Q&A: ‘Food as medicine’ and the fundamentals of addressing eating disorders
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Key takeaways:
- Delayed treatment for eating disorders results in worse outcomes.
- Establishing medical stability allows the patient to remain at home and engaged in their life.
According to data published last year, eating disorder claims rose 65% as a percentage of all medical claims in the United States between 2018 to 2022, with most claims in 2022 coming from patients aged 14 to 18 years.
We reached out to Amanda Downey, MD, assistant medical director of the University of California, San Francisco’s Eating Disorders Program, to ask about the fundamentals of addressing eating disorders in patients.
Downey presented a primer on eating disorders in adolescents and young adults at the ACP Internal Medicine Meeting.
Healio: Can you discuss the importance of history taking and medical screening needed to accurately identify patients with eating disorders?
Downey: History taking and medical screening are critical! Pediatric providers are first-line for these youth, so any deviations from the growth curve — including growth plateaus — should be a red flag to ask more questions. Even without any signs of medical compromise, it’s important to take youth and parental concerns seriously. We often hear that a youth is exercising for hours a day, or retreats to the bathroom after meals — these red flags should prompt additional questioning and history gathering. Even if there is no medical compromise, eating disorder behaviors and thoughts alone warrant compassionate care and treatment.
Healio: What are some misconceptions regarding eating disorders, and how does stigma interfere with prompt screening and treatment of eating disorders among young people?
Downey: Where to begin! Our research shows that disordered eating affects youth of all races/ethnicities, socioeconomic statuses, and genders. Still, the longstanding stereotype of white, upper-middle-class girls as the “prototypical” eating disorder patient continues to bias health care providers and contributes to systemic inequity within the larger healthcare system. For example, our own research at UCSF shows that Latinx youth with public insurance in California struggle to receive evidence-based care for eating disorders compared with other racial/ethnic groups.
Another area of growth for pediatric providers is the identification of those with restrictive eating disorders who may be in a normal weight or overweight bodies according to standard medical criteria. Pediatric providers are tasked with caring for youth with pediatric obesity but are much less comfortable identifying and caring for those with restrictive eating disorders at a higher weight. We cannot fail to care for these youths because they can be just as medically and psychologically compromised as those youths at a lower weight. Delaying treatment for those with eating disorders results in poorer treatment outcomes, so we must act to identify and care for these youths — all of these youths — free from bias.
Healio: What are the common medical interventions for patients with eating disorders, and when are referrals and additional support warranted?
Downey: There are two fundamental treatment modalities in the treatment of pediatric eating disorders: nutritional rehabilitation and evidence-based psychotherapy. Unlike with other mental health conditions, medications have mostly proven ineffective for youth with eating disorders, especially anorexia nervosa. More traditional psychiatric medications tend to be helpful for accompanying mental health conditions, like depression and anxiety. Unfortunately, when the body is malnourished, more traditional medications like the selective serotonin reuptake inhibitors are less efficacious.
Instead, we really think of “food as medicine” when treating eating disorders. Adequate and regular nutritional intake not only corrects medical complications and restores the developmental growth trajectory, but it is also equally critical to psychological recovery. Food really is the cornerstone of all eating disorder treatment.
Finally, family-based treatment (FBT) is the most evidence-based psychotherapy modality for youths with eating disorders. Unlike more traditional psychotherapy, the emphasis of FBT is on empowering caregivers to renourish the youth at home. This is critical for a couple reasons: First, establishing medical stability allows the youth to remain at home and engaged in their life. And second, renourishing the brain accelerates psychological recovery, such that more individualized therapeutic work can be undertaken later in treatment course. Because of this model, it’s important to remember that many of your patients may say they don’t like their eating disorder therapist — and that’s quite normal at the beginning of treatment! Pediatric providers should collaborate with the therapist and support the youth and caregivers to stick with it, hard as the process may be. I try to remind families that this approach, although sometimes causing distress and discord, is actually the highest expression of love for their child.
Healio: What should pediatricians, in particular, be aware of regarding future complications that could be caused by these conditions?
Downey: Luckily, most of the medical consequences of malnutrition are reversible with full weight restoration. Linear growth impairment and decreased bone density are some of the only complications that may prove irreversible. Frequent medical visits create the scaffolding to empower caregivers to prioritize early and aggressive weight restoration to minimize the risk of these complications and to restore psychological well-being.
I’m so grateful that pediatricians are increasingly interested in providing evidence-based care for youths and families with eating disorders. The process can be challenging — remember that distress directed at you is distress from the “eating disorder,” not the youth! You are walking with families and youths during their most vulnerable moments, and having a strong leader at the helm of the team can be the difference between full recovery and a lifetime of struggling with an eating disorder. You can make a huge difference.
References:
Downey A. Primer on eating disorders in adolescents and young adults. Presented at: ACP Internal Medicine Meeting; April 18-20, 2024; Boston.
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