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Concerns about weight and body image can be common, but what happens when these worries develop into something more? Learn about the various types of eating disorders, their causes and a few signs of these conditions during a conversation with psychologist Dr. Susan Albers.

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Eating Disorders: What You Need To Know with Dr. Susan Albers

Podcast Transcript

Intro:
There's so much health advice out there. Lots of different voices and opinions. But who can you trust? Trust the experts, the world's brightest medical minds, our very own Cleveland Clinic experts. We ask them tough intimate health questions so you get the answers you need. This is the Health Essentials podcast brought to you by Cleveland Clinic and Cleveland Clinic Children's. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.

Molly Shroades:
Hello, and thanks for joining us for this episode of the Health Essentials Podcast. my name is Molly Shroades and I'll be your host. Today we're talking a little bit about eating disorders. Many people struggle with their bodies and their weight, but when does that turn into an issue? We're here with Dr. Albers to discuss this topic. Thank you for joining us today.

Dr. Albers:
Thank you so much. Appreciate it.

Molly Shroades:
So, just starting off, can you tell us a little bit about the types of patients you see and what brings them into your door?

Dr. Albers:
Yeah, I've worked at the Cleveland Clinic now for 16 years and the majority of the work that I've done and patients that I've seen have struggled in some way, shape or form with eating, weight, body image. So, I'm very thankful today to have the opportunity to talk with you a little bit about the causes, the treatments, because this has been a topic that has been near and dear to my heart, a very big part of my professional work.

I'm so fortunate here at the Cleveland Clinic to work with a team of fantastic physicians, psychiatrists, dieticians as we will talk about today, that it really requires a team of people to work with eating disorders. And so I've been very fortunate to work here with many professionals who have been helpful. Before the Cleveland Clinic I did some rotations around eating disorders, and I've continued to study, look at research, worked with individuals every single day in my office doing individual treatment, individual counseling. And so, as I mentioned, I'm excited to talk with you today about what are some of the causes and where we go from here.

Molly Shroades:
Great, great. Now, just starting off with this topic, can you give us a general definition of what an eating disorder is?

Dr. Albers:
Yeah. Eating disorders are a psychological condition in which people have an unhealthy preoccupation with eating habits, their body image, food. In the United States alone, an estimated of a 20 million women and 10 million men have some sort of eating disorder at some point in their life. So, if you're listening today, it's very likely that you, yourself, a friend, a family member has struggled with eating in some way, shape or form. One of the things that I've learned as a professional over the years and is a myth, is that we can look at people and tell if they have an eating disorder based on their weight. And this is one of the things I really want to take home message that I want to dispel today is that eating disorders are really about somebody's relationship to food. It has to do with weight and food and body image, but it is less about food and more about how they think, how they feel and how they relate to food in their lives.

Molly Shroades:
Right, right. Awesome. Now I know that there are many different types of eating disorders. Can we kind of do a bit of a dive into what different types there are?

Dr. Albers:
Yes. There are several different types of eating disorders that I've seen in my office and are in the DSM–5, which is the psychological handbook of disorders. The first in many and people are familiar with is anorexia. And anorexia is characterized by a very persistent fear of gaining weight, of becoming fat, of a persistent decreasing of energy intake or decreasing of food intake. There's a lot of disturbance around their body image. So, other people in their lives can reassure them about their weight or body shape. And they themselves do not see their body in that way. To meet this criteria there's also an aspect in which the person has a very low weight for their developmental stage or their sex. But again, as I mentioned before, you can't really determine by somebody's weight. So, you do not have to be at a very low rate to have anorexia.

If you have symptoms of restricting food, fear around food, you may still meet the criteria for anorexia. Bulimia is there are three essential features of bulimia. The first is a reoccurrence of binge eating. So, eating large amounts of food. And this is sort of a caveat. It can be either actually eating large amounts of foods or perceived, feeling as if you have eaten large amounts of food. The second is some sort of inappropriate compensatory behavior. So, excessive exercising, purging behavior. And the last is the self evaluation of your body. That in some way, shape or form, you're very unhappy with it. And to be diagnosed with this particular disorder, you must be engaging in these behaviors at least once a week for three months. That is the definition in the DSM–5. And then in regards to binge eating disorder, this is by far in the United States, the most common eating disorder.

And it has all of the criteria of bulimia the excessive intake of large quantities of food. But what is different is that there's no compensatory behavior. There's no behavior to eliminate the intake. So, no excessive exercise or any kind of purging behavior. So, many people struggle with this. What I've seen over the years is an increase in the diagnosis. I think it's a disorder that's been underdiagnosed for many years, and that is maybe one reason why we're seeing an increase. Not that there is an increase in the number, but an increase in the amount of diagnosis. Another disorder that I've seen quite a bit of an increase is what is known as Avoidant Restrictive Food Intake Disorder, for short it's called ARFID. And basically this is a diagnosis in which people have a lot of avoidance or restriction of food intake around certain foods. Often I'll see people who will limit their intake to maybe about five or 10 specific foods.

They have a lot of issues around texture or specific tastes. A lot of fear that they may gag if they eat certain foods, or get sick. We often see this with kids and they're often diagnosed early on as being picky eaters because they have a limited food restriction, which is quite normal often with children. But we see them grow out of it. And as they are growing up and they continue to have a restricted food menu or foods that they're willing to eat, what we notice is some issues with that. They're not getting enough nutrients. They may have some social implications. They go to a party everyone's eating pizza and they refuse to eat pizza, or they won't even go because they know that they will not be able to eat those particular foods. There are also some other issues around food that you may have heard about orthorexia, which is a preoccupation with eating just healthy foods.

So, maybe somebody who will only eat a specific type of food, non-dairy, gluten-free. May spend a lot of money going to natural food health stores not eat at anyone else's houses who is not eating their specific menu. So, these are some of the general types. If a person does not neatly fit into one of these categories, there's also eating disorders unspecified. For me, I think that as a professional, the diagnosis is very important to help with treatment and categorizing. But at the end of the day, it's really, if someone is struggling with eating in any way or fear around food, really, we target a lot of the symptoms that they're struggling with. Diagnosis is very important, but we do have to remember that eating is something that we do three times a day, at least. And it's a social part of our lives. So, it can have such a huge impact on the quality and functioning of someone's life.

Some other symptoms, just general that we may look for, is a dramatic weight loss. Often when I have parents come in, they'll say with teenagers that they notice that they're wearing a lot of baggy clothes they're hiding in their clothes. A lot of [speaker 00:09:48] to eating. This is probably one of the biggest red flags that I hear in my office is when people are eating in secret or afraid to eat with other people. Also, suddenly becoming vegetarian or restricting a specific type of food, engaging in exercise obsessively and having difficulty with restrictive or inflexible behaviors around food or exercise. So, these are just a few of what I would say, the warning signs or the characteristics that people universally struggle with, no matter what kind of eating disorder that they have.

Molly Shroades:
Great. Now, it sounds like eating disorders can develop at many different points in your life. Is there any one age range or can this really be throughout your lifetime, just at any point?

Dr. Albers:
I think that's one of the misperceptions about eating disorders or one of the stereotypes is that we used to think, or it was publicized in the media that eating disorders is an issue that impacts adolescent white female girls. And what we've seen in research, and I've seen in the patients that have come on over the years that, that is a segment of the population. But it's so much more. I've treated many people who are experiencing eating disorders in their later life, midlife. Also, men in the 16 years that worked at the were Cleveland Clinic. I've seen a dramatic increase in the men who are seeking treatment. There has been specific populations now that we've seen an increase or a spike in the number of people who are struggling with eating disorders, such as the LBGTQ community.

We've also seen specific groups, there's recent research of Jewish communities that are seeing an increase. Also, people who have disabilities, athletes. So, within the individuals who struggle with eating disorders, we've seen some spikes in different communities who may have a specific vulnerability. But definitely not just girls, men, women, people of all different ethnicities and races struggle with eating disorders. So, it's another reason why I think it's such an important issue for people to learn more about and to recognize, and not have any particular stereotypes about because so many people can experience eating disorders at some point in their life.

Molly Shroades:
Now, I know we've already talked a little bit about symptoms, but are there a few that kind of are common symptoms across all the different types and what are few of the early signs?

Dr. Albers:
Yeah. The common thread among all of the eating disorders, and one that I think stands out to me is that eating disorders ultimately are about food. They're really not about food. When we really start to look deeply into them, food is a symptom and how the issue is expressed. But it's really about coping that each of the eating disorders, our way in which people find to cope with a stressor in their life, sometimes it's around control. Sometimes it's around a stressor in their life. What we've seen particularly with the pandemic recently is an increase in the number of people who are experiencing eating disorders. And in part that has to do with the overall stress that we've been experiencing in the world. There's also common thread of ruminating about food, thinking about food for long periods of time. The common thread is body image, having some sort of discomfort, shame, or dislike of a particular body image.

So, that's a common thread, no matter what the diagnosis is. Some early warning signs. Again, if you see someone who is dieting, that is the number one trigger often for people who experienced eating disorders. When I do an intake or an evaluation, one of the things that they say to me is that the eating disorder began with a diet. That they initially lost some weight and then it spiraled out of control. For many people who are dieting, they may go on a diet, go off a diet, and it does not create a significant issue. But for people who have an eating disorder, diets are often one of the number one triggers of an eating disorder.

When I do an intake or an evaluation, when we look at when the eating disorder started, one of the things they often say is that they went on a diet and that it spiraled out of control. That initially they really want it to be healthy or lose some weight. And that was the initial trigger to becoming very preoccupied and focused on food. Often people will go on a diet and go off of a diet, not an issue, but for those who have a predisposition for eating disorder, a diet can lead them down a very dangerous path and a slippery slope into more significant issues.

Molly Shroades:
Now, one thing I was wondering about while we were talking about the different types is can you have more than one at the same time? Can you kind of combine these or do you usually just stick to one type at a time?

Dr. Albers:
There's often overlap in the disorders that you may fall into more than one category. And this makes a lot of sense. As humans, we don't fit neatly into specific categories. So, you may have symptoms from different, some from the different diagnosis. What I often see though, unfortunately, is that people may start off with one diagnosis and change to another. For example, an individual may come in and they're struggling with anorexia, that they have a lot of food restriction and are underweight. And they get to a point where they can no longer sustain that and they are engaging in binge eating. And so then they fall into the criteria for binge eating disorder. So, there's a lot of overlap. There are some other disorders that may also be co-occurring at the same time.

For example, obsessive compulsive disorder. There's a lot of overlap and diagnostically sometimes we have to piece apart if this is an eating disorder, obsessive compulsive disorder. And so that may be co-occurring. Also, depression, anxiety, stress, all of these things can be happening at the same time. Seasonal affective disorder. Seasonal affective disorder is when people during the cold winter months experiencing more depression. What we see is often an increase in emotional eating and that can lead to binge eating. So, diagnostically it can become very complicated and there can be many different things going on. So, as a professional, you'd sit down with an individual and really piece apart all the different factors that are happening.

Molly Shroades:
It seems like this is extremely unique to each person and complex. But I guess I want to talk a little bit about some common causes and factors that can cause an eating disorder too develop.

Dr. Albers:
And it's very complicated and multifaceted. And over the years, we are still continuing to understand eating disorders by looking the research and we continue to learn more and more every day. Eating disorders are a genetic, psychological social biological disorder. So, there are many different factors that are contributing. We often say that there is not a cause, but there are often many triggers that happen that can be linked to the expression of the eating disorder. When we look at someone's genetics, we can look at often their family tree and see different members who have struggled with eating disorders, which indicates a strong genetic component. Also, when we look at twin studies, if the one twin has an eating disorder, there's a 50% chance that the twin will as well. I've noticed that quite a bit in my office when I've been treating a twin, that their twin is also struggling with eating disorders.

So, we know that there's a strong genetic component. But also there's a biological and social psychological component. So, people who struggle more with self-esteem, perfectionism, obsessive compulsive disorder, these personality traits are more likely to struggle with eating disorders. Also, this social piece of it. If you are amongst friends who struggle with eating or are talking a lot about dieting, if you are immersed in a diet culture, or a community that, like athletes, that feel a lot of pressure around the body and body image, this may also be a trigger. One of the triggers that I've noticed and in research has been discussed quite a bit is about trauma. And for those who have experienced any kind of body trauma, sexual abuse, violation of personal boundaries, this is often a common trigger as well. I spoke briefly about the pandemic, any kind of significant stress.

For most of the population the pandemic has been a very stressful event. It's caused a lot of collective trauma. So, over the past year, the National Eating Disorders Association showed an increase of 70% increase in the amount of calls to their help center. So, we know that something is going on when people experience stress and intense amounts of stress as well. So, to kind of summarize, it's complicated, there are many different factors that trigger an eating disorder. If you have a predisposition, you often are aware of it from family members, or you have some of the characteristics from other psychological issues going on in your life.

Molly Shroades:
Now, speaking towards the social element of this. A lot of events in our culture lead to binge eating. We have big parties like super bowl parties or holidays where we just eat, eat, eat, eat, eat. Where is the line blurred between something like a binge eating disorder and just going to parties and filling your plate five times?

Dr. Albers:
That is a great point. All of us experienced at some point overeating. I mean, we often do it particularly around tasty foods where at parties. And we know that feeling. So, it's very common to have that experience now and then. When it becomes an issue is when it's happening repeatedly eating large quantities of food often to the point of feeling ill or sick, or a lot of shame, regret, guilt. The really telltale sign though, is when people feel out of control. When they get to the point that they are not just consuming food, but it feels like when they tell themselves to stop or they've had a negative experience and they look forward and say, okay, I'm not going to do that again. They really have trouble putting on the brakes and stopping. Also, when it becomes a way of coping with any kinds of feelings.

So, someone is having a stressful day, they turn to food as a way to sooth or calm. And that happens over and over and over again. And there are not other ways that they're coping. That is really when I suggest that people look for some treatment. If they've tried to stop and they're not having a lot of success, or it's becoming a factor that's impeding the quality of their life. Let's say that they're buying large quantities of food, and now it's become stressful on their bank account. And or if it's impacting their social life, the romantic relationship that they're hiding food from their significant other. These are the times that people may want to reach out for some help and indicate it as being a significant issue in their life.

Molly Shroades:
Now, let's talk a little bit about emotional eating. What is that exactly?

Dr. Albers:
Emotional eating. Again, we all do a little bit of emotional eating and that's perfectly okay. Food feels good. It is something that is soothing and rewarding. What's happening on a biological level, when we eat foods that are tasty is that it's creating this hit of dopamine in the brain, that neuro-transmitter that feels really good. And it's a component of eating disorders, the emotional eating. Where it is different is that most people do little pieces of it. When emotional eating becomes the only way that people deal with their stress, that is when it becomes problematic or the emotional eating is creating a great deals of guilt or shame or secrecy. That's when emotional eating becomes more of an issue. But again, little bits of it are not an issue. When it happens repeatedly, that's when it becomes a hindrance in people's lives.

Molly Shroades:
Now, can we talk a little bit towards treatment and how these disorders are treated? Is there a different treatment based on your type?

Dr. Albers:
There are different treatments based on specific disorders. And unfortunately like a lot of different disorders or diseases. There's not one protocol. We really have to find a match between the person and the specific behaviors that they are struggling with. Traditionally, we work with a team of individuals to help someone who's struggling with their eating. So, a physician is going to help with any kind of medical issues that the person is experiencing, a psychiatrist, a dietician, a psychologist. We all work together to help the individual. There's also different levels of treatment. And this is really important to know too. That there is individual outpatient treatment. So, that's something that I do. People will work with me in my office, or now due to teletherapy, we will work individually. There's also group therapy, there's intensive outpatient, which means that someone is really dedicating a lot of time to their treatment.

They may be meeting with a professional three times a week in outpatient setting. Or if there have been very significant impact on someone's health, they will do inpatient treatment. So, there's different levels depending on how someone's health is currently doing. One of the primary treatments is cognitive behavioral therapy in which you address the thoughts and behaviors around food. Nutritional therapy is really important for people who are struggling with their eating. Often, if they are at a low weight or if they are not getting enough nutrients, what we see as that impacts how we think that they may not really be thinking very clearly due to low nutritional status.

Also, we work with a physician who will do a lot of blood work and look at how are people's electrolytes, their vitamin levels, how are they doing overall. Has this impacted their health? And we can't see it from the outside. Often blood work is a very helpful diagnostic criteria to understand how eating is impacting what's happening on the inside. If you have an adolescent or child who's struggling with their eating, family therapy is an important step. You want to find a professional who specializes in working with the entire family around changing their eating habits, helping the child. And this treatment is going to be a little bit different than if you're working as an individual adult.

Molly Shroades:
Wonderful. So, what are some of the biggest challenges that you typically see when you're trying to treat someone?

Dr. Albers:
One of the biggest challenges I think around eating disorders is some resistance from the patient. Often, initially someone does not see that they have an eating disorder. They may have lost some weight, and they're feeling initially really good about their body, or people unfortunately give them a lot of reinforcement. They've lost weight, and they say, you look great. And then the person becomes very attached to that feedback and suddenly feels good about themselves. So, there's some resistance and ambivalence. One of the things when people initially seek treatment is that they can be on that line between wanting to get better. The food has become drained, this food issue has become draining in their life. It's caused a lot of issues. It's become the focus of their entire life. And they're exhausted. On the other hand, they expressed that they can't imagine giving up the eating disorder that has become their primary way of coping and has become such a part of their lives that they can't imagine letting go of it.

So, it can be a really complicated dynamic. Also, there's a lot of what we know as diet culture, people talk a lot about dieting. They reinforce it quite a bit, so they may see what they are doing as being part of the norm or part of dieting and not really being aware of it being problematic. Another issue is family support. Sometimes a person is going at it alone and it's helpful to have friends, family members when somebody enters treatment to help them to make all the changes that they need to make. So, these can be some of the real challenges around eating disorder. Also, the medical complications. Unfortunately, eating disorders are one of the disorders that have the highest mortality rate of all the eating disorders. And that's a pretty scary statistics. When we look at the number of people who have eating disorders, there is a significant percent who have medical complications. So, these are all things that become a challenge in treatment in working with someone.

Molly Shroades:
That's definitely important to note, because I think many people don't realize that there are long-term complications that are related to these. Let's talk a little bit more about this long stretch of isolation we've just went through and what impact that's had on people.

Dr. Albers:
Over the past year, we've really experienced some extreme levels of isolation with the pandemic. And if there's one silver lining that we can really take from it, the pandemic, is the importance of mental health. I think there are people who have never experienced any kind of mental health issue in the past. And during the pandemic, there were higher levels of depression, anxiety, levels of stress, and a real appreciation that periods of isolation and disconnection are really tough on mental health. And for many people, it was a traumatic time and collective sense of grief in the country. If you had a predisposition for depression, anxiety, eating disorders, what we saw over the past year is that it really increased the number of people who are struggling with mental health issues. In regards to eating disorders, why we may have seen an increase and the number of people who were calling to the help centers around eating disorders.

I saw an influx in my office of people who were seeking treatment is because of the isolation. Eating disorders thrive in isolation, because when you are alone you can eat or not eat in any way that you engage in. When you are going out to dinner with people, eating with others, eating with family members, they notice what you're eating or not eating. Also, it creates a norm of comparing what you're eating to other people. So, when there's isolation, it gives an opportunity for eating disorders to thrive. Even in times not of the pandemic. If you find that your friend or family member is canceling dinner reservations, they're not eating with family meals, things like that. It can be really a significant sign that they are struggling with their eating. Also, the pandemic, as I said, it was a very stressful time for everyone and difficult on mental health.

That sense of disconnection is one in which people were not getting support. So, if they were experiencing eating disorder in the past, and they had family members who were supportive, they may not have seen them for long periods of time. So, people may not have recognized if there were changes in weight or changes in eating habits. So, thankfully we hope that the pandemic is we are moving out of the pandemic. I've noticed thankfully, a lot of people who are reaching out to get significant help and support. Again, for me as a professional, this significant advantage to the pandemic is being able to see people through teletherapy. I've seen people all over Ohio and in other locations not just restricted to my area. So, it's been an easier access for people who are struggling to find therapy and treatment.

Molly Shroades:
And it's interesting as we start going out and seeing people again, these social interactions picking all of that up can be an interesting factor here. When our friends support groups and when does the peer pressure get to people? It's kind of going to be an interesting balance act there too.

Dr. Albers:
Yeah. It's definitely a fine line. I think one of the important things, as you're saying, is socially to look around who you spend time with, is it friends, family members, and do they help, or do they hinder your eating behaviors? If you are in a group of people who talk a lot about dieting, have a lot of body image issues and are talking a lot about that. That can be a significant trigger for facilitating behavior. If you are with friends and family members who are accepting, supportive, this can be very helpful. So, you're absolutely right. As we reintegrate into society, there's a lot of anxiety about it happening. But take a moment to pause and think about for yourself who you're around, what impact the pandemic had on you and your eating habits. And what you want going forward.

Molly Shroades:
Absolutely. So, I'm just wondering, does a person ever really fully recover from an eating disorder or is this something that they deal with for their entire life?

Dr. Albers:
People do recover. And I want to emphasize that and really highlight that, because as I tell many patients who asked that same question, do people really recover? This is something that they worked on for years are very stuck. I could not do my job if I did not see people recover and thrive. And what is really important is the earlier the better of intervention, the earlier that you can identify, address this the better in terms of long-term care. What's really important is joining with a professional that you feel comfortable with, that you get some support.

So yes, people do recover. The issues that I've seen happen most often is that people doing well in their life. And sometimes if they hit a stressful time period in their life or a life change, like a pregnancy, a job loss, a divorce, a very stressful event, sometimes there can be reoccurrence. But when they've done therapy, they can see the signs coming and not get so far deep into it that they can't come back out of it. So, even if it does reoccur people who have experienced therapy can identify and avoid falling back into some of those habits. So, yes, I would encourage people to look into treatment because it does work.

Molly Shroades:
Now, as we wrap up, I'm just wondering about ways to get this conversation started. I know a lot of people are very hesitant to talk about eating disorders. It can make them uncomfortable. It can be a little scary. What are some tips you have for getting this conversation started?

Dr. Albers:
Yeah. It's a very important conversation to have. And one to not be avoided, even though, as you mentioned, it can be a little uncomfortable. If you have a friend or family member who you've noticed some of the behaviors that we talked about today, restricting certain food groups, having fear or preoccupation around food, some of those early warning signs, it's important to start the conversation of just really gentle questions of saying, you know, I've noticed that you've had some struggles around food. Or how are you feeling about your eating habits. Sometimes you may get an initial bit of a resistance or pushback, but know that you are planting the seed that you care and that you've noticed, and that they are important to you.

So, it's a good way to start the conversation. You can also buy some books. There are some great websites that provide information. You can share that with the individual in your life so that they can help to start that conversation going. There's also some media. If you see an article in the newspaper, it's something that you can bring up and discuss, but you don't have to be fearful that talking with someone is going to give them the idea in any shape or form. What's most important is to be non-judgemental and just really curious and compassionate when you bring up the conversation.

Molly Shroades:
Awesome. Thank you so much for talking to us today and sharing your insights with us, Dr. Albers.

Dr. Albers:
Thank you so much. If you have any other questions, I'm always happy to respond to people's questions because as I mentioned it's such an important issue I've worked with for a lot of times and the more information the better.

Molly Shroades:
Awesome. If you are concerned that your loved one may be experiencing an issue like an eating disorder, contact your primary care provider or Cleveland Clinics center for behavioral health at clevelandclinic.org/behavioralhealth. You can also call (216) 636-5860 to learn more.

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