Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered podcast. I'm Dr Neha Pathak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine. Eating disorders affect millions worldwide, crossing boundaries of age, gender, and culture. And yet, they're often overlooked, misunderstood, and definitely stigmatized. Today, we're going to speak with an expert guest about the complexities of one specific type of eating disorder, anorexia nervosa.

What we commonly refer to as anorexia, highlighting its risks and the pathways to hope and recovery. We'll unpack the nuanced definitions of a variety of restrictive eating disorders, including anorexia nervosa, atypical anorexia, and ARFID, avoidant restrictive food intake disorder, helping listeners understand their distinct characteristics and risks. We're going to explore early warning signs, risk factors across our lifespans, and how to approach a loved one you might be concerned about. This episode underscores the importance of early intervention, compassionate communication, and a commitment to seeking the right support for those affected by eating disorders.

Whether you're seeking support for yourself or a loved one, or just want to learn more, this episode is full of vital insights, and actionable advice to foster understanding and offer hope. But first let me introduce my guest, Dr Kamryn Eddy. Dr Eddy is the co-director of the Eating Disorders Clinic and Research Program at Massachusetts General Hospital and associate professor of psychology in the Department of Psychiatry at Harvard Medical School.

Dr Eddy focuses her research on studying the psychological and neurobiologic basis of restrictive type eating disorders in order to develop and test new treatments for individuals with these complex conditions.

Welcome to the WebMD Health Discovered podcast, Dr Eddy.

Kamryn Eddy, PhD: Thanks so much, and I appreciate you having me here.

Pathak: Before we jump into this really important conversation, I'd love to start off with your own health discovery, whether it comes to your research or your work with patients. What questions are you finding that patients are asking in private discussions with you that are giving you an aha around what patients are not necessarily comfortable bringing up?

Eddy: Yeah. It's a great question. One of the biggest questions that I get is one that has resonated with me for three decades, which is this question of: will I ever get better? So, I first became interested in anorexia in particular in high school when a close friend of mine who was a new transfer to our school pretty clearly had an eating disorder.

She was a young person who was quite underweight, but more than that, wouldn't eat with us at, any of the school functions, etc. And people noticed, and no one really knew what to say. When I started talking to her and became friends with her, I learned a lot and I learned that at 15, she had already been ill with an eating disorder for three years.

She had been described as having chronic anorexia, had been in and out of hospitals at that point, and more than that still, had been told that she had the bones of a, you know, 70 or 80 year old woman. She had osteoporosis. And she had been told that at this point she would never have children.

The message that she was being given at 15 years old was that she was chronically ill and that she was not going to get better. And I remember at 15 being struck by that, that that could be the kind of message that she was getting as a kid, like me. She was a kid, and it was really scary, and I think really sobering and sad for her.

One thing that I kind of carried with me over the years is just that, that kind of a message that she was being given was really one devoid of hope. So that it was kind of like. You know, this is where you are. You've been chronically ill. Like at 15 to be thinking that you're chronically ill. She is someone who continued to do treatment and she continued to live her life and she's someone whom I also continue to be in touch with.

And as an adult, you know, now about 30 years later, she is definitely recovered, and she is somebody who is the mom of a young person. She's also somebody who is a medical professional, and she has engaged in the world. What I carry with me for her is the idea that she was able to defy the messages that she was being given by the folks who were working with her, and she was able to recover and to have kids and to have a full life.

And what I think is really powerful for me when I think about her is the idea that, as a medical professional now myself, I have a really important role in carrying hope for my patients and in communicating to them that in spite of where they are with their illness. They absolutely still have a chance to recover.

And I think carrying a little bit of hope is really, really important because fighting anorexia is incredibly difficult and even more difficult to do when you don't have people who are being hopeful with you. So that's kind of my big medical piece that I carry. And it resonates with me a lot with my patients now, because that is a really common question that I get from patients and from their families is, Is this a life sentence? Is this a death sentence? Am I going to get better?

Pathak: Two things strike me as you're talking. One is that these symptoms present early in patients and then in young people, and also that there's something very noticeable potentially amongst. So, you are a group of young kids and you are noticing that there was something different with regard to the eating pattern that was concerning. And the second piece that really kind of strikes me is this hopeful message that the damage is not done, that there is a chance for recovery and for achieving all of the things that you want in your healthy life going forward. So pairing that identifying that there is something that may be of concern, and then pairing that with that understanding that now that we've identified it, there is some hope.

So I think that's really, really powerful to just kick us off in this conversation. Thank you so much for sharing that anecdote. So to take a step back then, can you just help us with some definitions, when it comes to anorexia? So, in your intro, we mentioned several different types of disordered eating that you focus on. So, can you help us with some of the definitions for these conditions? 

Eddy: Yeah, absolutely. So, I do focus a lot of my work on restrictive type eating disorders. I study anorexia nervosa, atypical anorexia nervosa, and avoidant restrictive food intake disorder. In some ways, these are kind of like who they are. They're three different eating disorders. I know today we're focusing on anorexia nervosa, so I'll start with that.

Anorexia nervosa is really defined by under eating, by a restrictive pattern of under eating that leads to a low body weight, and a low body weight or failure to grow, especially in young people. It's also defined by persistent fat phobia. So being scared of gaining weight, and in addition to that kind of a body image disturbance.

The body image disturbance could be looking in the mirror and seeing yourself as fat even though you're underweight. it could be something like overvaluing being thin. So feeling like your body weight and shape and being thin is really, really central to who you are as a person. And it could also be not recognizing that your degree of underweight is really dangerous for your health and your wellbeing. And so those are really the key criteria for anorexia nervosa.

Atypical anorexia nervosa looks very much like anorexia nervosa. The only difference is that in spite of significant weight loss, folks with atypical anorexia are not at a low body weight. That being said, it's a significant eating disorder that carries the same kind of risks that anorexia nervosa has.

It just may be even harder to detect for people, because it's not as immediately obvious. You're not necessarily noticing emaciated frame. But it significant medical risks, and it certainly carries the same degree also of psychological risks.

Pathak: And then can you tell us how this is different or what makes avoidant restrictive food intake disorder different?

Eddy: Absolutely. So ARFID, Avoidant Restrictive Food Intake Disorder, is an eating disorder that can occur across the weight spectrum. It's characterized by food avoidance or restrictive eating. That's distinguished from anorexia and atypical anorexia nervosa. In the sense that the food avoidance and restriction is not motivated by weight or shape concerns or a drive for thinness.

So instead, in ARFID, this is going to be folks who have a sensory sensitivity around eating. They're very picky eaters. They may have had a negative experience with choking or vomiting, etc., that makes them avoid eating. Or they may be folks who just have a low appetite or lack of pleasure around eating.

And it also carries significant medical risks and, of course, psychosocial risks too. But it is distinguished there because it's not about weight and shape concerns.

Pathak: And then just in terms of differentiating the anorexia and these avoidant restrictive type conditions from other commonly known, um, Eating disorders like bulimia. Can you talk us through that a little bit?

Eddy: Yeah, absolutely. So, there's a really strong relationship, you know, across all of the eating disorders, right? So they all carry this idea that, eating patterns are disturbed. That there's under eating, there may be overeating, there may be binge eating. Binge eating is eating a large amount of food and feeling really out of control, feeling like eating can't be stopped.

And then for individuals with bulimia nervosa, they're usually at a normal weight or overweight, and they will be folks who are engaging in binge eating and then some kind of compensatory behaviors. And usually what we're thinking about is some kind of purging. So engaging in some kind of behavior to counteract the effects of food that they're eating, like self-induced vomiting, misuse of laxatives or diuretics or excessive exercising or fasting. 

Pathak: I think just listening to you, I feel like I'm even more confident that this episode is really important for our listeners to be hearing and sharing with others because we're living in a time when, there is this focus on healthful eating, increasing exercise, there's these medications that are now being introduced for weight loss, that quiet food noise.

So it's really hard, I think, sometimes for us to distinguish what is appropriate. focus on maintaining a healthful weight and living a healthy lifestyle versus where it gets us into trouble from a physical and mental health perspective. Can you offer any of your insights and thoughts on this question?

Eddy: The boundaries between frank eating disorders and the sort of normative discontent that exists in our world and in our society, especially in the Western world, it's really challenging.

So you're absolutely right to highlight that eating disorders are important for us to be talking about. Even for folks without frank eating disorders, eating disorders. Eating disorders, psychopathology. So that is things like feeling dissatisfied with your body, feeling again, that term kind of overvaluation of weight and shape, feeling like it's central to who you are as a person, engaging in behaviors like dieting, restricting under eating, avoiding certain foods, certain types of foods, going on specific diets, especially when they're not prescribed by medical professionals.

Binge eating or purging, any of those behaviors are going to be more common than a frank eating disorder. And any of those behaviors, even when not part of a frank eating disorder, can be really problematic and distressing. And so, what I would say is, I'm really glad we're talking about this because I think that there is an under appreciation of how serious these issues are across the globe, really.

These are common behaviors that we see, especially in young people. and they're ones that we want to get people talking about so that we can recognize them and help people get help for them when needed. There's often a sense that eating disorders, they're kind of glorified times.

And part of that is again, this cultural belief that, in being thin or having a certain body image ideal, is just that is ideal. And the truth is, It isn't, it's not ideal, and it's not realistic for most people. And so instead, what we want to really do is work to shift our cultural ideals so that we can celebrate all bodies and all sizes and also appreciate that health comes in every size.

So your initial question to me was around the boundaries kind of between you know, when do these kinds of behaviors and ways of thinking become problematic from a physical standpoint and then also from a psychological standpoint? And I would say that it's probably kind of subjective. So from a physical standpoint, I'm a psychologist.

That one's a little harder for me to comment on. But I think that there are some real health markers that tell us when people are not doing well. Those can be things like vital signs. For women, it can also be things like missed periods and then absent periods, menstrual cycles, that can be a really big problem.

And it also relates not only to the maintenance of the eating disorder, because when folks are missing their periods, it also ends up being associated with mental rigidity and lack of enjoyment, sort of anhedonia, not finding things enjoyable anymore, which can maintain the eating disorder itself. But also, then associated with things like bone loss and bone fractures, which for athletes or other folks who are engaged in any kind of physical mobility can be a really big problem and can also make the eating disorder worse when mood gets worse, etc.

Pathak: So, can you tell us a little bit about who's at risk? What are some of the demographics, that we should be thinking about when we think about anorexia?

Eddy: So thanks for giving me the opportunity to answer that because I think what I would say really in short is eating disorders don't discriminate. You know, it's really hard and impossible, in fact, to pinpoint one demographic who will be the most at risk. There's a misconception that eating disorders are, you know, sort of a white girl illness, and that's just not actually not true, nor is it true that they only exist in young people.

So, the example that I gave is kind of a paradigmatic one, and it's a good one, but it actually isn't exhaustive. So, it's one example, and one way to think about it too is that eating disorder symptoms do often begin in adolescence. But they don't end in adolescence.

So, when we're looking at curves of when eating disorder symptoms start, they do often start early, but when did the diagnoses actually develop and then really get recognized and seek clinical attention? It's often not until, you know, later adolescence, early adulthood, and then even later adulthood for some of the other eating disorders as well.

In my clinical practice, I work with folks across the age span, and in fact, many of my patients are older adults who often have been struggling with their eating disorder for some time, for many decades. One of the things that we see is that there are multiple risk points. So, it could be times of transition.

That's one that we often think about for young people. That could be something like going from elementary to middle school or from middle school to high school. But then thinking about older adults, it could also be the transition from having your kids at home to then having the kids go to college and leaving the nest.

And then for older women as well, it could be periods of perimenopause and menopause that also put you at risk. 

Pathak: I'm curious about the types of signs and symptoms that we should be looking out for in our loved ones, in our children, that can be helpful as we're thinking about this as a potential reason for our loved one's relationship with food.

Eddy: So, some of the things that I would be looking out for, you know, as all parents are usually looking out for everything. So, it's hard to figure out, you know, it's kind of like being a pediatrician. Like how do you find anything when you're always on guard about everything? But for looking for eating disorders, some of the things that I would start by looking for are changes in eating patterns.

I know it sounds kind of simple, but I mean it in a big way. So our folks cutting out certain foods from their diet. Have you noticed that they're no longer comfortable eating X, Y, or Z, and why? Are they starting to talk more about weight and shape or feeling badly about their bodies? Are you noticing more isolation both around mealtimes and outside of mealtimes?

Those aren't things that are, you know, one to one correlation with having an eating disorder. they could also be pretty normative things that happen in adolescence, but they're going to be things that could give you a sign that something's going on. And so, as parents, and as caregivers and other providers, or just as friends, you want to be curious and open to finding out what's going on.

And so, even curious questions like, I've noticed. I've noticed this, I've noticed you're not eating dinner with us anymore. What's up with that? Curious questions can be a good way in to find out a little bit more about what's going on and then figure out how you're going to address it.

Pathak: I think that is so helpful and so key because I think for a lot of parents, caregivers, there's this fear that by saying something, anything, asking questions, you might putting this idea into your child's head. So can you give us some more helpful questions to start these probing curious questions that we can use, with our loved ones that we shouldn't be afraid of using conversation with our children.

Eddy: I hear that all the time as well. So people are really scared of saying the wrong thing. So they don't say anything. And I think that's the mistake, right? So always I encourage people to say something. It's really hard to talk about eating disorders. It's really hard to talk about, suicidality.

It's really hard to talk about any of these things that are really uncomfortable. And especially as parents and as adults, we're scared to bring things up that we think maybe the kids haven't thought about before. But the truth is, they're smart and they've usually thought about many things and if they're not doing them themselves, they're familiar with friends who are exposed to these things and they're exposed to them too.

So, rather than be scared of saying something, please just say something and often starting with “I” statements in terms of your own concern can be really helpful. So I've noticed this. I care about you. I'm here. If you want to talk, that can be a really nice way in and I think one of the other things that we can really try to do as grownups, as parents and as friends is really to model what we're hoping for.

So model being able to talk about hard things, making the hard to talk about “talk-about-able.” And also trying to model healthy relationships with food and healthy relationships with our bodies so being really mindful about how we talk about our appearance how much time we focus on our appearance and how comfortable we feel eating a wide range of things and really being able to model for kids and families that any and all is acceptable.

And we want to help them to feel good and feel confident. One of the things that I sometimes think about is, really trying to give space for kids feelings. So it is pretty normal, especially in times where we're talking a little bit about adolescence here. It's pretty normal to be thinking about your body, thinking about your weight, thinking about how your body might be changing.

Those are things that we want to give them space to be able to talk about and to be able to talk about the feelings, good or bad that they have about their bodies. and we want to hold space for that without immediately problem solving and helping them to change it. and that can be one way to think about the discussion too.

Pathak: So let's then dig into diagnosis and treatment when somebody does come into the clinic, as a patient or as a caregiver of a patient, what pathway do you go down?

Eddy: So, this day and age, most of really the frontline providers are going to be pediatricians, adolescent medicine physicians, primary care doctors, maybe, but also more general therapists, you know, because again, eating disorders are often comorbid. They coexist with a range of other presentations.

So they can exist with mood disorders. They can exist with anxiety disorders, autism spectrum disorder, ADHD, etc. So eating disorders will exist across the board. And for all professionals to be able to ask questions openly looking for eating disorders being comfortable to talk about them can be a really nice opening for folks.

So, but again, the frontline providers usually are the medical professionals who may notice changes in weight or eating behaviors, and then encourage them to get follow up. And so, a medical professional can be the one making the diagnosis, or certainly recognizing it first. There are a lot of screening tools that can be really useful for.

Asking questions around eating and whether your relationship with food could be problematic. And then what I recommend is meeting with a mental health professional who can ask more sensitive questions as well, get to know the person, and then figure out what's going to be the best route forward here.

For a lot of young people with eating disorders, family-based treatments are the first line. And that's because, there's a sense, especially with anorexia nervosa, that it's, the word that we use is egosyntonic. It's kind of a weird word, but it basically means the disorder kind of makes sense to the person, at least how it started.

It kind of makes sense. It feels like it's helping them and solving a problem for them. Maybe something as simple as I feel fat. This is helping me feel in control of my body. It's helping me to lose weight and feel better about how I look. But the reality is it's actually not helping. And even if it's helping in the short run, it's not going to help in the long run.

But because it's egosyntonic, it can be really hard for the person to engage in treatment on their own. So we usually, for young people, involve family members or other people who really care about them to help engage them and get them moving forward with recovery. For adults, individual treatment is usually the first line and cognitive behavioral therapy approaches are usually what we do.

Across the board, though, for individuals with anorexia nervosa, the first piece of eating disorder treatment is really around symptom interruption, and that is around interrupting the restrictive eating pattern and helping them to get back on track with healthy weight.

Pathak: So you mentioned that as part of treatment, you need a healthy dose of hope as well that treatment can be successful. Can you talk to us a little bit about to ensure that we're sort of going down the successful path? What are the prognostic indicators that we're moving in the right direction? I'd love if you can sort of talk to us about that hope piece a little bit more. 

Eddy: So one of the pieces for me is really trying to think about, you know, the clinician that you're working with. So again, somebody in the room needs to have hope. Hopefully it's, you know, could be the family, could be the patient themselves. But often patients are coming in and families even are coming in feeling pretty demoralized.

Sometimes they've tried multiple approaches before and they're coming in kind of with their last, last-ditch effort to try, and this can be true for the young people, you know, at 15, like my friend, or the patients who are in their 50s and they may be feeling demoralized. And so, as the clinician, you want to be working with a clinician who has seen recovery, believes in full recovery, and can model for you.

Absolutely, this is something that you can do. We'll help you figure out how to get there. And here are some of the steps. That's one piece. The second is around what are the components of treatment and sort of what are the pieces that may be those good prognosticators. One of them is active engagement and active symptom change.

So as is true really probably with most, most illnesses, early change predicts better outcome. So, and I don't mean early, like when you're 15, I mean early in treatment. So even if you've had 10 other treatment attempts this time, let's like jump in and try and help you move forward right away.

This is it. This is your time. And that can mean stopping the restricting really significantly making a big jump in terms of what you're eating. It can be something that shows your weight is changing right away in the first couple of weeks. Anything like that, that indicates early big change is something that really predicts how people are going to do.

And so what we try really hard to do from the beginning is really engagement around getting better. What are the reasons you're here? Why do you want to make change? What are you scared is going to happen? Okay, let's actually test that out. This is your opportunity. We can set up an experiment, see how it goes and see how you feel.

You've been doing this for a long time. You know what it's like. Let's do something different and see what it's actually like and help you learn that you actually might be able to cope with it differently than you were expecting.

Pathak: It seems like that first step of being engaged in treatment is showing up to the doctor's office. So, for those of us that might be in a situation where either the person that you care for is not present. Quite ready to seek care. What are some of the things that you can do to shift a conversation that's going to help them towards that path of recovery?

Eddy: So, I think part of it is, sounds like knowing your loved one well, kind of knowing what it is for them. That makes them tick, you know, what is it that would be the hook? And you know, I guess I use the term hook really gently. I mean it as a good thing. What's going to be the thing that helps them to get better?

So when I think about the woman I first mentioned, you know who as a kid I knew who grew up over time what she shared is that for her the hook now is her child She wants to be a good role model for her daughter. She wants to continue to get better for her daughter and, that can't be the only thing, but gosh, that's a really big one.

And that got her in the door to really keep going forward. A lot of times it is engagement in the world and realizing that there are other things that either you want to be known for or that you want to spend your time and your energy on, outside of weight and shape and eating that, just might make your life a little bit more fun.

And it's kind of being able to figure that out that can help people get in the door. And so I encourage those first conversations to be from the expression of, Hey, I've noticed this. I'm really concerned about you. I really love you. How can I help? I'm here when you're ready. And can we go in together?

Can I support you? Can I make the call for you? Can I bring you in? Can I share some of what I'm worried about? Because again, eating disorders, they cut really deeply and they don't usually go away on their own. They take some time and, they often need a lot of support to actually really make change because they are so ingrained.

Pathak: I love the emphasis on identifying purpose and passion in the person that you're supporting. And that's probably just something that no one else can do, but you, because you are so close and in this loving relationship with someone. So I think that. Is just such a powerful piece of the puzzle that we don't talk about enough as well to get someone, to move in the direction of engaging in treatment. So thank you so much.

Eddy: And I mean, I would honestly kind of highlight that piece as I hope one of the big take home messages would be that part of how people recover, how we think people get better, is that there is not as much room in their brains for the eating disorder anymore. One of my own patients said, you know, as she was recovering, there just wasn't room on my plate anymore for the eating disorder.

And I think she meant it literally and in every way figuratively as she started to really engage back in the world, those experiences became more meaningful, and they took up more space in her brain and in her sense of self. And that tipped the balance for her and that was worth more than staying stuck. But helping people to get unstuck, can be that first piece of motivation.

Pathak: So beautiful. I would love to invite you in our last few minutes together to offer any other thoughts, that you think someone listening should take away, when they're thinking about maybe their next encounter with someone that they're worried about, or potentially something that if they themselves, are suffering from, a disordered relationship with food or something that they can say to themselves to shift that narrative.

Eddy: So one thing we didn't talk that much about is what causes eating disorders. And I would say the truth is we don't know. There's a biological basis. There's a psychological basis. There's definitely a societal experience and basis for all of this. And what we do know is that eating disorders are not a choice and that it's not your fault.

So it's not a choice to get an eating disorder, it can be a choice to go on a diet, it can be a choice, some of the things in the beginning, but certainly nobody picks to have an eating disorder, but choosing to get better can be something that you make a decision for. So one thing I would encourage people to sort of hold for themselves is, you know, this isn't my fault, I didn't choose this, I wouldn't have picked this.

And so for people who are with them, trying to de stigmatize the illness and trying to recognize that they're probably doing their very best. They're trying to get out of this. they wish that they could get out of it and they don't really know how. So, I think that would be one thing.

And the other is that, you know, we have a lot of good treatments out there. And we are always working to develop new ones. So, being aware that there is help and that you can get better, I hope would encourage people also to come through the door. 

So, I've highlighted a couple of the approaches that we take for young people and for adults. but again, the truth is we are always looking for new interventions for folks with eating disorders. Anorexia nervosa in particular, it's complicated, both physical and psychological illness, that requires a multidisciplinary and often outside of the box kind of approach.

And so on our team at Mass General Hospital in Boston, we are doing just that. We're doing a lot of multidisciplinary research to try and understand these biological bases. things that keep people stuck in their eating disorder, so that we can then pinpoint them and target them in our interventions to help them then get better.

And we do this both with behavioral, cognitive behavioral kinds of interventions, and we're also doing it with different kind of hormone and endocrine interventions. And so those are things that I would just offer as, again, hope for people that we are using approaches that work, and we're thinking outside the box to develop novel interventions to really help continue to, help people get better. 

Pathak:A few things that I took from this discussion are that anorexia nervosa is a complex but treatable condition. Hope is crucial in recovery. Maintaining and communicating hope is essential for patients and families because it plays a significant role in motivating engagement and to progress in treatment. Eating disorders don't discriminate. They affect people across all ages, genders, and ethnicities with trigger spanning life transitions and societal pressures.

 We also talked about how treatment often requires family involvement for younger patients. Family based treatments are the first line of care. These treatments focus on empowering families to support system interruption and recovery. 

Parents and caregivers should not shy away from discussing eating concerns with their loved ones. Asking open, curious, and non-judgmental questions can actually create a safe space for identifying issues early on. To find out more information about Dr Kamryn Eddy, please visit our show notes.

Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform. If you'd like to send me an email about topics you're interested in or questions for future guests, please send me a note at [email protected]. This is Dr Neha Pathak for the WebMD Health Discovered podcast.