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Welcome to the Nimble Youth podcast, where we provide expert insights and valuable resources for parents navigating the complexities of their children's mental health. We empower parents to nurture healthy minds in children, teens, and young adults through real conversations.
Our team of seasoned professionals, including physicians, therapists and educators, delve into pressing topics, share research-based strategies, and offer practical advice for fostering mental and emotional well-being within your family.
Welcome to Nimble Youth, the podcast where we explore the challenges shaping kids' mental health and how families can respond with clarity, compassion, and courage. I'm your host, Matt Butterman. Today, we're talking about one of the most misunderstood and dangerous mental health conditions affecting young people, eating disorders. Eating disorders, which include anorexia, bulimia, binge eating, and others, often start quietly, but their impact is anything but small. According to the National Eating Disorders Association, eating disorders have the second highest mortality rate of any mental illness after opioid addiction.
And they're on the rise. A 2022 study published in JAMA Pediatrics found that hospitalizations for eating disorders among adolescent girls more than doubled during the COVID nineteen pandemic. But eating disorders aren't only a problem for young women. According to an article in the Trauma and Mental Health Report, hospitalizations for young men with eating disorders have surged by over four hundred percent since February, challenging the long held misconception that eating disorders are primarily a women's issue. In this episode, we're going to explore how eating disorders develop and what warning signs to look for, and how to approach conversations that may feel awkward, emotional, or even frightening.
Whether your child is showing signs of disordered eating or you're trying to understand this issue better, this episode will equip you with insight and hope. Joining us again is doctor Gretchen Hoyle, a pediatrician with over twenty five years of experience walking alongside families in crisis and recovery. Doctor Hoyle isn't a specialist in eating disorders, but she's often the first line of defense, the one who makes the diagnosis when concerned parents bring their kids in for a checkup. Today, we'll talk about how to recognize the signs, when hospitalization is needed, and what recovery looks like. Before we get into it, we remind you that the content of this podcast is intended for informational purposes only and should not be construed as medical advice.
While we aim to provide valuable insights on pediatric mental health, it is important to consult with a qualified health care professional for any concerns or questions regarding your child's mental well-being. Always seek the advice of your doctor or other qualified health provider with any medical concerns. So, doctor Ho, you've been a pediatrician for over two decades. Can you share how eating disorders typically show up in your practice and how you first became involved in identifying them? Sure.
So I did want to sort of reiterate the disclaimer here in that I'm not an eating disorder specialist. There are people who spend their careers working on this problem, and hats off to them because it's a tough one. But I do have experience in being the person that is sort of the first contact with the health care system for somebody who is experiencing an eating disorder. So today, I'm gonna talk a little bit about what that looks like because I do think it's relevant to parents. And then knowing that the management overall is sort of a multidisciplinary approach where you have folks who are different, like, they that where where you have lots of different specialists who get involved with helping, the patient overcomes their problem.
That make sense? It does. Okay. Why is the pediatrician's role so crucial in capturing these issues early on? Right.
So the way that this usually plays out for me in the clinic is that parents have noticed a significant amount of weight loss among like, for their child. And a lot of times, they have also noticed some behaviors around food that were not present before. And and most of this looks like restrictive eating, like the idea that they're eating less, they won't eat things that they used to eat, they don't wanna eat around other people, they're telling you that they're eating in private or they're just you know, you can tell that something has changed with their relationship with food. And when you overlap that with this weight loss, that is typically what presents to me in the clinic, that scenario. But there are other, like, lots of other eating disorder patterns that are out there in the world that meet criteria for different diagnoses.
But if those are not necessarily things that wind up in my office because the medical implications of extreme weight loss and restrictive eating are what typically trigger them, the visit with me. Right. Yeah. And there are a few physiological markers as well. Things like low blood pressure or lowering temperature.
Right? I think it might be helpful to sort of explain that there are two sort of different lenses to look at eating disorders from. So if you take, like, what the psychiatry folks do and, like, the behavioral health folks and the and the people who are going to rely on the DSM, and we're now on the fifth version of, that manual that has all of the different mental health conditions, and it has, like, a list basically of their symptoms. And then you have a a person who is trained to evaluate the patient and try to determine which of those symptoms they have, what the frequency of them are, how severe they are, and whether or not they then meet criteria for those diagnoses. So when you look at the psychiatrist lens, then they are sort of specifically, like, and intentionally not talking about the numbers around their weight or their weight loss or what their body mass index is because they're thinking more about what's happening in their brain.
Right? So they're thinking about, like, whether or not their behavior around eating is, you know, is pathologic, like, that they're restrictive, whether or not they're having episodes where they're binging, and then sometimes they're purging, in order to as a compensatory mechanism to binge eating, they're doing things to keep those calories from staying in their body. And then also a big component of it for the psychiatrist is what is happening in their brain about their body image. Like, what they think they look like, which is usually quite distorted. So, my experience has been that most of these kiddos who get into trouble with significant weight loss are still in the mindset that they need to lose more weight because they are overweight in their brain.
Right? Which is really, you know, that's a tough thing. And so that's part of it. And then the other part of it that's the psych psychiatric piece of it is that not only do they have this sort of distorted body image, but they also are sort of distorted body image, but they also are sort of obsessively thinking about weight and food and afraid of gaining weight, and that that has now occupied so much of their thinking that it's often impairing their day to day function. Right.
And that's a critical point here is that weight loss, while it certainly can accompany eating disorders, it's not, you know, a a surefire, marker for diagnosis. Right? It's primarily a problem in the mind, and so the physical manifestations of it can just vary. Correct. So yeah.
So there you can meet criteria for different eating disorders based on what's going on in your brain, and that can be separate from what's going on in, like, in your body. Right? But for what I do in primary care where I have somebody present then, in the clinic with this issue, typically, it is the weight loss that has gotten them in along with some of these other behavioral things. And so while, the psychiatric lens would say, okay, we're gonna think about what's happening in their brain, what is happening in their body is sort of what happens next for them is kind of left up to clinical judgment, but the clinical judgment person is me, so I need to be able to look at them in the in the setting of the, the visit and say to myself, okay, what is happening with this child at least in the at the beginning of this physically, and do they need to be in the hospital for us to be able to start down a path of getting better? Right.
So in the introduction, I cited some statistics that are sobering. It's a very deadly disease Yep. If not, diagnosed early. So for the child who comes in and is presenting, some of these, typical markers, how do you determine whether they're a candidate for hospitalization or not? Right.
And so this is where the numbers, like, the numbers do matter to me, like, in this scenario. So I do need to see what their actual weight is and compare this comparison to their height. So that's what body mass index is. And I need to get a sense as to what percentage they are of what we used to call ideal body weight or what their weight should be in relation to their height. And I have to think about how quickly the weight loss has happened.
And so, you know, this is part of why we do, you know, checkups every year. Right? So in theory, I should have put a weight on them sometime within the last year that I can say, okay. Well, at this time, you were this weight, and now you're here. So at least I have some idea as to what the, you know, duration of this has been, because kids are very, very good at hiding this.
Right? So, they will often, you know, wear clothes that make it, you know, hard to tell that they're losing weight, and it's not until, you know, that that weight loss has become so substantial that folks around them are starting to notice. And so, I do have to think about the numbers. Some of the numbers that I will think about is, like, you know, if their body mass index is, like, less than sixteen, that's not a hard and fast number. This is part of why the psychiatry folks don't wanna necessarily commit to specific numbers.
But, that's a number that I'll use. Sometimes I'll think about, you know, whether or not they have lost, you know, more than 15% of their original weight within a three to six month period or whether they've lost 20% within a twelve month period. Those are some criteria that make me think about where we are medically. And then I will start looking at their vital signs and lab work to try to determine kinda what the next course of action is. Right.
So there's a phenomenon called refeeding syndrome. This is actually something, throughout history. For instance, during the Nazi Germany regime when the concentration camps were liberated, there was a directive not to give food too quickly. To the emaciated survivors, because that can be a very dangerous situation. Right?
Can you talk a little bit about that? It can. So for some of these patients where this restrictive eating has been severe enough and gone on for long enough that when I meet them that I'm concerned, so, like like, you know, there's specific, like, just vital sign things. Oftentimes, the heart rate is one of the biggest ones that I can get easily, quickly, and recognize that we're in a, you know, metabolic place that could be potentially a problem. And so, heart rates are less than I'll have people sitting out in a clinic with a heart rate less than 50, and that seems really weird because that's really low, but that will happen in this context.
Their blood pressure can be really low. They can have a lot of what we call orthostatic changes, which means that when you change position, your blood pressure changes dramatically. And that can, you know, kind of explain why they often feel sort of dizzy and light headed and, you know, like, sort of weak and stuff. Their temperature can be pretty low. And then when we're talking about refeeding syndrome, there are some lab, you know, the lab work that we get when we are first meeting these, folks in this presentation to find out what their electrolytes are, because those can be, like, like, abnormally low, particularly, like, potassium, phosphorus, and magnesium.
Those can be particularly low. And sometimes if refeeding, if we start to introduce nutrition too quickly, then the shifts that happen with those electrolytes can be dangerous. And so I need to have a sense as to where they are, you know, lab wise as well. And the response to that is that if we are worried about refeeding syndrome, then, then hospitalization is a rational thing to do at the beginning of this process. And by hospitalization, I want to recognize this is there that at the beginning, if we're admitting them for this problem that I'm describing, where they are having, you know, potentially unstable vital signs or labs that are abnormal, then we're they're on a medical unit.
This is not like inpatient residential care for an eating disorder. That potentially happens later. That comes down the road. But they have to be medically stable to do that. So this is the medical stabilization part.
Okay. And so what we are trying to do here is, typically, we'll have them in the hospital for a few days. We are monitoring them on a cardiac monitor to make sure that there's nothing abnormal happening there. We're getting labs every day, to see what the changes of their electrolytes are and to make sure that or their lab work is not, you know, change shifting too quickly. And it also gives us the opportunity to have the nutrition folks do an assessment in the inpatient setting and start a refeeding program that's going to be safe and and reasonable for them, to be able to make sure that we're reintroducing nutrition, giving their calories back, giving their body back the nutrition that it needs, but we're doing it in a way that's not gonna cause, you know, additional trouble.
Right. Yeah. So for the child who has been, stabilized Correct. In the hospital Mhmm. How do you determine whether the next course of action is one of these residential treatment centers or or whether it can be done on an outpatient basis?
Yeah. And that is the million dollar question. I mean, that's always so so I, you know, usually, we can if they require medical stabilization, we'll get them in the hospital. We'll do that part, and then they then then that's the decision tree going forward is are we going to try to do recovery, in an outpatient setting? And sometimes that means what we call intensive outpatient.
There are some programs that are available where folks basically spend the day in the, in sort of a treatment center, but then they are at home at night. But that's not available everywhere. Right? I mean, those are programs that are, you know, often full and then also, just not available to everyone depending on where you are. And so, then the other options are in a residential setting where they actually go to a hospital for several months and they go through the process of working on now that the medical stabilization has happened, we're working on figuring out the thoughts and emotions and behaviors that go along with causing their medical conditions.
So now we're kind of getting into this somewhat, you know, predictable pattern of thoughts, emotions, behaviors that then affect your physical well-being. So eating disorders are often, you know, in that category of things. And so the idea here is that depending on how severe their, you know, situation was when they initially presented, what their medical instability was, how long it took for them to be stabilized in the hospital, how long their eating disorder has been going on. Because if you think about that circuit, that cognitive triad that we talked about in the cutting podcast, that, that if that track in their brain has been, you know, has has created this groove that they're in a circuit that is gonna be hard to rewire that, where those negative thoughts and not just negative thoughts, but if they're inaccurate. Right?
It's the thought that they are overweight, that they're disliked, that they're distorting their body image. We've got to figure out how to, you know, rewire that. And so depending on how long that's been going on, well, let us know, like, gives us some idea as to how long it's gonna take to kinda get it better. And then, like everything, insurance gets a say. Right?
And so, and so what we wind up doing, you know, there are some financial ramifications of this. They're substantial. And so even with plans where there is some coverage for this, there's still quite a bit of, you know, out of pocket expenditure. And so these are all realities that we have to take into account when we're trying to decide which of the arms that we're gonna go down on this algorithm once we've gotten them medically stabilized. And just parenthetically, that is also one of the reasons why early detection and early intervention is really key because the shorter amount of time that has been going on, the more likely we are to be able to do it as an outpatient.
Right. And so that, I think, it is important to be able to recognize that, if we can intervene early, we've got a better chance at being able to not have to resort to the residential setting. Right. And so regardless of whether the treatment plan going forward is, you know, a full on residential center or or outpatient, the team involved in the recovery is the same. Right?
We've got a doctor Mhmm. A therapist, and a nutritionist. Can you explain the roles that each of those players play? Right. Exactly.
And so this is, you know, a very, you know, certainly a common scenario for me to be involved in too. So this is sort of like after the acute care, and then sometimes this scenario is set up, when they've they they may have been to a residential care facility, but then when they come home, they need a tech team in place. Or we've chosen to do this as an outpatient. We still need a team in place. So that part is really important, is getting that team in place for, for sort of a multidisciplinary approach to their problem.
And so, typically, for me, what I do as the as the clinician or the medical doctor involved is I will do weigh ins frequently, and I will monitor any lab work that we need to look at their vital signs and then potentially manage any other, like, comorbid conditions, you know, often anxiety or depression. Most of the time, kiddos who have this condition, eating disorder condition, especially what we're mostly talking about here is restrictive type anorexia nervosa. So if that is what they have, a lot of times, they will have to meet criteria for anxiety or depression as a diagnosis, and so I will be managing that. Or sometimes I will have them see a psychiatrist to manage that. But that is sort of the medical arm of the team approach to, a multi multidisciplinary approach to eating disorders.
The nutritionist is the expert in trying to figure out how we are going to get energy back into this person's body in a way that they are going to, you know, so that we can restore their weight in a healthy way, and restore the energy balance back into their body. And so, so those folks, you know, are trained to be able to figure out exactly, you know, what our goals are gonna be as far as eating. And the nutritionist also works often with parents, because for a lot of kids, what is happening when they are in the recovery phase is that they really do need someone else to put their meal together for them or plate their food. Okay? And the reason for that is because they are still to somewhat they are still somewhat battling with the eating disorder that is telling them that they need to eat less and that they have, you know, that they're still dealing with the the, distorted body image.
And so they need to be able to let someone else put in front of them what they need to eat so they can just focus on what's on the plate and eat it without having to make decisions about what needs to go on the plate. And so the nutritionist will work with you a lot on figuring that out. Right. And then the therapist, I guess, we've talked about these established behavior patterns that kind of wear a groove in the snow in your mind. Right?
Correct. And so the therapist would work on restoring fresh snow. Right? So you can create new grooves, healthier ones. Connections.
That's right. Yeah. You wanna be able to find other pathways in your brain that make it so that you are not in that cycle of thinking about food and body weight and perseverating on that, and we need to be able to disrupt that. And so therapy, typically, cognitive behavioral therapy is one of the ways that is often addressed by the therapist. Right.
Are there any meds that can help with these conditions? Yeah. That's a great question. So there are certainly, you know, treating the underlying anxiety and depression is often something that is happening, you know, from my end or I'll have a psychiatrist involved with doing that. So typically, that's an SSRI, like we talked about in previous podcasts.
We'll often use fluoxetine or Prozac for that. It tends to be helpful in maybe reducing some of the rumination and perseveration on those negative thoughts. And also it allows me to sort of follow, again, those questionnaires that we use to get a handle on anxiety and depression. And also patients are often able to describe to me that they are not having as much trouble with the thoughts in their head that tell them, you know, not to eat. And so, we can quiet those thoughts a lot of times with those types of with an SSRI that's really geared towards treating their anxiety and depression.
And then, lately, have been using a medicine that is effective for sort of acute anxiety called hydroxyzine, which is an antihistamine medicine that can be effective in, turning down those, those worries about eating, like, in the short term. So we'll give it sort of before a meal, And it makes it just more, it makes it so the patient is just more able to engage in eating without having to constantly sort of battle those thoughts that are interfering. Right. So I I think a lot of families wanna know what's the long term outlook, for recovery, from an eating disorder and what, what's the time frame? What is the tip?
I know there's probably no typical Right. Recovery. It's highly individual, but, can you explain a little bit about what that looks like? Sure. And so, you know, of course, what I'm describing here is mostly, you know, anorexia nervosa, and it somewhat depends on which eating disorder category basket that, you know, the patient fits into.
But I will say that most, you know, most folks are gonna achieve, you know, a a full recovery. It often takes months, years over time to get better at, you know, at reducing the likelihood of having relapses. And so in that way, it reminds me a little bit of the pattern that folks go through with substance abuse where, if you know, where you can get to a place where things are functional without that behavior, and then under certain circumstances, it can reappear. And so, but for most folks I think they're quoting, like, you know, sixty percent of folks will achieve full recovery, twenty five percent will see significant improvement. And certainly by that, we mean, you know, that they are functional again, that they are able to do the things.
They can go to school and, you know, potentially, you know, later on will be able to work and do social things and, and have a functional life knowing that they have, you know, some challenges with food that they have to sort of stay on top of. There is some wedge of folks, who will it will be sort of a lifelong problem for them, and it can cause some functional impairment, you know, maybe about ten percent of the time that that is what the statistics are quoting. I think that, because, you know, I only kinda go up to, like, college age folks that I don't see as much of that, of course, in adults. But that's that, I think, when I talk with the therapists who take care of these folks, you know, there it is, it is a chronic condition. Right?
So it's the kind of thing that we want to be able to stay on top of, to be able to sort of anticipate times when it might pop up again. It's done with different stressors in someone's life, and be able to be prepared on how to address it. Right. So it's a treatable condition, but it is, you know, unfortunately, sort of a lifelong condition and It can be. Yeah.
And one that, you know, just has to be carefully managed. I guess, you know, for the parent who's concerned about their child, that they may be seeing some disruption in eating patterns, the key is just to bring them in early. Right? Yeah. That would definitely be my advice.
I mean, I think a lot of times the scenario that I will see is a kiddo who sometimes kids have started to have indeed started a little bit higher on the body mass index, you know, chart. And so when this sort of dysfunction or or or this problem started, it was, to some degree, a response to, to indications from their environment that, you know, that they were indeed overweight. Now this is in no way trying to say, you know, that, you know, parents are causing this or you know? But sometimes what is happening is, you know, all the pressures that we talked about with social media and body image and what, you know, young people are exposed to, a lot of times, you know, that that can be the thing that will kick it off, and then there can be some positive reinforcement as, if a if a child has been maybe a little high on the body mass index curve and now they're sort of in the normal range, you know, that can be reinforced with a lot of positive feedback. And so then they can kinda overshoot it.
Right? And so then they'll sort of get into this cycle where they'll continue to do that. And so I do, you know, really encourage folks to, you know, to come in early to have routine, you know, checkups and make sure that we've got a chance to talk about growth and development at each stage. And I think just like all the other things that we've rec that we've recommended for trying to keep kids mentally healthy, trying to reduce the exposure to toxic and, you know, things in their environment that are going to cause them to experience, you know, anxiety, depression, the things that we had talked about with, social media, that type of thing. Right.
Right. Mhmm. So it's something that needs to be addressed early on. And, with that early intervention, you know, there's there's hope for, getting the condition under control and, preventing some of those, very severe consequences. Correct.
Thank you, Doctor Hoyle, for sharing your insights and giving us a window into how eating disorders are diagnosed and managed. For our listeners, remember that early action will save lives. Thank you for joining us on the Nimble Youth Podcast. Please visit our website at www.nimbleyouthpodcast.com for recordings of past episodes and show notes for each episode. Next time, we'll discuss the alarming rise in chronic school absences and how that is impacting young people's quality of education and, in turn, their prospects for success later in life.
Until next time, please take care of yourselves and each other.