When Food Is the Enemy


When Food Is the Enemy
For many years, physicians tended to avoid discussions with patients concerning weight or eating habits lest they offend someone. With today’s epidemic of overweight and obese Americans, however, conversations centering on diet and exercise are playing an increasingly prominent role during office visits.

Clearly no one questions the need to talk to patients about the physical toll and increased risk of disease that comes from carrying extra weight, but mental health professionals urge physicians and nurses to choose their words carefully any time body image comes into play, particularly when working with adolescent patients.

For those with a genetic predisposition, eating disorders often take root during adolescence although full-blown manifestation might not occur until adulthood. While the ingrained stereotype for eating disorders is an extremely thin, Caucasian, teenage girl, area professionals note that eating disorders strike both genders, cross racial lines and run the gamut of body types.

According to statistics cited by the National Eating Disorders Association (www.edap.org), as many as 10 million women and one million men in the United States are currently locked in a life-or-death battle with an eating disorder such as anorexia or bulimia, while millions more suffer from binge eating disorder. Because of the secrecy attached to this form of mental illness, professionals believe the true numbers of Americans with an eating disorder are actually much higher than the cited figures.

In a 1995 report in the American Journal of Psychiatry, researcher Patrick Sullivan found that eating disorders have the highest premature death rate of any mental illness. Furthermore, a study by Dr. Greta Noordenbox published in the International Journal of Eating Disorders in 2002 found that only about 10 percent of those with an eating disorder receive treatment, and of those who do receive treatment, only 35 percent receive care at a specialized facility.

Nearly a decade ago, the seeds of the Eating Disorders Coalition of Tennessee (EDCT) were planted when Dr. Ovidio Bermudez, then at Vanderbilt Children’s Hospital, sat down with registered dietician and nutrition therapist Reba Sloan to discuss creating a multi-disciplinary network of clinicians trained to deal with the special needs of patients with disordered eating.

“Before we came about, clinicians didn’t know who to call or where to turn,” said Shelli Yoder, MS, MDiv, executive director of EDCT. “While the Eating Disorders Coalition of Tennessee does not provide treatment, we’ll help create the team.”

In addition to establishing a statewide network of specialists, EDCT has also reached out to communities to create family support groups, a resource library and a speaker’s bureau focused on education and prevention.

Yoder said education is a key element for both the general population and for physicians.

“It’s so easy to miss,” she said of identifying patients who need intervention. “It’s the rare case when you have someone who is struggling with anorexia, and it’s physically apparent … that is a small percentage of the individuals who struggle with an eating disorder.”

Jessica Samford Conley, BFA, MRC, LPC-MHSP, site director for the new Renfrew Center (see related sidebar), noted that the majority of bulimic patients will actually maintain a normal body weight or might be considered clinically obese.

Yoder and Conley both said that research has indicated that eating disorders begin with a genetic predisposition.

“And yet,” Yoder said, “someone can have that (genetic component) and go their whole life without ever developing an eating disorder, so there’s a nurture element that is a trigger.”

Triggers, she added, can be a traumatic occurrence or something relatively benign.

“We live in this culture of ‘we’re never good enough,’” Yoder pointed out. “I mean it’s everywhere. Our brain picks up on this, processes it and finds an outlet … most of it is in negative body image. Even in my field, I still feel impacted by the messages. I’ll flip through a magazine and catch myself doing a comparison and not even really be aware of it. It just kind of wears you down, it’s so subtle,” she continued of the pervasiveness of unrealistic ideals.

Dr. Carol Hersh, a board-certified psychiatrist who sees patients with eating disorders in private practice and at the Renfrew Center, said there are a host of issues involved in triggering an eating disorder, including family dynamics.

“We know parents who are very rigid about food tend to create situations where eating is not really related to hunger but to the presence of food,” she explained. “Children getting teased by family and especially by peers is a great push toward eating disorders,” she added.

Yoder pointed out, “There is a lot of prevention that can happen just by paying attention to the body messages we send and being more body positive.”

For pediatricians, family practitioners, internists and ob/gyns, that begins with a heightened sensitivity to the potential for eating disorders and the language surrounding weight.

Yoder said that by taking time to talk with patients, physicians could begin to uncover an unhealthy relationship with food or exercise. Answers to questions like, “What are mealtimes like for you?” “How often do you exercise each week?” or, “I noticed last time you were here you weighed x and now you weigh y … how does that make you feel?” have the potential to raise a warning signal and invite further discussion.

Hersh noted that pediatricians should consider unusual or unexpected changes in a child’s growth chart as red flags.

“If the weight starts to drop off the established curve or climb above it and the height doesn’t, then you have the hint of an eating disorder or a metabolic problem,” she said.

Hersh said marked changes in personality, heightened anxiety and changes in interactions between a child and parent could also signify trouble. However, she added, some of these changes come naturally with adolescence so the information has to be considered in context.

“There are lots of little clues,” she noted, “We don’t want to wait until we have a girl who is post-menarche but hasn’t had a period in 10 months … we don’t want to wait for hair loss or the enamel coming off the teeth because of induced vomiting.”

Conley urged any physician who sees eating disorder warning signs to seek out a specialist just as they would for many physical problems.

“A general practitioner is not expected to be an expert in alcohol or drug abuse, mental health or eating disorders,” she stressed. However, Conley, added, the practitioner does remain a crucial part of the team since eating disorders are compounded by multiple physical issues as a result of the abuse to the body.

“These are disorders that require more than a single discipline intervention,” concurred Hersh. “These patients require a team approach. That’s one of the things I see happening at Renfrew that I’m very, very happy about. We’re looking for long-term solutions to this problem, and the best way is to enlist the primary care physician’s assistance.”

Clinicians interested in sensitivity training or more information on eating disorders can contact EDCT at (615) 831-9838 or via e-mail at contactus@edct.net. Yoder also encouraged physicians to contact the organization if they have a patient suspected of having an eating disorder for assistance in finding qualified specialists across the state.

December 2007