for disaster.

And if they want to improve their eating habits I think seeking out a dietician would be more helpful than just using that app.

Jenn: Also, from personal experience of using MyFitnessPal in the past, I know that there’s at the end of the day if you complete a food log, it will tell you if you ate this way for five or six weeks you would weigh X amount of pounds.

And at a certain point, I just removed how much I weighed from it because I personally didn’t need to know how much I was going to weigh whether it was an increase or a decrease because I was just eating based on how good I felt.

And if I didn’t feel good, I tweaked it the next day, but it certainly can lead to some pretty scary stuff.

Holly: I think that some people with eating disorders might also have OCD, or have other certain rigid ways in which they think. And, again, that can be very problematic with those sort of messages on the app.

Jenn: So when it comes to apps and tracking like that I know that there’s been a lot of discussion over the last couple years on orthorexia.

Can you talk a little bit about it? And at what point that being cognizant of how much you’re eating and measuring, et cetera, might actually be more disordered eating?

Holly: Right, I think that there is a gray and ill-defined line between what is orthorexia and what is disordered eating, and what might be a full-blown eating disorder.

Like the definition of orthorexia would be someone who is trying to eat clean, or measure things precisely, which, again, just kind of like those apps can breed kind of a food obsession in a way.

And for some people maybe it doesn’t dictate their life, but for a lot of people it can start being that way. And I also have to mention often with orthorexia, a person might not actually be getting all of the nutrients they need if they’re kind of more on the more restrictive side, which does actually impact your brain and your thinking.

A malnourished brain is often an obsessive brain, and an anxious brain. So it so easily can lead into eating disorders, and disordered eating.

And it’s such like an unclear line about orthorexia. I would argue that orthorexia is disordered eating, but I can see how some people might just like to eat clean, and that’s that, and it doesn’t dictate their life, so I can see it both ways.

Jenn: So how does somebody battle back from low weight? Because the obvious component of it would be eating more if your metabolism isn’t really that fast, but what types of psychosocial treatments might be needed to battle back from low weight?

Holly: Yeah, I think first and foremost a medical assessment needs to be done if someone is low weight because there becomes a point if a person is medically compromised due to their low weight and malnourishment they might not be able to do it on their own.

They might need to do it under the supervision of a doctor, either an outpatient basis, or maybe even residential, or inpatient basis. So I think it depends how low weight is low weight for that person.

And that needs to be determined by a doctor not the person themselves. So I think that that would be step one in battling back, as you say, against low weight the medical assessment, and then see what needs to be done from there because sometimes it can get to the point you need more help. And definitely a medical assessment is a good place to start.

Jenn: So what are some of the differences between poor eating habits, and a diagnosable eating disorder?

Holly: I think in order to diagnose an eating disorder, or any disorder for that matter in the DSM you have to think about how it is impacting someone’s day-to-day functioning.

I mean, when you say poor eating habits, you could say that that could be disordered eating in some way, but maybe not an eating disorder.

I think if it escalates to the point it’s impacting someone’s day-to-day functioning, whether they’re let’s say not doing enjoyable activities, or don’t feel like they can because of their eating habits, if they’re isolating themselves more, they aren’t functioning as well in school, or in work. I think that’s when I would start thinking about it more of a disorder than poor eating habits, per se.

Jenn: Do you think that loss of control during the pandemic as many of us have felt one way or another has caused more folks to develop eating disorders?

Because, logically, food or eating habits is the one thing in an absolutely asinine world the one thing they can control.

Holly: Yeah, I think that that’s a great question. I would couple loss of control along with trauma and stress of the pandemic, and also isolation of the pandemic. Eating disorders often are born and thrive in isolation.

I think we’re seeing a lot of people who may have had eating disorders are now relapsing during the pandemic because of stress, because of trauma, because of isolation, a variety of things, and people are also developing eating disorders for those same reasons, so absolutely.

I’m sure the same can be said for other mental health issues like depression, and anxiety, and PTSD, and things like that.

Jenn: In your time working, what have you found is one of the strongest misconceptions about eating disorders in general? And do they result in stigma about the disorders?

Holly: Yeah, that’s a great question. I think a misconception that definitely contributes to stigma is there is a certain type of person, and a certain body type that is an eating disorder.

I think that people often think of when they think of an eating disorder is a young, thin white female because that is what we often see/hear about in the media.

But honestly, I would say, most people with an eating disorder may be normal weight, or even overweight.

And I think that prevents a lot of people from seeking treatment because they don’t look like they have an eating disorder, or they’re not asked the questions even by their own physician because they don’t look like they have the eating disorder, or they’re a male and not a female.

They’re a person of color and not a white person. So I think that has to be the biggest misconception I’ve seen and even, I treat adolescent, and young adult females at McLean’s Residential Center, and so often I hear like, why am I here? I don’t look like I have an eating disorder. I’m not sick enough.

When the reality is they’re in residential treatment, and, of course, they need that support, but it is just like an overwhelming message, I think that we all get that’s really problematic.

Jenn: I would be remiss if I did not ask do you know anything about the diagnoses rates of eating disorders in BIPOC folks, and if they are being disproportionately diagnosed, or treated?

Holly: Yeah, that’s a great question. I don’t know specific percentages of eating disorders in BIPOC people. However, I read one study, which is really interesting. Physicians and clinicians were given a scenario, a clinical scenario of a patient.

Describe the patient as white. Describe the patient as Hispanic. And describe the patient as black. And it was all the same clinical scenario. And I think 44% of the clinicians identified the white scenario as having eating disorder, and they need help.

I think maybe 40% identified the Hispanic person as needing help. Only 17% identified the black individuals needing help under the same scenario. And so that person would have not gotten identified, or treatment which is so, so problematic.

Jenn: Naturally my mouth is just hanging open over here as Holly is talking because it’s like the intersection of a bunch of my favorite things understanding implicit biases and doing research, so that was just, that was fantastic.

One thing that has been kind of a fun new trend, fasting. Do you have, and by the look on your face, I feel like I’m going to get a pretty good opinion on this.

Can you share your perspective on intermittent fasting, one-day, or three-day fasting? Does it actually have a benefit to you psychologically? I know some folks have said they feel like they’ve got better energy, or they’re more empowered, or stronger, but what’s the hype?

Holly: In my opinion, I think any sort of fasting is disordered. I would question like what is guiding someone to fast no matter what that fast is, whether it’s intermittent fasting, one-day fasting, three-day fasting.

I mean, if it’s recommended by the person’s primary care physician for something I’m not thinking about. Maybe there’s a scenario where fasting for a prolonged amount of time is necessary, or makes sense, but I can’t think of anything off the top of my head.

I wonder when you describe someone actually feeling better, or more empowered when they fast, a lot of our patients who engage in eating disorder behaviors do feel more empowered, and better when they’re actually engaging in their eating disorder behaviors because they have an eating disorder.

So I’m wondering if the fasting falls in that spectrum unless it was recommended for some reason by a medical professional.

Jenn: So I know I mentioned in your introduction that you work in neurogastroenterology as well. Can you talk a little bit more about the relationship between how what we’re eating, and when we’re eating, and how it impacts our brain function, and our mental health?

Holly: Yeah, yeah. Yeah, so I work in a pediatric neurogastro clinic, which is a motility clinic, and not all those people have eating disorders. They’re there for different reasons, but I think our bodies are built to eat frequently, and to nourish ourselves.

We often call the gut the second brain in some ways. And I think we’re learning more and more about the gut microbiome, and the ways in which what we eat can impact that, which can also impact our brain.

I often describe the brain and the gut like a neurological highway between the two. And you even think of someone with IBS, like irritable bowel syndrome, actually, they’re more prone to also have depression, and anxiety, too.

And I think there’s more to that in a biological physiological sense than just like, oh, that you have an anxious stomach, that person has anxiety.

Jenn: As someone with chronic digestive disorders who has gone to motility clinics, totally understand the anxiety of it. Also, because like when I was younger I was afraid to eat in public because I didn’t actually know what it was going to do to my body.

Could I get to a bathroom in time? Could I do any of those? So for me that was the onset of my anxiety around food, and when I was eating, and what I was eating.

Holly: Absolutely, absolutely. And I think we see that so much it’s very circular where it comes kind of chicken or egg type question.

Sometimes if someone has GI issues, they start eating less, or eating at different times, or avoiding eating for whatever reason that can actually make their GI issues worse in a lot of ways. And then it just becomes a cycle, and it’s a tough one to break, but it can be broken.

Jenn: And we did have folks ask for a little bit more explanation on what a motility clinic is. I’m not the expert, I’m just a patient of one. So if you wouldn’t mind, that would be fantastic.

Holly: Yeah, yeah, so the motility clinic, for instance, people sometimes have what we might call slow transit, meaning from putting it in your mouth, to the waste that comes out, physiologically it’s moving slower, and they have to be treated in a variety of ways.

We also see a lot of different people with functional pain, or in different ways whether it’s functional abdominal pain, functional heartburn, in different ways, which can also be impacted by motility.

So it’s called a neurogastro clinic because the neurology of it, and the physiology of it can impact the motility, but, also, with that brain-gut connection there’s that neurological piece too.

And, interestingly, we often use a lot of the medications we use in psychiatry to also treat different GI issues because there is such a connection. There are more serotonin receptors in your gut than there are in your brain. So that’s why there’s that connection there.

Jenn: Can you talk a little bit about the manifestation of anxiety and our appetites? And I know I alluded to it from the personal experience of with a digestive disorder.

I became anxious about eating outside of the house, but how can the manifestation of anxiety whether it’s overeating, skipping meals, how that could actually exacerbate an eating disorder, or fuel the onset of one?

Holly: Yeah, absolutely. I think that anxiety presents itself in different ways for different people. And I’d say some people who might be anxious may also have stomach pain, feel nauseous.

They might struggle with constipation, or diarrhea, and they actually might avoid eating when they’re anxious. And then that could potentially reinforce itself in different ways. Like, oh, I felt better when I didn’t eat.

And, oh, I lost some weight too, and now I’m getting complimented for it. And then it can snowball from there. I have to mention we’re talking I mentioned anorexia, bulimia, and binge eating disorder.

There’s also something called ARFID, which is avoidant/restrictive food intake disorder, which is when someone avoids eating, and they might become severely malnourished and lose weight, but there’s actually not a body image component there.

It can present itself a lot in autism spectrum disorder, in OCD, but also anxiety and phobias as well when someone’s avoiding eating.

So that’s kind of one end of the spectrum how anxiety can impact the way someone eats, and develop an eating disorder, but there also could be the other end of the spectrum where someone might binge when they’re super anxious because it’s a coping skill for whatever their emotion dysregulation might be whether they’re depressed, or anxious, or whatever.

Eating makes them feel better and more in control. And that can become a habit as well. So I think it can be problematic on both ends with low weight, or normal, or high weight, when anxiety plays a role with appetite, and what you can eat.

Jenn: Can you provide some more information about how eating disorders affect our brain? An example that was brought up was under structural changes for men who deal with orthorexia long-term.

Holly: Off the top of my head I don’t know the exact answer to that question about structural changes in the brain for men with orthorexia. I mean, what I do know is there are structural changes in the brain, and I’m sure it’s similar, but I’m not for certain, but I suspect it’s similar for both males and females.

I think I mentioned earlier a malnourished, or starving brain can be an anxious and obsessive brain. And when I say malnourished, I mean you’re not getting the micro and the macro nutrients that you need in a day.

You could be normal weight, or overweight and still be malnourished. So I’m not even speaking about anorexia when I say malnourishment. So I think my answer to your question is there are some changes, but I can’t speak to the specific ones at this moment.

Jenn: I know that there’s been an increase in the backlash against diet culture, and instead a lot of folks are focusing on body positivity. Do you see that as being helpful to reducing the prevalence of eating disorders?

Holly: Yes, sure. I think that there is certainly a body image component in eating disorders that are often created by this from men and women, this thin ideal, or the other end of becoming more muscular, or bulking up, whatever it may be.

There are these messages from the media that there’s this ideal body. And sometimes people can take that to the extreme, and think about that’s where their self-worth, and confidence can come from.

So I think the more we can talk about body acceptance, and beauty in all sizes and all bodies, and where our bodies are meant to be the better because it can help dissuade that stigma of the thin ideal, or the bulked up ideal.

So I think it’s a positive thing. I think it’s going to take time for that to really shift as a culture, but now’s a good time to start. So I like that kind of messaging.

Jenn: And I think the pandemic has certainly actually helped accelerate that because gyms have been closed, people have had to rely on what they have at home to be creative.

And we’ve had to spend a lot more time with ourselves, and hopefully get more comfortable with ourselves as well.

Holly: Absolutely.

Jenn: So we had someone write in saying my daughter is 15, and does not have good eating habits. How do I get her to establish good eating habits when she’s really picky, and will not listen to anything that I suggest?

Holly: Hmm. I think it’s tricky to give specifics, but I think it depends if she seems to be losing weight, or kind of falling off her developmental growth curve, I think that talking to a dietician, and a PCP would be important.

I think creating a culture within the home of anything goes in terms of what you can eat. I think often parents give very unintentional negative messaging around food and diet culture because that’s what we’ve grown up with.

And what we’ve seen too, like, oh, I can’t eat that, or, oh, I’m doing Weight Watchers now, or kind of even body talk in the house. Again, usually it’s well-intentioned in order to help a child, but it happens all the time when there’s a lot of diet talk, and food talk within the home.

So I wouldn’t be talking specific calories per se, but I would kind of focus on nourishing your body, nourishing your brain, all things in moderation. There’s no such thing as good foods, or bad foods because I think that breeds black and white thinking about food, which can also fuel disordered eating patterns.

So I think there’s a number of things that you can address, but looking kind of at the culture of food around the home, and the diet culture in the home, and thinking about how you could do things a little bit differently, or talk about things differently could be helpful in setting that kind of example.

Jenn: I know we had previously talked about fasting, but a participant had brought up fasting for religious reasons. Can you address that reason for fasting falling under your previous comments about it?

Holly: Yeah, yeah, so fasting for religious purposes, of course, that is something to be respected. And I think that what I was referring to when I said there’s no such thing as good fasting is when it’s kind of used in a diet sense.

I will say this. When someone is in eating disorder treatment like higher level of care treatment, like residential, or inpatient, the recommendation is that they not engage with that religious practice at that time because it can derail treatment.

And we’ve even had rabbis tell people, and talk to patients like it’s okay, you need to take care of yourself and your body first. Let’s not participate in that fasting right now, but in general fasting for religious purposes that doesn’t have the thought of, oh, I want to lose weight, or change my body in any way. That’s a little different.

Jenn: Can you speak to some of the medical complications of short and long-term effects of eating disorders?

Holly: Yeah, yeah, so let me speak to anorexia low weight first because I think it kind of differs like what the eating disorder is. If you’re low weight and malnourished that can impact every organ system.

I think I’ve spoken to the changes in your brain, but it can impact bones and bone development. We’ve seen teenagers with osteopenia, and early stages of osteoporosis due to malnourishment.

It can impact your vital organs, including your heart, which is a muscle. We often see more acutely people presenting with low heart rate, and low blood pressure, which is a sign of their heart isn’t functioning as it should because your heart is a muscle and it needs fuel to work.

So I think we see kind of in a lot of sense kind of general organs shut down for your body to preserve the energy it needs to work the essential pieces.

For instance, gastroparesis meaning you’re speaking of motility, not moving food through your system, it’s moving very slow. If someone is restricted often time their GI system starts shutting down because your body is trying to conserve its energy for your heart and your brain to work.

So I think acutely, those are the kind of things that we see in starvation. If that continues that can ultimately lead to death, or long-term medical consequences, cardiac arrhythmia, heart problems, and things like that, okay.

But if you think about someone who’s normal weight, or overweight which we often see in bulimia, and binge eating disorder, with bulimia when someone is binging and purging, and potentially even abusing laxatives, which can cause significant diarrhea you can have electrolyte imbalances, which can be very dangerous because your muscles need your body to be physiologically in sync with the electrolytes in order for things to work properly.

And so that can lead to cardiac arrhythmias and even death. And particularly when it’s coupled with like binging, purging and laxative abuse.

And then, of course, binge eating disorder, if someone is struggling being overweight, or obese over a long period of time they might not see as many issues in the short term, but in the long term the health consequences that you see can be cardiac disease, Type 2 diabetes, high cholesterol, things like that. It really kind of ranges in the spectrum depending what the disorder is.

Jenn: So we had a school nurse write in, and they are a nurse for grades six through 12. And they’ve seen an increase in parents being concerned about eating disorders in the students namely restricting calories, and increasing exercise.

The head of the school asked them to do a health unit on eating disorders with the students, but as a nurse they have concerns that this would actually exacerbate the problem. Would a better course of action be to address, and support the parents?

Holly: Honestly, I could see why not both. If you’re going to create a curriculum surrounding the education of eating disorders because I think I spoke to the culture in the home, and the diet culture in the home can often be problematic.

So no matter what, like kind of health education a child is getting in school they’re going to spend most of their time at home, and listen to what their parents and their siblings how they speak about food and the culture around food ‘cause that’s where they’re eating the most.

So I think absolutely. I think if you’re going to create a curriculum, and try to educate everybody, parents should definitely be a piece of that, but I do also like the idea of education in the school as well.

But I would be very careful for it to not turn into like telling people what to eat, and what’s good or bad because that’s what I’ve seen in physical education classes, which is more than like teaching a person how to diet, which is kind of gone, you know, is kind of good intentions gone haywire.

So maybe in the development of that curriculum having an eating disorder specialist involved in that could be helpful. I mean, that sounds really great that the school is even thinking about that.

Jenn: So how does somebody self-recognize, or recognize in someone close to them, the signs of an eating disorder? And are there any signs that might get accidentally overlooked by somebody who doesn’t know exactly what they’re looking for?

Holly: Yeah, I mean, it can really vary. I mean, I think the most obvious might be rapid weight loss, or weight loss in general. And that doesn’t matter if the person’s underweight, or overweight. I’ll give an example.

Let’s say someone is 200 pounds and technically overweight. If they lose 50 pounds in two months, that’s a problem. So kind of recognizing rapid weight loss can be the most obvious. Maybe frequently going to the bathroom after meals can often be an indication of purging. Finding excuses to skip a meal.

All of a sudden becoming a vegetarian, or a vegan if that’s not in the context of all this, or changing the way they eat, having certain foods that they avoid eating might be a sign of a budding eating disorder.

If they’re not doing activities that they typically enjoy, and seem to be kind of withdrawing and isolating. I mean, that could be a warning sign of a lot of different things, depression included, but I think oftentimes we see that with eating disorders, too, because so much of our social lives often revolve around food and eating within our culture.

And so people with eating disorders will start to isolate themselves around that. I don’t think any of these one things point to an eating disorder, but kind of taken all together can all be warning signs.

Again, that goes back to the stereotypes we have of an eating disorder being a white female. I think oftentimes red flags are missed because, of course, these red flags can be in anybody.

Jenn: Do you know anything about connections between diets that are a little bit stricter, or more specific like keto, paleo, Whole30, and disordered eating, and/or the onset of an eating disorder? Have you noticed that there’s any correlation between those?

Holly: I definitely see a correlation because diets like that can be very restrictive, and have pretty strict rules of the do’s and don’ts, and I don’t know the ins and outs of all of these diets, but I know that they do draw attention to what you can’t eat, what you can’t eat, when you can eat. And this goes with the intermittent fasting too.

So I would throw that in there. I think that in the right person who might have a propensity for the development of an eating disorder that can be the start of it in a lot of ways. I think many, many eating disorders are started with a diet gone bad. So I think if anyone is going to engage in any of these specific diets that can be restrictive, or have like a lot of foods that you’re not allowed to eat to be aware of why you’re doing it.

Is it even enjoyable? Is it doing anything for you? Do you need to talk to a doctor about it too, and make sure you’re getting all the nutrients you need? I would just kind of ask the why. Why engage in that? What’s the goal?

Jenn: So I know that you’ve talked about the work that you do at McLean’s program the Klarman Center, but what exactly does recovery look like beyond an inpatient, or an outpatient program? And what happens when recovery isn’t linear, or the person ends up relapsing?

Holly: Yeah, yeah, well, that’s a good point. Recovery isn’t always linear. There are oftentimes lapses and relapses, but that doesn’t mean a person can’t get back on track. I think the important piece beyond a higher level of care program is to have a full compliment of team members and resources.

So what do I mean by that? To have close contact with your primary care physician, or the pediatrician, to have an eating disorder informed dietician. Not all dieticians are eating disorder informed.

So I think that’s important to note, too, and something to ask when you’re making an appointment with a new dietician. A therapist can be really important. A psychiatrist, if psychopharmacology is indicated.

There are also often community supports as well. I know MEDA, the Multidisciplinary Eating Disorder Association has many, many community resources, and particularly now during COVID even has like online meal support groups and groups.

So I think that a person’s recovery can look like a lot of different things. And I think the longer someone spends time in recovery the easier it can be to get a handle of it, but to not get discouraged if you have lapses or relapses. The important thing is that you recognize it, and get back on track.

Jenn: Alright, so let’s say that I think I know somebody who might qualify as having an eating disorder. How do I talk to them about this? How do I approach them? And what do I do, God forbid, if they blow me off?

Holly: Yeah. I think that’s a hard position to be in, especially if it’s like a friend, or a family member, and you’re really worried. I would approach it with an open-mind and asking, not an accusatory stance, but asking questions about what’s going on.

You can offer observations. I’ve noticed you’ve lost some weight. I’ve noticed you’ve gained some weight. Is everything okay? I mean, ultimately, a person’s not going to get treatment until they’re ready to get treatment.

So you can never force someone, in most circumstances can’t force someone to recover, or get into treatment, but I think if it’s a loved one just to kind of ask questions, be open-minded, and let the person know you’re there.

Jenn: Is there any reason why we couldn’t bring it up multiple times, or is that something that could possibly be detrimental to our relationship?

Holly: I think it depends on the relationship in a lot of ways. I think if someone’s not open to get treatment, and hammering them with questions every day that person might start pushing you away a bit, but I mean everyone’s different, and their relationships are different.

So I think that it depends on the person, and it depends on the relationship, but if you’re really concerned, I would ask a question, or just state your own concern, but know that you can’t control it either.

Jenn: Can you talk a little bit more about the external forces that contribute to eating disorders like peer pressure, mainstream media’s vision of what the ideal body looks like, even vanity sizing in clothing?

Holly: I mean, I think that influence from external factors like the media isn’t the whole story, or else we would all have eating disorders. I think it certainly can influence, especially when we’re bombarded by messages all the time.

We take them in both consciously and unconsciously. And I think media awareness, and education of even little kids about how they analyze media messages that’s where it really starts.

I mean, when I meet someone, or doing a consult with someone with an eating disorder, and I ask when did your concern about body image start? They often seven, eight, middle school, often these body image thoughts start so, so young.

The behaviors might not start ‘til later, but that kind of not liking the way you look, and that low self-confidence, and shame and guilt, and body image components often do start young.

So I think media education for our kids, and speaking of school curriculums that someone brought up earlier I think that that would be a big part of even an elementary school curriculum is media education.

But I think these external factors do play a big role, but aren’t the whole story because someone might in order to have an eating disorder there’s genetic components to the development of an eating disorder that have been shown in twin studies, and have been shown in different family studies.

I often look at it as a biopsychosocial model. So there’s these biological components. There’s these psychological components of different psychological co-morbidities that someone might have that can contribute to the development of the eating disorder.

These external factors you speak of in the media are kind of that social component. So I don’t think it’s the whole story, but I think it’s a big piece.

Jenn: As we learn more about the causes and treatments for mental health disorders, are you finding that there’s anything different, new, groundbreaking, about how we’re addressing eating disorders now?

Holly: Yeah, that’s a great question. I think that we’re always learning more and more, but there’s more research to be done like as a psychiatrist I do a lot of psychopharmacology, and think of the medical perspective.

I think kind of the next phase of advanced research is thinking about the gut microbiome. And we talked about the gut being the second brain like kind of thinking those advancements from a biological standpoint.

I mean, there’s different ways that people tend to approach treatment that have developed over time. And I think that if you looked at many mental disorders 30 years ago you’d think about it in a different lens than you might now. And I think the same can be with eating disorders as well.

Jenn: So you said you’re a psychiatrist. So as a psychiatrist, what do you find is the most common treatment myth?

Holly: Common treatment method in terms of psychopharmacology, or in terms of like a grander treatment team?

Jenn: Oh, sorry, I said treatment myth.

Holly: Oh, treatment myth.

Jenn: Yeah, like myth or misconception. Sorry, your connection is unstable, so, in classic pandemic fashion.

Holly: Okay, so treatment myth. Hmm, that’s a good question. I don’t know if I can think of the top of my head a myth per se. I don’t know, I’m blanking on that question, I’m sorry.

Jenn: I could let you noodle on that while I ask you the next one. Are there any parts of treatment that you’ve found your patients being either surprised, pleased, or a combination of both that it’s actually part of the path of recovery?

Holly: Yeah, yeah. I think oftentimes when someone first engages in treatment particularly if they need to gain weight, and sometimes it’s quite a bit of weight they need to gain they might think, no way am I doing that.

Like not on this planet am I doing that. That sounds awful, that’s really scary. I can’t do that. There’s no way that’s happening. However, if they continue to put one foot in front of the other, and their body begins to heal, their brain begins to heal.

They start thinking about things differently really engaging in their individual therapy, really engaging in family therapy if they’re in family therapy, maybe being treated treating their different psychological co-morbidities by the time that person is in a healthier body, many times we see like, wow, I actually do feel better physically and mentally.

I’m thinking more clearly. I’m not as cloudy. And I think that that is kind of the first step in recovery recognizing how good health can feel. That doesn’t mean that it’s always going to be linear.

That doesn’t mean they’re always going to feel great about themselves, or what they’re doing, but I think kind of having that seed of things can feel better is a great first step.

Jenn: I read a quote recently, and this is I’m definitely not getting it accurately, but it was that anything that’s a challenge or struggle is broken into thirds.

A third of it will feel really good. A third of it will feel terrible. And a third of it is that sweet spot where it’s just right. And it seems like that would be the same path for recovery as well.

Holly: Absolutely, like it’s not all rainbows and sunshine once you get there. It continues to be a piece of work, but I think when people start recognizing individually how they’re feeling, or how their life is expanding.

I mean, life with an eating disorder can be a very small life in terms of you’re not engaging, might not be engaging with your friends, or family, or doing things in the community that you would normally do because you’re obsessing over food.

But then if you start the healing process you see someone’s life like really flourishing again, and start kind of rearranging values, I think is really important, recognizing what are my values. Is my number one value really to lose a bunch of weight?

And usually the answer is no, sometimes it’s not, but like usually it’s no, there’s other values in there, and recognizing what those can look like. Not easy, but I think is a very important part of treatment.

Jenn: I think we’ve got time for one more question. Can you talk a little bit about the role of families, and social circles in eating disorder treatment?

Holly: Absolutely, I think that there is certainly a psychoeducation piece for families and friends because as we talked about different stereotypes, and misconceptions of eating disorders and treatments not only does the individual need to be educated, the patient needs to be educated, but their social network, and their support system needs to be educated as well.

So I think that that is certainly a piece. If you think about the family aspect there could be a number of things that need to be addressed there. The environment at home, how meals are structured at home.

Sometimes there’s a trauma component, like really talking about that. So I think it’s important. No one lives in a silo. And I think engaging a support system for an eating disorder is so, so important. Just like it is in many treatments for other psychiatric conditions too.

Jenn: I lied, we got one last question that’s a really wonderful one from the audience. If somebody is newly diagnosed with an eating disorder, or starting treatment for the first time what message of hope do you think would help them the most?

Holly: It gets better, and especially, if you’re considering getting treatment, or starting to talk about it that’s an amazing first step that you’ve already made, making that decision. And sometimes that first step is the hardest.

Remembering the thought process, and recovery is not always linear. You might back step at times. You might take a leap ahead at times, but you can get there, and people recover from their eating disorders.

Jenn: I think that’s a really wonderful way to wrap up the session. So, Holly, thank you so much for taking an hour of your time to hang out with me, and all the folks who joined us, and to everybody who did join us, thanks so much for joining.

This actually ends the session. Until next time be nice to one another. Be nice to yourselves, and wash your hands. Thank you again, Holly. Have a great day everybody.

Holly: Thanks for having me, bye.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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