Episode 252: #59-1 Eating Disorders

The Virtual Curbside is a production of the Utah Chapter of the American Academy of Pediatrics, the Utah AAP, working together to improve children's lives through education, advocacy, and networking. Hi, this is Paul Workus from the Utah AAP. Welcome to this week's edition of the Virtual Curbside, where we bring pediatric providers together with subspecialists to get smarter about all things pediatric and better acquainted as a community of caregivers.

The Virtual Curbside is brought to you in part by a generous grant from Primary Children's Hospital. Primary Children's Hospital, the child first and always. Welcome back to the Virtual Curbside. We're very fortunate this month to have the extraordinary Nikki Milopoulos with us talking about eating disorders. And just a little side note about this, Nikki talked about this at our annual Common Problems.

conference. And if you haven't been there before, you should think about maybe visiting us for the Common Problems Conference. It's a great time to visit Utah in early June and cross paths with some very smart people. Welcome, Nikki Milopoulos. Thanks for having me. Nice to be back. It's very kind of you to make time in your busy life to talk to us. Should we dive right in? Absolutely. Okay. Tell me what things you would like to disclose before we chit-chat.

I would like to disclose that I am an employee at the University of Utah in the Department of Pediatrics, and I am not representing the university or the department. I'm here just as myself and that I have a... financial conflict. I'm finally making money as a shareholder of Pfizer and Merck. And now I am a consultant for a company called Carrot Fertility.

And as it turns out, none of those are going to have a huge bearing on what we talked about today. That is true. We appreciate your individual and collective expertise. So let's talk about eating disorders. What is an eating disorder? I mean, it seems like a good question.

Yeah, an eating disorder has been described as a serious but treatable mental and... physical illness that can affect people of all genders ages races religions ethnicities sexual orientations body shapes and weights and that is directly from the national eating disorder association website What that means is that an eating disorder is a relationship with food or someone's body that makes it so that the natural biological...

hunger and satiety cues are being influenced by something else. So there is now a pathological relationship with food or exercise or the body. How common are they? Fairly common. So this most recent quote is that in the United States, 28.8 million Americans will suffer from an eating disorder at some point in their lives. It has been stated that somewhere between 1% and 3% of adolescents will experience an eating disorder.

What was that again? One to three percent of adolescents. That's a lot. And is it your estimation as well that we miss a lot of them? Yes, I think we miss a lot of them if we're not thinking about them and asking about some basic symptoms. And I'm guessing that if they affect a lot of people...

of different types and different ages that we may see different presentations at different ages and stages. Yes, that is a very important observation. So I think traditionally, when we think about eating disorders, we think about... the very thin teenage girl who sees herself as obese or as having obesity or a lot of extra weight and, and that she's refusing to eat when in reality.

Someone with a body mass index of 45 may have a restrictive eating disorder and they are actively starving themselves, trying to lose weight and being successful at losing weight or maybe not, but they're not eating. Since eating disorders are not one thing, and really, as you suggest, don't necessarily fit the mold of what we worry about. When should I worry about an eating disorder? Oh, so we should all be considering an eating disorder.

If someone comes to us and says, gosh, I'm suddenly feeling really tired or I'm more irritable or I. feel depressed, or my skin is really dry, my hair is falling out. Getting more cavities. I'm suddenly dizzy. So really pretty much everything because eating disorders can affect almost every system of the body. And so we need to bear in mind when we're thinking about our differential diagnosis, you know, is this something like diabetes mellitus or is this...

an intentional, I'm avoiding food or I'm actively vomiting to lose weight type of a situation. And so always keeping it in our differential. And as you were saying a minute ago, Keeping it in our differential doesn't just mean glancing at the growth curve. It means that we've had a conversation, probably. Correct. It means having a conversation.

As you mentioned a minute ago, eating disorders are not one thing. Let's talk about it because there are different classifications that have different diagnostic criteria. Let's get the uncommon ones out of the way first. There are a couple of uncommon eating disorders. When it comes to uncommon eating disorders, I like to think about rumination.

So that's something that when I hear the word rumination, I think of cows, actually. So people with rumination disorder are those who eat food and then regurgitate it. And that's happening. often, at least once a week for at least a month. And they can chew food and spit it out. They can swallow it and spit it out. They can chew it and swallow it and spit it out. And this is not an intentional regurgitation.

It is an intentional regurgitation, but not in the sense of someone who's actively trying to vomit. Okay. Like where they need to like stimulate their vomit reflex. Okay. Okay. We'll come to purging in a minute, but it's different from classical purging. Correct. Different from classical purging because someone with a rumination disorder has no intention of losing weight or changing their weight as a result of the regurgitation. Okay, great. And then what's the other uncommon eating disorder?

Pica is another uncommon eating disorder. So those, you know, when I hear pica, I think, oh, pregnant woman who has iron deficiency anemia and is, you know, chewing ice, sucking on pennies, going after dirt and, and really pica. is more than that. Pica involves eating items that are not typically thought of as food and that do not contain significant nutritional values such as hair, dirt, paint chips.

That is a persistent consumption of that non-nutritive, non-food substance for at least one month. And the importance of that is that we're looking at why that happens. And as you point out there often.

causes for that iron deficiency and whatnot. Correct. Okay. Let's come to the common eating disorders. And I think most of us can identify anorexia. and bulimia, but it's more complicated than that, right? Because anorexia is subtypes of anorexia, and that's not all of the disorders. Correct.

So within anorexia nervosa, we see the restricting subtype. And I think we're going to talk about all of these in more detail in a moment. So I'll just gloss on these for a moment. So a restricting subtype versus a binge purge. subtype versus an atypical subtype. And that atypical might be the example I gave of the person with a BMI of 45 who is restricting, but because they don't meet that underweight and perceive themselves.

to be overweight criteria that it falls in the atypical category. Bulimia nervosa is what I think most of us think of as binge. And we'll talk more about how that differs from the anorexia nervosa binge purge subtype. And then binge eating disorder, which wasn't recognized very well until probably the last. 15 years which is the most common eating disorder in the United States.

and is characterized by recurrent episodes of eating large quantities of food. But then a little more than that, because there's also the emotional component to that. And then avoidant restrictive food intake disorder, which... We see typically among younger children, not so much in adolescence. And then relative energy deficiency of sport, which previously was called female athlete triad. But the reason the title was changed to relative energy deficiency of sport is so that includes the males.

who are engaging in those same behaviors and are experiencing metabolic consequences of that. And then I also wanted to add to those orthorexia. which I didn't mention during my common problems presentation. And I think we tend to see orthorexia in... older adolescents and adults. And that was coined in 1998 to describe an obsession with proper or healthful eating. So there's people who are so obsessed with only eating healthy foods that they won't eat a cupcake at their child's birthday. Okay.

So sort of like a food scrupulosity. Yes. Yes. Like a food scrupulosity. Okay. That, that makes sense. Well, let's, let's take those apart in more detail. Let's go back to anorexia nervosa.

I think we all have a sense of that, that it's restrictive eating. And that's kind of the overarching principle, right? Yes, that there needs to be this restricting energy relative to the body's energy requirements. So who's at risk for anorexia nervosa? So the people who are at risk for anorexia nervosa are typically adolescent girls, although it is not exclusive to girls. And they are people who are experiencing anxiety. They are people who may be a little obsessed with their behaviors.

They may be obsessed with the ideal of a specific body image. And one of my former mentors liked to say that anorexia nervosa is a developmental disorder. because the typical onset of anorexia is that stage of early adolescence where the identity is beginning to form. Oh, interesting. I mean, it does strike me that it's really a difficult process.

for a lot of adolescents to come to grips with the idea that your body changes so completely. Yes, absolutely. And it doesn't help that the beauty standard is that every woman should look like an 11-year-old boy. No, it does not help that the beauty standard is that. Exactly. So in cultures or smaller sections of society, right? So perhaps it's the school that someone goes to or their friend group where.

the majority of the people in that space value thinness than someone who may be more prone to developing anorexia nervosa is. at greater risk, right? And especially if it's someone who has anxiety or an obsessive behavior. You're at odds both with the fact that your body doesn't look the way that it used to look. And this doesn't require social media, but social media also applies a standard that's in many ways completely unrealistic.

Absolutely. And where social media has become even more dangerous and unrealistic is in the fact that on Instagram or Twitter or I don't know. many other places, Snapchat, where kids go, that someone can modify their image and present it as reality. Right, right. Very sad.

And what are the diagnostic criteria for anorexia nervosa? The diagnostic criteria for anorexia nervosa are this performing a history that... identifies that there has been a restriction of energy intake relative to the requirements, so relative to energy requirements, that leads to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.

And that there is also an intense fear of gaining weight or becoming fat or persistent behavior that interferes with weight gain, even though someone is at a significantly low weight.

There is a disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. And then importantly, Even if all of the DSM-5 criteria for anorexia are not met, a serious eating disorder can still be present, such as in the setting of atypical anorexia, which includes individuals who meet the criteria for anorexia but who are not underweight.

despite significant weight loss. Okay, so let's take subtypes apart then. The way that I think most of us think about anorexia nervosa would be the restricting subtype, right? Yes, absolutely. So that's someone who's restricting calorie energy intake for all those reasons. Usually there will be a weight loss or low weight maintenance. Is that correct? There will be a weight loss, right? And that weight loss.

happens over the course of three months. And it's caused by restricting calories in combination with or with exercise. So it can be restricting calories, no exercise, restricting calories with exercise or just exercise.

would not without intentional restriction but failing to increase the number of calories needed to account for the increased exercise was that too confusing and we need to do it again no no that's not confusing at all i think the thing that i think i don't think clearly enough about with this is that it's an energy mismatch between what my body needs to do.

what it does both metabolically and whatever activity and exercise that I do. And so then I would be consciously restricting my calories so that I don't meet those needs. Exactly. Okay. All right. This is making a lot of sense. So the atypical type, as you mentioned, is someone who you may look at the growth chart and say, this person is not anorexic. Correct. Because maybe their BMI is...

Because we're still using that in kids, even though we're trying to get away from that in adults. But so someone whose BMI is greater than the 95th percentile for age and gender. In which case we say, oh, no, there's no way they're just they're losing weight. So there's something else going on. OK. Or, oh, they decide to make some healthy lifestyle changes. Right, right. Congratulations. You have an eating disorder. Great job. You lost 25 pounds since we last saw each other.

That's rough. So now let's talk about the binge purge subtype, because I think most of us are going to think about that in terms of bulimia nervosa instead. How is it different? So the difference is that restrictive energy. So anorexia nervosa specifically includes restricting caloric intake to less than what the body's needs are. So when we think about a binge in anorexia nervosa.

that individual is going to think of a binge as 100 calories. Whereas the binge in bulimia nervosa is a binge of more than what a... typical person would eat in a meal. So there needs to be the binge followed by a purge behavior plus the restriction. Okay. So somebody who has bulimia nervosa may not have weight loss. Correct. So someone with bulimia nervosa probably will not have weight loss because they are not restricting their caloric needs to less than what the body's...

demands are. Instead, they're eating food. So they're maybe have a very disordered eating pattern where maybe they skip breakfast, they have a small lunch, and then have a big dinner because they're starving. And then that big dinner is actually more of a binge because it has this out of control, you know. oh, I can't stop until I finish the entire package. And then, oh my gosh, I just binged. I need to go purge. Okay. And so because I've eaten so many calories in a single setting.

And they aren't able to purge faster than the body is able to absorb 50% of those calories. They don't lose weight. Okay. What are the common complications of untreated anorexia nervosa? Oh, common complications of untreated anorexia nervosa. Well, when the body is denied of essential nutrients. It is unable to function normally. So then it starts to, or is forced to shut down and slow down all of its processes to conserve energy, which will result in serious medical consequences.

Those might be having a slow heart rate or low blood pressure, decreased mentation, so they're unable to focus very well. They may experience... dizziness or syncope. On the gastrointestinal system, when it starts to slow down, they may develop gastroparesis or gastroparesis, depending on what part of the country someone resides. They will experience abdominal pain and bloating. Some will experience nausea and vomiting as a result of the gastroparesis.

They can have blood sugar fluctuations and some will become very hypoglycemic in the morning before it's time to have their first meal. They're more likely to develop infections because their immune system isn't working as well. They can be very constipated. and develop hemorrhoids or pelvic floor problems. What else? They have very dry skin and brittle nails and thinning hair.

As you mentioned at the first, there are a whole lot of different complications, which is why when we see an adolescent, for instance, with postural orthostasis, one of the things we need to sort out is, could this be an eating disorder instead of either? vasovagal issues or postural orthostasis and tachycardia. Yes, absolutely. All right. Let's move on to bulimia for a minute because I think...

We use the term binge and purge, but it's probably a good idea for us to explain. So what is binging? Sure. So binge eating is eating definitely greater amount of food than a typical person would eat in the same period of time. in a discrete period of time. And in the DSM-5, that discrete period of time is defined as two hours. And then there's a sense of lack of control and inability to stop eating. And then,

That binge eating is followed by recurrent, inappropriate compensatory behaviors to prevent weight gain. And those compensatory behaviors may be vomiting or inappropriate use of medication, such as taking laxatives to try to get the calories out. bottom end or diuretics to try to eliminate the fluid. Some people may abuse stimulant medications that are commonly prescribed for people with ADHD.

They may engage in excessive exercise or they may fast, which is different than restriction. So fasting as a form of purging, it means, oh my gosh, I just ate 3000 calories. I can't allow myself to eat for the next three days, or maybe it's just for the next day because I ate so many calories. I'm not going to allow myself to eat anything because I need to get those calories out of my system.

Which is a bit more complicated than the way we usually think about purging. Correct. Correct. And then all of these behaviors need to be occurring at least one time per week for three or more months. So if we ask our question to someone, you know. do you ever do you ever skip meals you know and and they say oh um yeah sometimes okay you know well how recently have you skipped a meal yesterday okay why did you skip that meal you know we kind of

It's the why. Yeah. I mean, because sometimes we skip meals because we're running behind or we're trying to get our work done over lunchtime or something. But it's the why. The why. And then I guess there's probably that group, too, of people who for religious purposes are going to fast for one day a month or maybe even one day a week. And then we need to make sure that that purpose of fasting.

is because of the religious intent and not because they're trying to lose the calories that they ate in a binge. Sure, sure. And again, a kind of scrupulosity in some ways. Yes. Yeah. Anything else we need to know about the diagnostic criteria of bulenia? So with bulimia, there's that whole piece of self-value where someone feels worthless because of how their body shape or weight is.

undue influence of body shape and weight that determines self value and and importantly the disturbance is not only exclusively during episodes of like restricting? I'm not sure I understand. Okay. So people with bulimia nervosa may not be engaging in any of their disordered eating behavior. but they still feel like they're not worth having friends or they don't deserve something because they don't look right. Because, right. Okay.

That's very helpful. Moving on to binge eating disorder, is binge eating disorder just binging and purging without the purging? Yes, sort of. So that's a good way to think about it for sure, that it is this binge eating without restriction and without purging. So there are no behaviors to prevent weight gain. And that it's occurring at least weekly for at least three months. So very similar to bulimia nervosa criteria. And that there's also at least one of the following behaviors. So either.

eating faster than normal or eating until feeling uncomfortable or eating large quantities when not hungry or feeling embarrassed about eating behaviors or eating is followed by very negative emotions. They're probably wildly underdiagnosed. Wildly underdiagnosed. And the prevalence of binge eating disorder is estimated at at least 3% of the population and appears to be more common in women, but maybe not.

Aside from the disordered thinking that's involved in that, what are the risks of binge eating? So the risks of binge eating are the emotional or mental health risks. One, right, because there's this guilt and also there is an association with depression. And then the other piece is the weight gain that often occurs with the binge eating and the fact that the binges are unhealthy food binges typically.

Someone with binge eating disorder isn't going out and eating a huge, beautiful salad of vegetables and some grilled chicken or salmon. Someone with binge eating disorder is going to go eat the entire green bean casserole. Yeah. The reason you diagnose and treat it is to help people develop a more healthy relationship with food and with their sense of self. Yes, exactly that.

So how does avoidant restrictive food intake disorder differ from anorexia? Okay. So that's an also good question. So people with avoidant restrictive food intake disorder. do not have the body image distortion that someone with anorexia nervosa has. And they also don't have the intention to lose weight. So when this gets identified and we're performing our history.

and say, hey, it looks like, you know, your weight has decreased a bit. And I'm worried about you because I'm noticing these changes in your vital signs. And we got some labs and those were a little unusual. And they're not going to be crazy labs, right? It's going to be like, maybe their, their BUN is elevated and maybe even their creatinine is a little low because they're losing muscle mass and saying, are you trying to lose weight? And often those people will say.

Oh no, I don't want to lose weight. Well, could you eat more? Maybe, probably, I don't know, but I can only eat certain foods. I can't eat all of the foods. And that avoidant restrictive food intake disorder, importantly, is not explained by a lack of food or having some other medical condition that's affecting appetite or another mental disorder.

So sometimes, I don't know, what would be a mental disorder that would cause changes in food? So maybe someone who's having delusions or hallucinations and feels like the food's been poisoned is not going to eat, right?

because oh no i can't eat that food because that's poisoned it's going to make me sick so this avoidant restrictive food intake disorder is a little challenging to address because we commonly call those people the picky eaters And we need to really explore that so that the picky eaters are expanding and challenging. their relationship with food to try new foods and, and increase the variety of foods that they eat so that they're improving their overall health.

they're able to stay on a growth curve because that's really when avoidant restrictive food intake disorder becomes a problem is when it interferes with normal growth and development. So it's not just, I don't care for mushrooms. But I carve off enough of food types that it makes it difficult for me to maintain good health. Exactly. And then I guess, you know.

We can see avoidant restrictive food intake disorder. I used an extreme there with someone who kind of has a psychosis setting, but we see it more commonly in people with anxiety disorders or who have autism spectrum disorders. So maybe there's a sensory issue with food. or those who have an obsessive compulsive disorder, or even those who have attention deficit hyperactivity disorder. Sure. And then lastly, the relative energy deficiency of sport.

As you pointed out, it's important that we have moved beyond calling that the female athlete triad. It strikes me that in some ways, this is a modification of the other things we've talked about, that energy intake doesn't match energy need. And these are people who are generally expending a lot of energy. Yes, these are generally people who are expending a lot of energy and they are not adequately compensating with.

calorie intake to support all of that energy expenditure and so we see that they lose weight and their BMI drops and in the definition it's a BMI of less than or equal to 17.5 and that in in those with a uterus and ovaries that they experience amenorrhea so cessation of menses for at least three months and then also having the effect on low bone mineral density. So maybe we're seeing more stress fractures. Oh, interesting.

You would have to think that one of the things that may be persuasive in the long term is that adequate nutrition is probably going to improve performance, not decrease performance. Yes, that's a really great point, Paul. So getting adequate nutrition has been very clearly documented in sports medicine research to improve athletic performance. And it seems like that if somebody's trying to perform at the highest level, that may be the key then to talking about it.

Well, Nikki, this has been very, very interesting and helpful. It's really, really sort of expanded my view of eating disorders. I think I need to think about this for a minute, and then let's get back together next week and talk a little bit about screening and some of the treatment issues. Anything else you want to share before we move on from today?

I just want to really make sure people are keeping the prospect of an eating disorder in mind when they see someone whose growth may not be moving in the direction that they expect. Learn about the screeners that I think we're going to talk about next week. We're going to talk about those next week. And to recognize that adequate nutrition and a healthy relationship.

with both nutrition and activity is something that we're trying to teach from a very early age. And as a result, I think it has to be somewhere near the heart of what we do. Yes, you described that well. I think we've come from a space where... telling people you need to eat better, you need to lose weight, you need to get more exercise, sounded like reasonable counseling, but the way it was being given.

can sometimes in a very well-meaning spirit, right, can sometimes trigger someone to develop an eating disorder. Very helpful. Well, Nikki Milopoulos, thanks for your time. We'll talk again next week. For those of you out there listening, please send your questions to questions at vcurb.com. Remember to like and subscribe and recommend us to a friend and we'll talk next week.

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