← This Is So Awkward
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- [00:00]
A
You know that feeling. Too many updates, too many meetings, too many things falling through the cracks. Monday.com was built for that gap, the AI work platform designed from the ground up for people and agents to work side by side and deliver more together, drafting the brief, flagging risks, running a competitive scan. Your agent can do it all. And the best part, anyone can build one. Even you. Try it. Create your first Monday agent today at Monday.com
- [00:31]
B
Vanessa when we re release episodes of the podcast Oftentimes we choose to re release episodes that are upbeat and engaging and exciting for people in all sorts of ways because that's what people gravitate towards from time to time. They want to listen to content that feels both informative and like a little bit of a break from the exhaustion of life. This episode we are re releasing for kind of the opposite reasons. It's a hard topic talking about disordered eating and eating disorders, but it is one that is everywhere around us and impacts kids from all walks of life, kids of all ages, kids of all genders. And we have, I mean, frankly, the goat of eating disorders in our Midst. We have Dr. Kelly Bhatnagar, who is not only an expert in eating disorders and disordered eating, but is a contributor to our curriculum and all of our body image eating disorders and disordered eating lessons in our curriculum. There are seven of them out of our 100 lessons. And she has become really a primary go to resource for us and a friend.
- [01:58]
C
Yeah, I mean, Kelly is, as you will hear, an extraordinary guide through just a tremendously complicated topic. She treats people who are struggling with eating disorders and disordered eating. And she works in schools and she is involved in national organizations and yet she is so able to keep the language clear and simple and nonjudgmental as we explore vocabulary, as we unpack warning signs of eating disorders and we get underneath the realities of these increasingly common struggles amongst people of all ages. And we help parents think about what they should be looking out for and how to approach conversations about food and body image so that you're creating a culture in your home that supports kids who are struggling and also, you know, models the sort of path forward that is most empowering.
- [03:07]
B
I mean, you will be glad that you listened and if you've heard it before, you will be glad you listened again. Hi Vanessa.
- [03:25]
C
Hi Cara.
- [03:26]
B
Our listeners are going to get tired of hearing about our membership, but I want to start this episode by connecting what you're about to hear from Kelly Bhatnagar and what we do on Less Awkward. So we are going to Be in conversation with Dr. B. Kelly, who is an expert in body image issues, disordered eating and eating disorders. On our library, which you can access through our membership, we have tons of content that covers each of these different buckets in this general vertical of sort of body and eating. And we have the Awkward bot that is trained on all of the good science that we use to support our writing and all the content we put out. And it's trained on our podcast transcripts. So if you have questions about body image, eating disorders, disordered eating, and you don't have time to re listen to this amazing episode that you're about to hear, you can go to the Awkward Bot. You can put in your question and the data that Kelly talks about. The answers that Kelly gives here will come back to you in 10 seconds.
- [04:53]
C
And before we begin the episode, we just want to put a trigger warning in for those listening for whom it's not safe to listen to, to an episode about eating disorders. And we hope, we believe that we've presented this material in a supportive and informative and empathic way, but just wanted to give folks a heads up. And also if you have kids in your house who tend to listen to whatever you're listening to and it's a concern for them as well, just want to give you a heads up on that. So with Dr. B, as she calls herself, and as Kelly as we call her on the episode, I mean, her bio and her resume is so astoundingly deep and impressive that we won't get through all of it, but we'll give some top line stuff. She's a clinical psychologist licensed in Ohio and Colorado and has specialized in the study and treatment of eating disorders and related psychological conditions for over 15 years. And, and in 2018, she was named a fellow in the Academy for Eating Disorders, which is a really prestigious honor. In addition to that, she currently is serving a three year term on the Board of Directors in the Academy for Eating Disorders and is a member of the American Psychological Association, Ohio Psychological association and the Cleveland Psychological Association. So I know this episode has been a long time coming and we really waited to find someone who we felt like could match both incredibly deep professional experience with real hope and joy and optimism and empowerment. And you'll just have to listen to Kelly for five seconds to realize that she embodies all of those things.
- [06:45]
B
Kelly, we are so thrilled to have you on. This is so awkward. The podcast. Welcome.
- [06:54]
D
Thanks so much. I'm thrilled to be here. This, I have to say, is one of my favorite podcasts So I am super excited to be here. And I say that because I have teenagers of my own. Well, one teenager, one soon to be teenager of my own.
- [07:07]
B
Well, that is high praise from someone whom I consider to be one of the best voices, most clear and thoughtful and studied voices on the topic of eating disorders and disordered eating. For you to come in here and say, this is one of your podcasts, maybe we should just end there. We could just like, mic drop, we're out. It's really. That is high praise. We have a lot to cover today. This is an episode that's been a long time coming for us. We have covered Body Image on this podcast in our book on social media, I mean, countless times at this point. But what we haven't covered, mostly because we've just been waiting to schedule with you, is eating disorders and disordered eating and understanding the terminology, the distinction between those things, how okay or not okay it is to talk about these subjects or with the kids in our lives. Where are these labels and names important? Where are they destructive? We're going to get into all of it. So let's start at the top with a little vocab. And can you help our listeners understand the difference between an eating disorder and disordered eating?
- [08:40]
D
Yeah, absolutely. And I will say that's probably one of the most common questions that I get, especially for parents presenting to our clinic. You know, what's the difference between disordered eating and eating disorder? And when should I be worried? What should I be concerned about? You know, which is a great question. And so how I like to look at it is just in general, eating behaviors exist on a spectrum, right? And this spectrum can range from normal or actually the term I personally prefer is balanced eating, you know, and then moving into more problematic, even dangerous eating and, or like weight management behaviors, you know. So I think, though, it's important to note that any sort of maladaptive eating behaviors can greatly impact a person's physical, psychological and emotional health. So it's important that we're paying attention to all of it, you know, but to really differentiate disordered eating from an eating disorder, so they can look very similar. So essentially, disordered eating includes many of the same symptoms, behaviors of an eating disorder, but they typically occur at a lesser frequency or a lower level of severity than what we see with an actual eating disorder. But again, I'm going to say this over and over again. It's still really problematic if it's disordered eating, but some examples can include restrictive eating, compulsive or binge eating, chronic dieting, irregular or inflexible eating patterns, self induced vomiting, food fears or food avoidance, laxative, diuretic enema misuse, steroid misuse, diet pills, all of those things kind of fall under the umbrella of disordered eating or an eating disorder. So they essentially can look similar. But you may not qualify for the actual eating disorder diagnosis per the DSM 5 because of frequency, intensity, duration, or severity of the symptoms at any given time. But disordered eating can be a precursor to an eating disorder.
- [10:43]
C
Kelly one of the things and I, I feel like maybe we should have started with this is that many of the people listening to this episode have themselves struggled and may still be struggling with an eating disorder or disordered eating. And we talk a lot about leaving your baggage at the door. So when we talk to parents about puberty and adolescence, we encourage them to leave their own experiences at the door. But when it comes to this area, it's really hard to do that, particularly if you yourself are still in the midst of your own illness. And so I'm wondering if you have any advice or framework for, for people listening who struggle with these issues themselves and are caring for kids who may be struggling as well.
- [11:34]
D
I think that due to stigma and just lack of good information about eating disorders circulating on the Internet or in other places, this can be a really challenging topic for anyone to talk about, let alone someone who has their own history of an eating disorder and may need to support a child or an adolescent with an eating disorder. It's important to know, though, too, that an estimated 9% of the U.S. population, or 28.8 million Americans, will have an eating disorder in their lifetime. You know, and of teenagers, when we're thinking about teenagers, 2.7% will experience an eating disorder in their lifetime, and 13% will develop an eating disorder by the age of 20. So this is a major health crisis for all of us. So we have to be comfortable talking about it, and we have to be, as parents, feel comfortable talking about with our kids too, despite our own histories as well. So what we do know about eating disorders is that they tend to run in families. So we know this from family research studies, from twin studies, from genome studies, and all of that. We know that they tend to run in families. So when a kiddo presents to me in the clinic, chances are that an important adult in their life has some history of an eating disorder. They do know someone within their family that may or may not struggle with an eating disorder as well. But I guess what I always say to parents and to others, too, is that this doesn't mean that they cannot help their child or being an important resource for recovery. And in fact, some of the best partnerships I have had in treating a child has been with a parent with their own history of an illness because they know the pain that an eating disorder can cause. They know firsthand the experience of what it's like living in the brain of a person with an eating disorder and who, in most cases, who has their child's best interest at heart other than their parents? So even if they weren't able to make decisions for their self, you know, or are able to help themselves fully in terms of recovery, they can make decisions that can help their child. They can partner with their clinicians to be able to help their child, too, you know, so I think it's really important and that we're just all having these conversations and we're not excluding those with their own history because A, we still be playing into the stigma of eating disorders and presenting blame with it, and B, you know, we're taking away a valuable resource from a child who may need their parent.
- [14:00]
B
I would imagine that there are some number of parents who you don't even know about their history because the numbers are massive. And they have evolved past that diagnosis. Right. So they have been treated, and they no longer carry the label of either eating disordered or having disordered eating. Do you ask. Do you ask the adults?
- [14:22]
D
That is part of our intake question. When we do talk with parents, when, you know, when we're making a diagnosis and doing a formal eating disorder evaluation similar to any other diagnosis, we do go into an extensive family history where we will, in fact, ask about, you know, the family, not just parents, you know, but we'll ask about grandparents and other relatives, too, because of what we know about how eating disorders run in families. So, yes, that is something that we will ask.
- [14:48]
C
And what's your advice to parents about if they themselves have had experiences, what should they share? What shouldn't they share? Like, what's the line there, Kelly?
- [15:01]
D
You know, I think it depends on the stage of illness that the child is in and what they're ready to hear, you know, and that's not at all dissimilar to any information that the child. Right. So I could be sitting with a kid in the early stages of an illness where they may not, due to lack of insight about the illness, that I can get them the best statistic, the best information, and it's going in one ear and out the other ear or kind of being misconstrued by the eating disorder. You know, and so when and I also want to hold and honor, you know, when a parent is comfortable sharing, you know, that'll be a conversation. I think it's a more personalized and individualized conversation that we're accounting for where the child is, what the parent is comfortable with, you know, and how ready they are to talk about their illnesses. But I will say in our evidence based treatment approaches for kiddos with eating disorders, we are so hyper focused on resolving the crisis at hand, getting that child better that usually initially that's not the place for those sorts of conversations unless it's directly interfering with our treatment plan.
- [16:08]
B
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- [16:29]
D
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- [16:31]
B
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- [16:42]
A
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- [16:55]
B
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- [17:13]
C
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- [17:40]
B
So upgrade your everyday Download the Quince app for app exclusive offers or go to quince.com awkward get free shipping on your order and 365 day returns. Now available in Canada and the UK too. That's Q-U-I-N-C-E.com awkward. I mean, it strikes me as we're using this language that eating disorder is a diagnosis, right? But disordered eating is a description and it's so Interesting. The different emotional reaction I feel inside myself as we use these two different words, almost like one feels a little bit more solvable. It's just a description. Today you're feeling sad. Today you're. This today, right. Feels a little more temporary, whereas eating disorder. Having an eating disorder feels heavier. And I think the way that many of us grew up, especially, you know, I distinctly remember when Karen Carpenter died, right, and the messaging around that and what an eating disorder was supposed to be based upon that. And of course, that was one example of one type of eating disorder, but it conferred a tremendous amount of fear and shame. And it also, it kept the idea of what this is so narrow. So a lot of people who are now parenting, I think we miss the bigger boat on some of the issues that are captured by this term. And I think the idea of seeing something as a diagnosis, sometimes it makes us feel like it's always gonna be there, like it's a chronic illness that we're never gonna be able to shed. And I, for one, can say that in the world of pediatrics, I've seen lots of kids be diagnosed with eating disorders and then get better and then no longer carry the diagnosis of being eating disordered. So to Vanessa's question, how do you pull all that together and not just take the parents baggage, but also the burden of what they carry from what they know of these problems from when they were younger, what was messaged and marketed to them? How do we flip that narrative a little or expand the view a little?
- [20:01]
D
Oh, that's a great question. You know, this leads to. What I hope is the most important takeaway from this discussion is that there is hope and that eating disorders are absolutely treatable, you know, particularly with kids and adolescents. You know, early identification and early intervention is critical to successful treatment outcomes. You know, so I think you're right. So many people who have had either disordered eating or an eating disorder go on to live healthy, happy, fulfilling lives, you know, where they're not burdened or their life is not. They're not experiencing significant interference in their life because of these symptoms any longer. So I think that's a really critical message. But I also strongly agree with what you're saying about needing to widen what our conceptualization of what constitutes an eating disorder is, you know, because I think you're right. I think of us think of the Karen Carpenters of the world, you know, and other celebrities. And I will say that anorexia nervosa tends to be glamorized most often in the media. You know, and on social media and whatnot. You know, the Karen Carpenters of the world are not the only faces of eating disorders, you know, so eating disorders do not discriminate. And whereas they've historically been thought of as privileged white young women's, you know, illnesses, we know for a fact that that's not the case anymore and that we don't discriminate based off of ethnicity, you know, sexual orientation, gender, SES status, any of that, you know, so it's important that we're. We're looking for eating disorders in all groups. But then along with that, too, you can't tell an eating disorder by looking at someone. And some of the sickest kiddos that I've worked with are kids that live their lives in average or higher than average bodies, you know, but yet they're missed by their pediatricians because they think, oh, you know, you don't look scary thin like Karen Carpenter did, so you must not have an eating disorder. So for me, that's part of the education piece, needing to get good information before we have these conversations with our kids, and also making sure that we're addressing our own biases and our own stigmas about not just eating disorders, but just weight and shape in general so that we're having effective conversations.
- [22:13]
C
Kelly, can you describe the most common diagnoses you see of eating disorders so that our listeners have a baseline understanding of what to do, be on the lookout for, and what language to understand?
- [22:26]
D
Sure. So I could talk about, you know, the most common eating disorders that we see in kids and teens and the ones that present to our clinic. So we'll start at the top alphabetical order here. Let's start with anorexia nervosa. So when I think of anorexia nervosa, and it's in a clinical sense, what I'm thinking of is a. The behavioral aspect of it. So the restriction of energy intake, not getting enough fuel for your body, not eating enough, that leads to a significantly low body weight in the context of one's age, their sex, their developmental trajectory, and their physical health. And again, that kind of goes back to the public service announcement about not being able to look at someone and tell that they're at a significantly low weight, because really, it's relative to their own body and their own growth trajectory. And also important with kids and teens to think about. With anorexia, we're not just worried about losing weight, but we're also really worried about kids not making their excess expected gain. So if they're falling off of their growth curve or their weight stayed exactly the same two years later. You know, we know kids should be growing at this time. So that's also going to give us a red flag or concern about anorexia nervosa. But what we see with anorexia too is this intense fear of gaining weight, which sometimes can be either denied or doesn't feel like it's the case with some people with the diagnosis. But what we'll still see is a persistent behaviors that interfere with weight gain. So whether or not they're saying it's because I'm afraid of gaining weight, they're still acting in ways that prevent weight gain from happening when it's medically necessary. And then oftentimes we do, like I said, see that body image disturbance component and a lack of recognition about just how serious this illness is. So that's how we think of anorexia nervosa. The newer to the DSM 5, the newer eating disorder diagnosis is something called avoidant restrictive food intake disorder, arfid. So this one, it can look similar to anorexia nervosa, but it has some difference. So anorexia tends to have a more abrupt onset. This is something that happens, you know, a little bit more acutely, what we're seeing versus arfid. Kiddos with arfid, they tend to have a much longer history. So these are kids that are historically known as picky eaters. You know, the ones that although grow out of it, they're just really, really picky, yet their pickiness is interfering either with their growth and development or just with family functioning. You can't have, you know, dinner together as a family because we're so limited on what the child is able to eat. But kids with ARFID tend to have a younger age of onse and they're missing that body image component that we typically see with anorexia.
- [25:02]
B
Can kids with ARFID have diagnoses like celiac or allergy, where eating a certain food makes them feel bad? It's low grade. No one really understands that there's an allergy or that there's an underlying problem and then they develop ARFID on top because it becomes sort of this vicious cycle.
- [25:21]
D
Certainly. And I will say that can occur with other eating disorders as well too, you know, and I think that's why a full medical workup is a really important part of the eating disorder evaluation, evaluation process to make sure that we're not missing some of those things that might help explain some of the symptoms. Or some of the behaviors. So, and, and then the last thing about arfid, when thinking about arfid, we kind of think of what I like to call three different flavors of arfid. So in one category of arfid, kids, we have kiddos with sensory sensitivity. So maybe they don't like the texture, the flavor, the smell, the temperature of certain foods. And that requires them to limit some, maybe many food groups at a single, at a period of time. The next flavor of kids with arfid are kids that have a fear of aversive consequences. So they're just afraid something bad is going to happen so they'll throw up. Yeah, that's right, exactly. So if I eat this, I'm going to get sick, or if I eat this, I'll choke, or I'll have pain, or I'll be alert. I'll have another allergic reaction similar to what I had in the past. And then they may limit their repertoire because of that. The final category is kiddos that have a disappearance, lack of interest. There are just some people who are biologically hardwired to have lower appetite, premature fullness, and just don't experience the same levels of pleasure that maybe other people do when it comes to food. So kids with ARFID can have one, two, or all three of these presentations at a given time.
- [26:43]
B
Let's move past the A's, the anorexia, and ARFID into the B's. Can we talk about things like bulimia and binging?
- [26:52]
C
Sure.
- [26:53]
D
So, binge eating disorder. So this is when one is experiencing recurrent episodes of what we think of as binge eating. So this is eating typically in a discrete period of time, maybe two or so hours. Amount of food that's considered definitely larger than another person would eat under similar circumstances. Now, I know that's somewhat subjective and it makes it challenging for us.
- [27:17]
C
Is that a clinical definition? It is. Oh, my gosh.
- [27:21]
B
It's all relative.
- [27:23]
D
It's all relative. And there continues to be lots of discussion about what precisely this means so that we can better understand binge eating behaviors. You know, But I will say when people come to our clinic and talk about some of the binge eating episodes that they have, you can tell also too, what helps us to differentiate it as well is they're also describing a feeling of not being in control. So some of my clients have said, you know, Dr. B, at times I feel like a robot. I don't even taste the foods. I'm eating mechanically at that time. So it's eating that larger amount of food paired with that lack of control that really constitutes a binge eating episode. And then there will be other symptoms such as, you know, eating much more quickly than usual, eating until uncomfortably full, eating when not hungry. And it's paired with lots of intense emotional reactions too, such as embarrassment, shame, disgust, feeling depressed or feeling guilty. That kind of accompanies these binge eating episodes as well.
- [28:19]
C
So, Kelly, people often think of bulimia as connected to binge eating. Can you either validate that or debunk that and help people understand the clinical definition of bulimia?
- [28:34]
D
Sure. So bulimia nervosa and binge eating disorders share kind of the hallmark feature of binge eating episodes. So we still see that those overeating episodes or those binge eating episodes, the lack of control. But what differs bulimia from binge eating disorder is that we typically see compensatory behaviors that go along with the binge eating episode. So these behaviors are typically done to prevent weight gain. And it includes self induced vomiting or purging, a misuse of laxatives or pills, fasting, excessive exercise. So that's really what's going to make binge eating disorder look different from bulimia nervosa. But what I will also say too, where it gets kind of confusing, is that you can also see purging or self induced vomiting or over exercise in anorexia nervosa as well, you know, and I think that's where a lot of people get confused. I have anorexia and bulimia, you know, and right now, per the DSM 5, you can't be diagnosed with both though, really what it's going to come down to is your weight status relative to where it should be at any particular moment in time.
- [29:38]
C
Kelly, for people who don't know, can you just explain what the DSM 5 is? Sure.
- [29:43]
D
So the DSM 5, I call it our diagnosis. This bible, for lack of a better description, really it's a comprehensive book of any sort of psychological or psychiatric diagnosis that one could have. And it's divided up by different sections. So this is where we learn and how we find research based descriptions of what an anxiety disorder is and all the different types of anxiety disorders, mood disorders, category for feeding and eating disorders and whatnot. So it's what we use, our comprehensive book that we use that's updated regularly to assess, assist clinicians with their diagnoses.
- [30:16]
B
It's like a giant yellow pages.
- [30:18]
D
A giant yellow pages, yes.
- [30:20]
C
But there are things that we see culturally or societally that may not have made it into the DSM 5 yet.
- [30:28]
B
I mean, beyond that, Vanessa, what is in and what gets removed is massively politicized and people debate it constantly. And the DSM is not updated very often. And so, you know, getting a diagnosis in or losing a diagnosis can translate into years and years and years of no reimbursement for certain. Right. Because it's not just naming for the patient, it's also naming for the insurance companies so that then a service can get paid for. So the DSM is so complicated, but it's designed to help keep everyone speaking the same language.
- [31:12]
C
So for people who have a kid in their life about whom you're concerned and it isn't a clinical diagnosis, you should listen to your gut that whatever behavior you're seeing is still something to seek help for. There are ways to get help and support even if it is not physically in the DSM 5, right.
- [31:35]
B
So here's an example, Kelly, maybe you can speak to this one. Bigorexia.
- [31:40]
C
Yeah.
- [31:41]
D
So you know, I, when I, when the initial thought that came to mind was yes, when in doubt, ask a question, you know, you know, no matter how awkward, you know, like ask a question, you know, and even think about it with so many different things, we have our clinical terms for it and then we have our lay terms for it and think of like I, you know, I think of my 13 year old, he and his friends, they have like new language for every single thing. But when I actually. Wait, explain to me what you mean by whatever they're talking about. I'm like, oh, that that translates to this in my mom mind, you know, and I think comes to the same goes with eating disorder behavior such as bigorexia. So I think helping people then to again break it down to the behaviors. When you say bigorexia, what exactly do you mean? What are you concerned about? What sort of behaviors accompanied so we can all understand and you know, like Carter was saying, making sure we're speaking the same language, that's going to aid us in being able to help.
- [32:36]
C
So let's talk about the two things that are not in DSM 5, right? Orthorexia, bigorexia. And I would argue, Kelly, and I don't know if you agree that those are things we're seeing a lot in males in teenage boys and young men, and yet it's not a clinical diagnosis, but there are pieces of everything you've talked about in these other diagnoses and behaviors and health consequences of what, what people are doing. Do you want to Kind of share. I hate to. I don't want to compromise your, your work as a clinician because I know they're not technically. And I've had this back and forth with different practitioners about this terminology. How do we engage with these terms? Besides, obviously, as you said, if you're worried, ask questions and get help. How do we engage with these terms that reflect concerning behavior but may not have an actual diagnosis?
- [33:32]
D
I think my personal style as a clinician is to try less to engage with the terms and again, more engage with the symptoms. Now, this doesn't mean at all I'm going to shy away from it, particularly when it comes to actual clinical diagnoses using that term, explaining what that means to kids, families, adults, whoever that might be. But again, what I'm going to break it down to is whether we have the term or not, what's problematic and what's the way if you living your life. You know, I think of orthorexia in particular in many regards. People think be great, right? You're really focused on healthy living and a healthy lifestyle and, and whatnot, you know, but behaviorally, if you are no longer going out to restaurants, afraid now to eat what other people prepare, you know, where you can't share meals with your family because of this health obsession, then is it really healthy? You know, so it's kind of like shifting people away from the terms and more to the symptoms and the behaviors would be my therapeutic approach for better, like I said, better understanding and then
- [34:35]
B
intervening and so just to level set. So the concept of orthorexia is what I think it's probably not the right word, but an obsession with is the word I would use. That's probably a little drastic, but an obsession with health, healthy eating, exercise, it's a. It's a fixation that occupies brain space in the direction of being healthy, but it occupies so much of your brain space that it becomes problematic. Is that a reasonable way of describing orthorexia?
- [35:05]
D
Yes. And also too, I think even when thinking of some of our actual clinical eating disorder diagnoses, again, it feels so entangled to me. It feels also intertwined. Right, because you can't really differentiate. Because again, many of the patients that come see me, the first thing that they'll say is, I started making these changes in order to get healthy. I saw a TikTok video saying that this is what I should do to focus on my health, to lower my cholesterol. And then for some people who have the genetic vulnerability or whatever reason they occur, they developed into something more. So I don't think you can kind of like, tease them all apart because we'll see symptoms of orthorexia within some of the other eating disorders as well.
- [35:46]
B
That's right. And the same with bigorexia. Right. So the concept of bigorexia is that in our society, many males in particular are not looking to lose weight in order to have the body image they desire, but they are looking to bulk up, especially with lean muscle mass. And so this concept of bigorexia is this combination of maybe it's restrictive eating, maybe there's a purging element, maybe there's a supplement or a medicinal element, maybe there's an exercise element. And it all kind of cobbles together in service of, quote, getting healthy or. Right, getting fit. But it crosses a line into being disruptive in someone's life. Is that. Would you say that's a fair.
- [36:36]
D
Oh, yes. And I think you bring up such a great point speaking to why so many men and boys are missed in eating disorder diagnosis. If they're coming in using different terms that, you know, we don't historically have associated with eating disorders like losing weight or wanting to get thin or thin ideal, you know, then it's easy to say, okay, then that can't be an eating disorder or not even think of it. Have it even come to mind, you know? But again, taking it back to the behaviors, we could be still seeing some of the same features as we do in anorexia. It still might be a restriction of energy intake, but it's now just the restriction of carbs and other things at the expense of only eating proteins, you know, in order to change the body shape and weight. So how we talk about the questions that we ask of men and boys are really important as well.
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So upgrade your everyday Download the Quince app for app exclusive offers or go to quince.com awkward get free shipping on your order and 365 day returns now available in Canada and the UK too. That's Q U I N C E dot com so to this exact point, can you help weigh in on the debate over talking to kids about this, educating them about the terminology about disordered eating, about eating disorders versus not because we've heard opinions on both sides. We have our own opinions, which I'm going to hold back. I just want to hear yours. But we've heard opinions on both sides and one group group says, you know, when you introduce the terminology it sort of both pathologizes and glamorizes all of these issues and it will send kids down a path of perhaps becoming more curious about these behaviors and engaging in these behaviors. I've heard that argument around sex education, and it falls flat when you look at the data. Right? The opposite is true. But that's one argument. The other argument is no language is powerful. Teach kids this terminology so that they can communicate clearly. And you can see my bias and how I'm asking you the question, but do I have this wrong? Is it a bad idea to teach kids about these specific topics that we've spent the last several minutes walking through?
- [41:21]
D
I completely fall in the camp of, yes, we talk about it. And it is critical to talk about, you know, for the point that you brought up. Knowledge is power. And we need to educate kids so that they're getting good information about this because eating disorders and disordered eating can be so dangerous, you know, And I think it's a bit naive to think that kids, teens in particular, don't know these terms anyway, or aren't being exposed to information on the Internet, you know, via social media or other places they're getting information. So I kind of look at it as my responsibility as a parent and clinician to make sure they're getting good, accurate information, you know, and educating one about eating disorders, you know, and the related consequences, the health consequences that can come along with it. You know, when I talk about eating disorders in the. The kids that. Or the schools that I consult at, it is anything but glamorous. And the kiddos that I sit with and the adults that I've sat with too, you know, the stories of their lives sometimes can be anything but glamorous. And then that can be the real picture of an eating disorder if talked about in an appropriate way. So I'm a huge advocate for needing to educate not just kids, but families, parents, school personnel, pediatrician, anyone. That can be kind of a frontline defense for helping to identify disordered eating or these problematic behaviors in kids so that we can better help them to that end.
- [42:45]
C
Kelly, can you talk about the on ramping or potential avenues for on ramping towards disordered eating or eating disorders? And you mentioned one, the idea of, quote, getting healthy and starting to change behaviors. And I'm wondering if you could give us a sense of what some other avenues might look like so that adults, and frankly, we hear from kids all the time who are worried about friends, what people can be on the lookout for?
- [43:16]
D
Yeah, you know, that's somewhat of a tricky question because it really can look different for anyone, you know. So for me, this kind of first takes me to the place of what causes an eating disorder and what's the etiology? So many times I Have parents in particular present to my office and say, you know, Dr. B, if only I could figure out what is the root cause of this illness, then we can get everything under control and things will be fine. And that's a really complicated question because what we know right now is that eating disorders are very complex, you know, and they're multifactorial. So the model I use is, I call it the three P's. You know, they're predisposing factors. So these are the things we know that eating disorders are biologically based illnesses. There are some people who are, have the genetic vulnerability and have these predisposed personality traits that make them more vulnerable to having an eating disorder. Then we have what I call precipitating factors. And these are the life stressors. So this could be, you know, for a student athlete, a coach saying, hey, right, if you could drop some weight because you'll be better in your performance, you know, it could be. It is the season right now preparing for prom and all the dieting that's going on, you know, and efforts to get healthy and lose weight for different events or social events that are coming up. For some kids, it could be trauma or other things too. But there are lots of different life stressors that for those with the genetic vulnerability, can kind of kick that gene combination into action to develop into an eating disorder. And then finally to complicate it even more once a kid is sick, we have what we call perpetuating factors. So these are things that maintain the illness, keep that cycle of the illness going. Something as simple as after a kid has lost a significant amount of weight, goes to school, and they hear from all of their friends, girl, you look so good right now. Look at you, you know, and that's something that can work to maintain the illness. So because it's so complex, you know, we don't have the luxury of time to be able to figure out all of what, you know, what for one kid, what's the root cause for their particular eating disorder. So instead we're going to be really focusing on what's maintaining the illness in that moment to get them better. But with that, with kind of circling back to your ramping up question too, there are telltale behavioral signs that you would want to be on the lookout for. And again, these are just red flags. For some kids it could mean something. For some kids, it could mean nothing. But just to kind of ping you into, like, I need to pay closer attention or ask some questions, you know, essentially it starts with, with observations of disordered Eating, I guess, is the best way to put it, you know, and this is why disordered eating is important too, you know, but this could be meal avoidance. So suddenly a kid doesn't want to eat dinner with their family anymore, or they're no longer going to the cafeteria to have lunch with their friends, so they're avoiding cafeterias in other places for purging behaviors. This could be going to the bathroom or showering after every single meal. You're noticing that that's happening all the time. It could be hiding food or eating in secrecy, exercising more than what one sport requires, or when injured could be one of those signs. There are some physical signs, too. A kid's looking pale or fatigued, dizzy, bluish, grayish color, hair might be falling out. Those can be some physical signs. And then I would also see that there are some mood signs that I would want to be hewed into as well. So does their mood seem lower than usual? Are they more irritable? We all know how we get when we're. We're angry, you know, Are they more irritable than usual? Are they isolating from peers even more? You know, so those are the things that I'll be kind of looking for and really encouraging educators and pediatricians and other people to look for as we're thinking of the ramping up.
- [46:55]
B
So, Kelly, a related question. What do adults do or how should they think when their kid suddenly announces, I'm vegetarian or I'm vegan? Sometimes that choice is a moral, ethical one. Sometimes there are choices in service to becoming, quote, healthy, which can be an on rep. Like, should we worry when our kid announces that?
- [47:17]
D
Like many other conversations with kids and teens, I would approach it with curiosity first and foremost, you know. So tell me more about them. What are your reasons? I'm kind of giggling to myself because if I had nickel for every that came in and said, I saw in my health class a video about how meat is processed and I'm giving up meat for good. And, you know, then I would be a very strong right now, you know, and so I think those are the things that I would want to be thinking about, you know, like, tell me your reasons why, you know, and again, I feel like I've said this so often, but it's so true. Pairing it back with behavior. So what's your plan for how you. How you plan on making sure to get enough nutrients, you know, and making sure that you're getting adequate protein sources and that we're achieving that balance that I like to think of as well, you know, also I encourage parents to think about too what's important for your family and culturally, you know, what does this mean for the parent who has to prepare meals every single night? Does this now mean that I'm going to have to make a vegetarian option, a vegan option and, you know, a meat option for my family? And how conducive is this to it? Because as a family we all work together with things like this, you know. So I'd ask the question, I want to better understand the reasons why. And I would say because we do quite commonly see a switch over to veganism and vegetarianism. And again, I say this with, I want to, first and foremost, there's absolutely nothing wrong with those lifestyles do not in and of themselves mean that somebody is struggling with an eating disorder. But you know, if there is a sudden change, you know, and we're seeing, you know, a kid not having a willingness to be able to nourish themselves properly in addition to this change, you know, then I might be, I might be a little bit concerned about it.
- [48:58]
C
So, Kelly, that brings us to the hot topic, the endlessly hot topic of social media. And I mean, where do we begin on this? Right? There's investigative reporting on the impact of social media on body image. There is all sorts of research and reporting on the impact of sites like Reddit and Pro Ana or Pro Anorexia, discussion rooms and platforms giving people, you know, specific advice on how to pursue eating disorders. I mean, the list goes on it. There's influencers on TikTok, encouraging use of supplements and even steroids on male eating disorders, on how to get bigger. I mean, there's, there's everything. And yet we try to take a balanced approach about kids and social media and recognize that there are positive aspects and benefits. But in the context of body image and eating disorders, it's a very scary world. And I'm curious, curious, what is your approach to it? What do you recommend to families that you work with about how to balance the influence of social media and kids health and well being?
- [50:10]
D
Oh, great question. You know, again, another hard one because unfortunately we live in the day and age where we cannot avoid social media anymore. This is the primary form of communication and a major source of social interaction amongst kids and teens. And as much as we, you know, we do our best, until they're developmentally ready to use things like social media, we have no idea what our kids are going to be exposed to outside of the parameters of our own home. You know, so again, not walking on eggshells and what I always encourage parents too, is hard as it can be. And as much as most of us don't want to get off Facebook or some of the earlier forms, we've got to know how to, you know, the different forms of social media. Many people don't even know that things such as Pinterest is considered a form of social media or, you know, Reddit and things like that. So. So being familiar with the different social media platforms and what our kids are going to be seeing and exposed to on the different platforms I think can be really helpful too. I also, when I'm talking about it with my kids too, I also encourage, you know, not just thinking about, like, what people are saying, but what images are you seeing as well, because you could see something on Instagram, a post on Instagram or something of a person who their words are conveying something very, you know, pro eating disorder recovery or pro positive body image, you know, and. And whatnot. Yet there be other products that they're pushing or things like that that actually don't match up with that message as well.
- [51:42]
C
Yeah, I mean, I think that that sort of cultural critique, the ability to parse and again, this develops as kids become more and more sophisticated thinkers and gain insight. But it's not just a blanket. Social media is terrible or there's nothing I can do. What you're pointing to, Kelly, are the sort of layers and layers of nuance and complexity, partially because it's based in people selling kids and adults things. And so when it becomes a commercial enterprise, there's a lot of clever ways to mask it or disguise it or even confuse people. So I think that's a really, really important, important point about what are you hearing versus what are you reading versus what are you seeing and being in conversation with kids on more nuanced and complex levels. I think that's fantastic advice.
- [52:40]
D
You know, I was actually just thinking, I love, I think it's beautiful how a colleague in my practice actually put it, how she works with her clients and with her own kids as well. She actually has almost made it into a bit of a game. And when they're on social media platforms, they play what are they trying to sell here. Even if the product is not necessarily, you know, obvious. Let's look at this together and let's play. You take a guess, I'll take a guess. What are they trying to sell to us here? Is it an ideal? Is it a product? Is it a baby?
- [53:10]
C
Fascinating.
- [53:10]
D
I thought that was brilliant, you know, brilliant, fun, kind of interactive way to kind of talk about it with our kids too.
- [53:16]
C
That's amazing.
- [53:17]
B
Is brilliant. That is brilliant. We promised we would quickly cover racial differences in how a lot of these eating disorders and disordered eating issues impact populations. I don't want to wrap before we give people just a little bit of information. There may be tied into social media, maybe not. Can you just give us a little top line information about racial differences with each of these or with the general gist of eating disorders and disordered.
- [53:52]
D
Yeah, we do know that in marginalized populations that again, that they are under diagnosed and under identified and we're not screening in minority populations like we are in majority populations, you know, and that is incredibly problematic and leading to lower rates of presentation in treatment facilities. And kind of circling back to what I said about early identification and early intervention being critical, we are leaving demographics of people vulnerable to these illnesses for a long time. That takes us outside of that window of opportunity for good, solid intervention, you know, so this is an area that I get really, really worried about. In fact, we do know that in some racial and ethnic groups that certain eating disorder behaviors actually have higher prevalence rates than in white populations. So binge eating disorder behaviors in the African American community tend to be higher prevalence rates. There's some data to suggest that in Hispanic populations that there are higher rates of purging behaviors, you know, kind of depending on the study. So I think it's an area that we desperately need more research and need more intervention so that we're being able to help all people.
- [55:04]
C
Because, Kelly, we have not talked about this in really specific detail, but eating disorders are. Now, I'm not sure because new data came out about fentanyl poisonings, but eating disorders are the number, number two leading cause of. Where does it fit in the cause of death amongst adolescents? Right. Because I think things just got rejiggered. So you know better than I do. Right?
- [55:28]
D
Yeah. So right now it's considered the second leading cause of death regarding psychological problems after the opioid crisis, you know, so anorexia in particular. So. And also we know that suicide rates in kids and teens with eating disorders are elevated as well. You know, so the are really ser. And for even with mortality rates being higher, the physical and mental health consequences are so drastic, you know, that again, this is why it's considered a public health crisis.
- [55:56]
B
But I think it's important to bring in a little bit of silver lining. And the silver lining that I see is that especially among females, body image ideals have broadened tremendously over the past couple of decades. And I believe that is in large part due to sort of this recognition of cross cultural differences in beauty standards and new versions of body ideals. When we were growing up, there was exactly one body ideal. It was straight and narrow and skinny, and it just all looked the same.
- [56:35]
C
And.
- [56:36]
B
And now it does feel like there are lots of different body types that are hailed as beautiful. Like, in a very authentic way. These are beautiful. Curves are beautiful. And that, to me, creates a little sense of hope in all of this because we're all built differently and to not try to all be, you know, square pegs in round holes. There is actually an evolution of the definition of beauty in our culture. We have not gotten to where we need to be by any stretch, especially based on the data that you presented at the top. But it does feel a little better. Is that fair?
- [57:20]
C
Yeah.
- [57:20]
D
You know, I think that we have been better about advocating for body diversity. I think the more that we are talking about fat phobia, the more that we're talking about weight stigma, the closer that we're going to get to our goal. You know, actually, I used to give a talk about image talk on the changes of the ideal shapes throughout the different decades. And it is truly fascinating to think about what was the ideal from the 1920s to the 1940s to the 1960s to now, you know, but there, I think, yes, I think as we're learning to celebrate body diversity and just diversity in all sense of the word. Word.
- [57:57]
C
Kelly, that's what I want to say, because the body ideal was also white. Like, it was. It was an ideal of white culture.
- [58:05]
B
And thank you for naming what I was trying to say. That's.
- [58:08]
C
And I think. And I think people listening, people of color listening were like, well, in my house, actually, that wasn't the body ideal. And it was, you know, it was great to have lots of curves and be bigger and, you know, so I think there is a racial overlay to all of it, including, as you have talked so beautifully about in the research community and what is actually being studied, and it all stems from that. So there is so much more to talk about. You have the most reassuring and optimistic tone when talking about really quite a difficult, sad subject. And I hope that people listening who have children that they care about, who are worried, borrow some of your hope and some of your optimism and some of your sense of empowerment and feel like there is a path forward. And Kelly, I hope you will come back and visit us and share more of your wisdom because there's still so much ground to cover. Thank you for for joining us.
- [59:16]
D
Us. Thank you. And I would be happy to. It's such a privilege to be to be on here.
- [59:21]
C
There's nothing like putting someone on the spot while they're sitting and recording to ask them to come back, right?
- [59:27]
B
I want to hear you say no.
- [59:30]
D
I would love to.
- [59:32]
C
Thank you, Kelly. Thank you so much for listening. You can email us with questions, feedback or episode requests@podcastawkward.com if you want to
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B
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