Transcription:

Bill Klaproth (Host): A secondary effect of the COVID-19 pandemic, has been the significant increase in eating disorder diagnoses and relapses in the pediatric population. Eating disorders are among the most fatal psychiatric illnesses. So, concerns raised by parents, friends, teachers, or others should be taken seriously and evaluated by a physician, as soon as possible. However, eating disorders take many forms and can be tricky to identify. Dr. Michelle Bowden, a General Pediatrician at LeBonheur Children's Hospital who specializes in Adolescent Medicine and is an Assistant Professor at the University of Tennessee Health Science Center, is here to talk with us about LeBonheur's Eating Disorders Clinic as well as how parents can receive support while navigating their child's eating disorder.

This is the Peds Pod by LeBonheur Children's Hospital. I'm Bill Klaproth. Dr. Bowden, thank you so much for your time. It is great to talk with you. So, first off, let me ask you this. Tell me about the Eating Disorders Clinic. When did eating disorder services begin at LeBonheur?

Michelle Bowden, MD (Guest): Yeah, I'm happy to tell you about that. It has been a passion project of mine for the last few years here at LeBonheur and we're really proud of what we've been able to create. But we really saw a need about four or five years ago, for some eating disorder services here at LeBonheur, recognizing that we had a growing patient population of adolescents, mostly who were being admitted to the hospital and showing up to general pediatrics clinics who very likely had an eating disorder. What's interesting about eating disorders is they're very unique illnesses in the adolescent population that require some specific treatment modalities and really specific care you're for it those diagnosees. And we weren't really offering that and there wasn't anybody in the region who was offering that. And so I had some personal experience with friends and that had had eating disorders and felt really passionately about that being a part of what I was going to practice. And so we started this Eating Disorder Clinic to address the needs of our community which has turned out to be a really robust and great place for patients to land when they have eating disorder concerns.

So, we offer a multidisciplinary clinic every week at LeBonheur, in which patients who either have diagnosed eating disorders or concerns for eating disorders can come and be evaluated by a dietician. They can have child life services. They can see me as their medical provider. They can get labs. They can get heart monitoring to make sure that they are healthy and safe to continue in their treatment plan and to receive a diagnosis and then get into the appropriate treatment for their eating disorder. So, we're really proud of what we get to do and feel like it's a service that we not only offer the Memphis community but really the surrounding area.

Host: Yeah. So, this is alarming that this is a growing trend. So, it sounds like the Eating Disorders Clinic is much needed in this area. So, let me ask you this. What are eating disorders? You mentioned that each case is kind of unique, so it sounds like eating disorders can take many forms. Can you explain that to us?

Dr. Bowden: Absolutely. And I think it's really important to recognize that eating disorders occur in all different types of patients. So, I think historically there's been some bias in eating disorder language and diagnosis that where not all patients have been treated equally and what we're recognizing now is that eating disorders occur across the spectrum in terms of it happens in people of all races and colors and then some people of color, certain eating disorders actually occur more commonly and things like bulemia nervosa or binge eating disorders that happen more commonly in people of color and then there are beliefs that eating disorders like anorexia nervosa only happen in women, or only happen in adolescent girls. And I actually have a robust portion of my clinic that is represented in adolescent males or in really early pubertal males in the 11 to 12 year old age group. So, I really think it's important that we all recognize that this happens across the spectrum and people of all colors and both genders and every socioeconomic class.

And there are different disorders that may occur in each individual patient. So, the ones we see most commonly, the first is anorexia nervosa which most people are familiar with and probably have ideas of the very, very thin picture of someone that you know may have been famous and had an eating disorder had anorexia nervosa. But most commonly in adolescents that doesn't present that quite that severely, thankfully. What we typically see is a patient who has started progressively started restricting the number of calories that they eat over time, very often accompanied by also increasing how much exercise they get. And over time they lose a good bit of weight and so sometimes that means that they become underweight. Sometimes that means that they stop growing appropriately. Like they don't gain the height that we would expect them to gain as a early teenager. Sometimes it means that they are overweight and become normal weight but the ways in which they're losing weight and the rapidity that they lose weight is dangerous for their bodies. And so those are all potential diagnoses of anorexia.

We see bulemia nervosa in which patients you may eat a normal amount but then purge those calories, very often by vomiting but also sometimes by overexercising, sometimes by misusing medications even sometimes medicines that are necessary for life like thyroid medicines or insulin. And then we have a newer diagnosis called avoidant restrictive food intake disorder that represents a fair number of our patient population. It's also called ARFID in which a patient doesn't necessarily try to change the way their body looks. They're not concerned about the way their body looks but they have a very restricted diet for other reasons. So, maybe they have autism spectrum disorder. Maybe they have OCD. Maybe they're just really picky eaters but instead of a picky eater who typically starts getting better food intake as they get older, they become more and more restrictive and then are at risk for having a low weight or not having enough nutrition or maybe even having vitamin deficiencies. So, we see all of those types of patients in our clinic and are happy to do assessments for any of those.

Host: Wow. That is a broad range of different types of eating disorders. This is really insightful. And when you said that this happens to all different types of patients, my perception was that this generally happens to females. So, you said this happens across the board, to people of color, to boys, to girls. So, really insightful what you're talking about. Okay, so, I'm a parent. I know that something may be wrong. What are some things that we should look for or be cautious of?

Dr. Bowden: Absolutely I think that's such a great question. And I hope that we have lots of parents out there asking that question. You know some early warning signs that I think about are a child who decides they're going to go on a diet. So, unfortunately our kids, just like most of us, are inundated with ideas about the way that their bodies should look and that comes from being on social media, that comes from their peers, that may come from a sports team that they're a part of. But I worry about kids who decide that they need to change the way their bodies look and decide to do that through a diet, specifically the more extreme diets things like keto diets or vegan diets or vegetarian diets or deciding even something as what we would hear somebody say I'm decided to quote unquote eat clean, can be really damaging in an adolescent body. So, that can sometimes be a first warning sign that we may need to talk about this as a family and we may even need to get some help to address this for our teenager. But I tend to get more worried if I see a patient who starts on one diet and then picks up another one and another one. Very often the kind of patients that I see you started off with wanting to cut back on their carbs, but they didn't lose as much weight as they thought they were going to. So, they then also started cutting back on, they cut out meat. So, now they're a vegetarian and they don't eat carbs and then maybe that's not enough. And so I decided to only eat salads. Very often I think parents can see that progression of well I've cut out sweets and then carbs and then meats, and that progression is not normal and that child is not getting the full spectrum of nutrition that they need to get.

Some of the other things that I think you'll notice in adolescence is that they start really being conscious of what they're eating. And so you may see them start checking food labels. You may see them become active in preparing their food even to the point that they don't want to eat something that someone else in the family has prepared. And sometimes they just totally withdraw from being able to eat family meals all together. So, they may stop participating in family meals or going out to eat with the family and all of those I would consider warning signs that the child really needs to be seen by someone. The family needs to start talking about that cause those aren't typical behaviors in adolescents. The other couple of things that I would just mention is just things like going to the bathroom right after a meal can be indicative of potentially purging. If you're worried that your kids may be engaging in a behavior like that, counting calories or other quote unquote macros could potentially be damaging for these kids and could indicate that they're more worried about their bodies than what they're letting on.

And of course if you start noticing physical signs. So, things like child isn't gaining weight the way that they should or they start losing weight. If they start complaining of things like I'm really fatigued or I'm having weakness or I feel like I'm going to pass out. One of the really classic symptoms is feeling cold all the time. And that's because we just don't have enough nutrition to fuel our bodies to get the warmth to our extremities that we need. And then of course if a patient is over-exercising. They may have injuries to certain muscle groups if they're participating in certain sports for hours every day or overexercising certain muscle groups. So, all of those things can really be potential warning signs that a patient should be evaluated further for.

Host: Those are really interesting things and very helpful to any and all parents. So, like you said it usually starts with extreme diets and that leads to then elimination of foods. It sounds like they're kind of on a hamster wheel of just cutting things out and cutting things out and cutting things out which is not good. Also watch out for if they go to the bathroom right after a meal. If they're counting calories. And then you said look out for physical signs, losing weight, fatigue, weakness, overexercising. So, really helpful tips for us parents. So, thank you for that Dr. Bowden. So, then if we recognize any of these things you just mentioned, what are our next steps if we suspect our child might have an eating disorder?

Dr. Bowden: Again, this all starts with asking the right questions right. Is being involved enough in our children's labs to know that these things are going on that they're not willing to eat dinner with their family anymore, that there really worried about the way that their bodies work, that they're started to be more socially withdrawn. All those things are good questions that I appreciate parents being aware of and wanting to dig in further. That's really what our Eating Disorder Clinic exists for is for parents who may be really concerned and may even be pretty certain that their child has an eating disorder. Or if they're just like you know what, they’re engaging in some of these things because they think they're being healthy but I'm not sure that they are. And I just need some more education. So, really anything on the spectrum of that is something that we and the Eating Disorder Clinic are happy to evaluate and to provide feedback for. The nice thing about that clinic is that we can say you know we're not worried about this right now but let's follow up in three months. Let's give you some education about what appropriate adolescent nutrition looks like and follow up in three months and see how that's going. But if a patient does wind up having a more severe illness, we also have connections to area experts and eating disorders counselors, therapists, nutritionists, dieticians who all have expertise in eating disorder care. And if a patient should need a more intensive treatment regimen, then we also can make those referrals and help get a patient into the care that they need. So, I think the key is really looking for a place and a person who is experienced in eating disorders, who goes out of their way to recognize these issues especially in adolescents and is willing to make those connections with a full team of people who are going to be treating an adolescent with an eating disorder. Because it's never just one person. It's never just the doctor or the dietician or the therapist. It really requires a team approach for these patients to get well.

Host: So, look for someone experienced in this. And like you said, a team approach, and that's what you provide at the Eating Disorders Clinic at LeBonheur Children's Hospital. And it sounds like you want parents to ask you those questions. If they have concerns like hey, I don't know for sure, but here's what I'm seeing. What do you think? It sounds like you would rather have them ask those questions upfront. Then not, and waiting until something really looks wrong. Is that right?

Dr. Bowden: Absolutely and we're happy to provide however much or little support that patient and family may need.

Host: Well that's really good to know. So, let me ask you this. Have you noticed an increase in eating disorders during the pandemic? This has been tough on a lot of people.

Dr. Bowden: Unfortunately we really have and that's true across the country. I work with treatment centers from around the country and we would all tell you that since March or April of 2020, the need for eating disorder treatment has really exponentially grown. I read a statistic recently eating disorder treatment center referrals are seven times higher than they were before COVID. So, we're all at risk and watching the secondary effects as we call them of COVID play out in terms of how this is affecting our adolescents. And so one of my favorite things to tell parents is eating disorders are never about food. It's easy to make them about food. But eating disorders are really about control and in March 2020, most of us lost all the control that we felt like we had over our lives. And that includes our teenagers that most of them weren't able to go to school anymore. They experienced social isolation, they maybe started spending more time on social media. So, they started being more aware of social pressures to look a certain way. And then they had time. They had time to think about what they were eating. They were not on their sports teams anymore. And so they started working out at home.

For many of my patients, that has turned into really disordered eating and disordered behaviors and obsessions with food and the way our bodies look and has turned into anorexia or bulemia or another really severe eating disorder. And so, it's really sad to know that that's how it's played out and it's been disheartening to watch this happen in many of my patients. What we know is that we are trying to meet the demand of that. That the eating disorder treatment centers and that our clinic and LeBonheur are really rising to the task of helping patients and families get the care that they need too weather this and to not have any more potential outcomes from COVID than they have already had. And so we're really grateful that we get the opportunity to provide that but we do know that COVID is indeed a risk factor for the development of these disorders especially in our adolescent population.

Host: Yeah, it's easy to see the toll that the pandemic has taken on people. When you say seven times higher. Wow. And something else that really stuck with me. You just said eating disorders are not about food, it's about control. Really interesting. And that's really good to keep that in perspective. So, we've been talking about children this whole time but this can be really nerve wracking on parents as well. What are some ways that parents can help receive support?

Dr. Bowden: That's a great question. And I hope that we will continue to recognize the toll that having a child with an eating disorder takes on the parent because it really is. It's a scary thing to experience your child with such a severe mental and physical illness knowing that eating disorders are probably the most lethal psychiatric illness. Because patients can literally waste away and die from malnutrition when they have a severe restrictive eating disorder. So, we have begun to offer some support for parents here at LeBonheur. We've offered a new, just beginning support group for disordered eating for parents who have children with disordered eating which includes anorexia, bulemia, binge-eating disorder, avoidant restrictive food intake disorder or even maybe your child doesn't have one of those diagnoses yet but you're worried about their relationship with food. We've started this group. It's called Comfort From our Cupboard. And it's really meant as a parent support group for those who are loving children, adolescents, maybe even brothers or sisters or maybe their teachers, who are helping care for the patients who really need extra love and support from their caregivers. And so it's a group that's going to meet a couple of times a month via Zoom. So, it's all safe and COVID friendly and we'll offer parents who have experienced having a child with an eating disorder. We'll be able to offer comfort and support and hope for those who may be just entering that journey. They can learn from one another. They can support each other. They can gain education about what are some tactics that worked for you or tactics that worked for me and you know the days that you just need somebody to listen and say hey I've been there and I know that it gets better that that will be a part of this group too. And so, we're really excited to be offering that and you can be on the lookout for more information from us. It's Comfort From our Cupboard offered here at LeBonheur.

Host: That's really good. Comfort From our Cupboard. And when you support the parents you're also supporting the children as well. So, really great to learn more about the Eating Disorders Clinic at LeBonheur. Dr. Bowden, and this has really been informative. Thank you so much for your time. We really appreciate it.

Dr. Bowden: Thank you It's been a pleasure.

Host: That's Dr. Michelle Bowden. And for more information, please visit LeBonheur.org. And be sure to subscribe to the Peds Pod in Apple podcasts, Google podcasts, or wherever you listen to your podcasts. You can also check out LeBonheur.org/podcast to view our full podcast library. And if you found this podcast helpful, please share it on your social channels. This is the Peds Pod by LeBonheur Children's Hospital. Thanks for listening.