Motherhood Moment: Healthy Habits: Eating Disorders

The Wall Street Journal recently exposed TikTok’s malign effect on teen girls, inundating them with videos that promote starvation diets that put some in the hospital and on long-term recovery programs for their eating disorders. However, TikTok’s predatory algorithm only spotlights a long-brewing health problem; it is not the cause.

“Eating disorders are, together, the most lethal ailments known to psychiatric medicine, and illnesses for which the modern therapeutic arsenal is limited,” says psychiatrist James Greenblatt, MD, Chief Medical Officer for Walden Behavioral Care in Waltham, MA. “Make no mistake—we’re in the midst of a national eating disorder crisis which is magnified by the widespread social isolation and school closures tied to COVID.”

“Anorexia nervosa (AN), which has the highest patient fatality rate of all psychiatric disorders, is associated with a relapse rate of upwards of 50 percent within the first year following treatment. Five to ten percent of those with AN die within a decade of initial diagnosis, a figure that increases to between 18-20 percent by the two-decade mark,” explains Dr. Greenblatt, whose latest book is Answers to Anorexia (FriesenPress, 2^nd edition October 18, 2021).

Eating disorders burden the U.S. economy to the tune of over $65 billion per annum, and despite significant scientific advances across the fields of genetics, bioinformatics, and systems biology, mainstream treatments that target the core biologic underpinnings of these ailments do not yet exist.

According to Dr. Greenblatt, eating disorders have been described in the western medical literature since the 19^th century. The one factor that all eating disorders share is malnourishment—specifically, an undernourished brain.

The promising news is that new science points to nutritional and pharmaceutical therapies that can prevent eating disorders from occurring—in contrast to the purely reactive measures that are currently applied only after a patient develops an eating disorder.

I had a chance to interview Dr. Greenblatt to learn more.

How has Covid-19 affected the prevalence of eating disorders?

Like too many other psychiatric disorders, eating disorders have realized nearly unmitigated growth (in terms of incidence + prevalence) during the COVID19 pandemic.

Hospital / clinic staffing shortages. . .loneliness, isolation, and hopelessness resulting from extended lockdowns. . . extensive time spent at home, allowing for excess scrutiny over one’s eating habits and (potentially) time spent surfing social media. . . disruption to normal food acquisition and eating habits. . . complete disruption to the normal rhythms of life. . . constant fear and anxiety regarding one’s personal safety and the state of the world at large. . .

All these factors, and more, have played a part in what researchers have observed regarding incidence rates of psychiatric disorders since the start of the pandemic. Rates of anxiety and depression (across all demographics, i.e., children, teens, and adults) are skyrocketing worldwide, and similar increases have been noted amongst eating disorder diagnoses.

A few examples:

A clinical team in Australia has documented a 104% increase in the number of children with anorexia nervosa requiring hospital admission since the start of the pandemic.1,2

The number of people hospitalized for eating disorders in the U.S. has doubled during the pandemic.3

Waitlists for inpatient eating disorder treatment facility admission are currently running from 6 months to 1 year+ in the U.S. and the U.K.

A UK-based provider of mental healthcare services has tracked a 61% increase in the number of inquiries about anorexia treatment and a 26% increase in inquiries regarding binge eating disorder treatment since the start of the pandemic.4

A 2021 study performed by U.S. researchers found that 1/3 of eating disorder patients hospitalized since March 2020 identified COVID19 consequences as a primary correlate of their disorder(s).5

The implications here are serious.

Eating disorders are, together, the most lethal ailments known to psychiatric medicine, and illnesses for which the modern therapeutic arsenal is limited. Anorexia nervosa (AN), for example, which claims the macabre title of “highest patient fatality rate of all psychiatric disorders,” is associated with a relapse rate of upwards of 50% within the first year following treatment.6-13 5-10% of those with AN die within a decade of initial diagnosis – a figure that increases to between 18-20% by the two-decade mark.12,13 There is currently no medication approved by the FDA for the treatment of AN, and reigning AN treatment models are devoid of psychotherapeutic modalities that have been demonstrated to be consistently effective.

In tandem with other reports pouring in from around the globe documenting sharp increases in eating disorder patient referrals and admissions, these statistics expose a grim reality.

“Crisis” is the term proffered by noted experts Walter Kaye, MD, and Cynthia M. Bulik, PhD in reference to the current state of affairs in the treatment of AN and other eating disorders. . . a word that I maintain is absolutely appropriate.6

Haripersad YV, Kannegiesser-Bailey M, Morton K, et al. Outbreak of anorexia nervosa admissions during the COVID-19 pandemic. Arch Dis Child. 2021;106(3):e15.
Monteleone P. Eating Disorders in the Era of the COVID-19 Pandemic: What Have We Learned?. Int J Environ Res Public Health. 2021;18(23):12381. Published 2021 Nov 25. doi:10.3390/ijerph182312381
Asch DA, Buresh J, Allison KC, et al. Trends in US Patients Receiving Care for Eating Disorders and Other Common Behavioral Health Conditions Before and During the COVID-19 Pandemic. JAMA Netw Open. 2021;4(11):e2134913.
PrioryGroup. Eating disorders. https://www.priorygroup.com/eating-disorders. Nd. Accessed December 30, 2021.
Matthews A, Kramer RA, Peterson CM, Mitan L. Higher admission and rapid readmission rates among medically hospitalized youth with anorexia nervosa/atypical anorexia nervosa during COVID-19. Eat Behav. 2021;43:101573.
Kaye WH, Bulik CM. Treatment of patients with anorexia nervosa in the US—a crisis in care. JAMA Psychiatry. Published online February 24, 2021. doi:10.1001/jamapsychiatry.2020.4796
Reynolds P. A devastating disorder, poorly understood. IEEE Engineering in Medicine and Biology Society. EMBS.org. https://www.embs.org/pulse/articles/a-devastating-disorder-poorly-understood/. Published December 14, 2020. Accessed February 10, 2021.
Smink FRE, van Hoeken D, Hoek HW. Epidemiology of eating disorders: incidence, prevalence and mortality rates. Curr Psychiatry Rep. 2012;14(4):406-414.
Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Arch Gen Psychiatry. 2011;68(7):724-731.
Pompili M, Mancinelli I, Girardi P, Accorrà D, Ruberto A, Tatarelli R. Suicide and attempted suicide in anorexia nervosa and bulimia nervosa. Ann Ist Super Sanita. 2003;39(2):275-281.
Jáuregui-Garrido B, Jáuregui-Lobera I. Sudden death in eating disorders. Vasc Health Risk Manag. 2012;8:91-98.
South Carolina Department of Mental Health. Eating disorder statistics. State.sc.us. www.state.sc.us/dmh/anorexia/statistics.htm. Nd. Accessed September 29, 2020
Kostro K, Lerman JB, Attia E. The current status of suicide and self-injury in eating disorders: a narrative review. J Eat Disord. 2014;2(1):19.

How can adults be aware of the warning signs of eating disorders in kids and teens?

Behavioral and/or physical indicators of a potential eating disorder may include:

• Sudden / new / dramatic weight loss

• Depressed mood, despondency

• New behaviors surrounding food (such as preparing food in private, developing ritualistic behaviors around food, commencing a new diet, suddenly restricting foods or entire food groups, suddenly adopting a vegan/vegetarian diet; weighing himself/herself/themselves constantly; tracking calories)

• Novel and/or unusual aggression or irritability

• Visits to dieting or pro-anorexia (pro-ANA) websites

• Unusual or novel disengagement with the family unit and/or previously close groups of friends

• New and drastic changes in exercise habits (e.g., a sudden increase from 1 hour of exercise per day to 3-4 hours of exercise per day)

• Wearing overly large / baggy clothing to hide weight loss

If your child or teen displays any of these behaviors consistently for a period of more than a couple of weeks, seek the guidance of your pediatrician or other licensed health professional as soon as possible. . .whilst simultaneously keeping lines of communication open between you and your child / teen.*

*No matter what your child / teen is going through, he/she/they very much need(s) a loved one in his/her/their corner.

What should an adult do if they suspect they might have an eating disorder?

Seek the guidance of a licensed mental health professional as soon as possible. . . Preferably one with experience in treating eating disorders in adult populations and experience in utilizing an integrated model of care that includes biomedical analysis (e.g., physical and laboratory testing to assess nutritional status).

What is the link between nourishment and eating disorders?

In a word: profound.

Sadly, while eating disorders are universally recognized as involving abnormal eating behaviors resulting in abnormal, excess, or insufficient food intake (and remember: food = nourishment), the role of nutrition / nourishment in disorders such as anorexia are routinely ignored by mainstream medicine.

Mainstream treatment programs for eating disorders usually focus on calorie intake as a metric of health restoration – numbers on a sheet of paper or a scale – which is not always synonymous with “nourishment” (for example: a Big Mac hamburger and a large Mediterranean salad with fresh fish, fresh greens and veggies, and healthy fats such as olive oil provide about the same number of calories. Does this mean they’re both equally healthy and nourishing?). So, too, do mainstream treatment programs focus – almost exclusively – on psychological therapies that target the mind but not the body.

Such practices are based on a longstanding assumption that has been held by traditional psychiatry for over a century: that the mind is the mind / the body is the body. . . and that mind and body are completely separate entities.

This erroneous belief has persisted despite overwhelming empirical proof to the contrary (not to mention the basics of human organismal biology).

Consider:

The human body has evolved to be able to manufacture many of the nutrients it needs to function properly. Vitamin D, for example, can be synthesized in our skin upon exposure to natural sunlight; cholesterol, a building block of critically important hormones and signaling molecules, can be made by the liver, intestines, and other tissues throughout the body.

There are many nutrients, however, that the body requires to function optimally but cannot manufacture on its own. These are the “essentials,” and include (among many others) vitamin C, vitamin A, amino acids from protein, essential fatty acids, and minerals such as magnesium and selenium.

Essential nutrients MUST be obtained through the diet; there is no other way for the body to acquire them.

When it comes to neurobiology, ‘essential’ assumes an even greater significance, as many nutrients are REQUIRED by the brain for optimal function.

The human brain, which represents just 2% of a person’s total bodyweight, makes up a stunning 20-25% of the body’s total metabolic requirement.1 A high-octane generator of consciousness, the brain’s energetic and nutritional requirements are immense. What this means it that a deficit of any of the things required for proper brain function - whether oxygen, glucose, or nutrients essential to neurotransmitter synthesis – will affect brain function before physical symptoms begin to manifest.

When the brain is deprived of needed nutrients, the stage for an eating disorder is set.

Research dating back to the mid-20th century has yielded concrete, unequivocal proof that nutrition impacts mental health.

The [in]famous Minnesota Starvation Experiment of (1944-1945) was conducted to study the effects of starvation upon the human organism.

36 men participated as subjects in this experiment, which was designed and led by the [in]famous researcher Ancel Keys.2-7 For 24 weeks, the subjects consumed a restricted diet of only 1,600 calories per day, while remaining physically active. The result was extreme weight loss.

Weight loss, while expected, was not the only consequence of the men’s progressive starvation. Some of the most profound changes that the subjects underwent had to do with their mental health, evidenced through significant shifts observed in their mood and behavior. Like the patients with anorexia nervosa I see in my office, the men the experiment became obsessed with food. They thought constantly about food, developed bizarre rituals around meals, and even dreamt about food.

As the experiment moved forward, the subjects continued to develop psychological characteristics typical of anorexia: depression, obsessive-compulsive behaviors, anxiety, irritability, and delusional thinking. Their ability to concentrate became seriously diminished, and their comprehension and judgment faltered.

Surprisingly, the subjects continued to suffer detrimental psychological effects and to display abnormal behaviors even after their caloric intake was increased in the latter part of the study. Many of them experienced severe depression and distress. One chopped off three of his fingers with an axe. Fifty years later, this man was unsure as to whether this action was intentional, although he vividly recalled that he’d been mentally unstable at the time. The overseeing researchers ultimately attributed his behavior to a severe “semi-starvation neurosis.”2-7

The Minnesota Starvation Experiment demonstrated clearly that eating too little food for a prolonged length of time causes psychological symptoms—symptoms that mirror those of anorexia and other eating disorders. All of the subjects in this experiment had undergone extensive psychological screening prior to the commencement of the study, and all had been deemed to be in perfect psychological health. . . yet after only a brief period of calories restriction their mental health became seriously compromised.

The timeline of events is critical, here. The subjects’ psychological symptoms didn’t cause their anorexia or other abnormal eating behaviors; on the contrary, psychological symptoms emerged within three months as a consequence of starvation, and the severe nutritional deficits that came with it.

Modern research has uncovered profound genetic connections between abnormalities in the body and mental health.

In 2019 the results of one of the largest studies ever conducted on anorexia nervosa (AN) were published, establishing with unprecedented surety the biologic underpinnings of this disorder.7 The study involved the collection of genetic data from 16,992 AN cases and 55,525 controls from seventeen different countries. Analysis revealed eight distinct genetic loci that were associated with AN; further, data revealed that the genetic basis of AN overlaps with other psychiatric disorders such as depression, anxiety, OCD, and schizophrenia.8,9 Said lead researcher Dr. Cynthia Bulik, “This provides concrete evidence that genes are involved in risk for developing [AN].”8,9

The paradigm-shifting revelations from this study did not stop with AN susceptibility, however. Beyond contributing to AN risk, the eight genetic loci identified were found to be associated with metabolic traits such as cholesterol levels, body mass index, obesity, and blood sugar levels.8 While the research behind this initial study is ongoing, the connections that have been revealed thus far between genes, AN risk, and metabolism are so significant that they coalesce a powerful rationale for rethinking AN as a psychiatric and metabolic condition. Or, as described by Professor Bulik, a “metabo-psychiatric” disorder.”9

Physicians, dieticians, and mental health clinicians who treat eating disorders MUST consider the implications of these findings. A – massive - genetics study involving tens of thousands of eating disorder sufferers from around the world has confirmed that (i) genes contribute to AN risk, and (ii) genes associated with an eating disorder are linked with specific metabolic abnormalities.

And what is metabolism? Put simply, the totality of chemical reactions in organisms that sustain life. All vital to health and optimal function, and all entirely dependent upon the availability of essential nutrients.

Every process of human metabolism is driven by vitamin and mineral cofactors; without these cofactors, vital enzymes either do not function or function inefficiently, and the complex machinery of metabolism falters.

The takeaway: We KNOW essential nutrients are required by the human body. We KNOW that deficits of essential nutrients negatively impact the brain. We KNOW that prolonged malnutrition is powerfully associated with psychiatric dysfunction, and that starvation even in previously healthy individuals can induce psychiatric illness. We KNOW how to measure levels of essential micronutrients in patients via simple lab tests available to virtually any licensed physician, as well as how to implement regimens of nutritional supplementation.

We also know that, by themselves, psychological interventions are often not sufficient for individuals with eating disorders whose brain and neurotransmitter functioning is suboptimal.

It’s time to turn the page on outdated ways of thinking and outdated models of eating disorder treatment that separate body and mind. . . and which ignore the very basics – the established, unequivocal basic laws – of human biology. The successful treatment of eating disorder hinges absolutely on the rectification of psychological and biological upset, i.e., Nourish the Brain / Nurture the Mind.

Camandola S, Mattson MP. Brain metabolism in health, aging, and neurodegeneration. EMBO J. 2017;36(11);1474-1492.
Keys A. Experimental human starvation; general and metabolic results of a loss of one fourth the body weight in six months. Fed Proc. 1946;5(1 Pt 2):55.
Keys A. Nutritional problems of starvation and rehabilitation. Certif Milk. 1946 Jun;21:5 16.
Keys A. Human starvation and its consequences. J Am Diet Assoc. 1946 Jul;22:582-7.
Keys A. Experimental studies of starvation on men. Bull Chic Med Soc. 1946 Jul 20;49:42-6
Keys A. The residues of malnutrition and starvation. Science. 1950 Sep 29;112(2909):371-3.
Keys A, Brozek J, Henschel A, Mickelsen O, Taylor, HL. The Biology of Human Starvation (Volumes 1-2). Minneapolis, MN; University of Minnesota Press: 1950.
Watson HJ, Yilmaz Z, Thornton LM, et al. Genome-wide association study identifies eight risk loci and implicates metabo-psychiatric origins for anorexia nervosa. Nat Genet. 2019;51(8):1207-1214.
Reynolds P. The biology behind eating disorders. IEEE Engineering in Medicine and Biology Society. EMBS.org. https://www.embs.org/pulse/articles/the-biology-behind-eating-disorders/. Published December 14, 2020. Accessed January 15, 2021.

How can families find support and treatment options?

Clinical Care

Pediatric and Adult Care / Primary Care medicine represents the “front line” of eating disorder treatment. While they may not – and usually shouldn’t – be the last providers to whom families and parents turn for help, pediatricians and PCPs represent a necessary starting point.

Accordingly, any individuals who are concerned about their child’s / their own health are encouraged to reach out to their respective pediatricians or PCPs, even if just to ask a few questions. Gaining perspective and understanding is never a bad thing. . . and it is always better to act on guidance received from a licensed health professional as opposed to “Dr. Google.”

Of course, if a child is consistently displaying any of the behaviors listed above (warning signs), it is imperative that a health provider be consulted on an “ASAP” basis.

It is equally as imperative that anyone suffering from an eating disorder – whether a child, teen, or adult – ultimately receive dedicated care from a psychiatric specialist who has experience in the treatment of eating disorders. Most pediatricians and PCPs do not receive the kind of specialized training that is necessary to properly diagnose and treat eating disorders. . . one of a million reasons why the field of psychiatric medicine exists.

The pediatrician / PCP, then, is a necessary starting point from which a plan to access and acquire more targeted care can be hatched. A pediatrician / PCP may make a referral for psychiatric professionals in the area who have experience working with eating disorder patients, and can also recommend a licensed dietician or nutritionist to assist with meal planning.

The reality is that eating disorder patients often assemble, out of necessity, a team of providers, each member being dedicated to a unique facet of care. The care team for a patient with binge eating disorder (for example) may include a PCP, a psychiatrist, a registered dietician, an acupuncturist, and a gastroenterologist. A comprehensive treatment plan for a teen with anorexia (another example) may include psychotherapy, targeted nutritional supplementation, and meditation. . . accordingly, such a patient will require a multimember care team.

Knowledge and Support

The internet is overflowing with resources – some legitimate, some not – on eating disorders, as are the virtual shelves of online vendors with books on eating disorders.

While parents, families, and patients are encouraged to cultivate understanding about eating disorders – especially during treatment – it is vital that they exercise discretion with regard to the sources of information.

The good news is that there are many solid resources available for parents, family members, and patients that are based in sound science.

The National Eating Disorders Association (www.nationaleatingdisorders.org), for example, maintains an excellent webpage full of articles and parent / patient resources, as well as a moderated community forum intended to provided parents, patients, and survivors with peer support.

The National Institutes of Mental Health also maintain a web resource dedicated to eating disorders that provides information on signs & symptoms as well as treatments and therapies; this can be accessed at: www.nimh.nih.gov/health/topics/eating-disorders

I myself have also written several books on eating disorders that present a comprehensive, integrative model for treatment. . . a model that addresses psychology and biology together and prioritizes the correction of underlying nutritional imbalances. These books have been written for patients and their families, and provide clear, accessible guidance about how to implement an integrated, multifactorial approach to the treatment of these complex, multifactorial disorders.