Eating disorders are more common than you’d think. In fact 30 million Americans will struggle with an eating disorder at some point in their lives.
The Eating Disorder Program at Akron Children’s Hospital is growing to meet the needs of these families according to the Medical Director of Adolescent Medicine Dr. Stephen Sondike in a recent interview for Health Matters on WHBC AM.
“We are excited to take care of all teenage health issues but specifically we are actively growing and supporting our eating disorders program,” said Dr. Sondike. “We see individuals with anorexia nervosa, bulimia nervosa, female athlete triad and anyone who has a concern about their child’s eating habits.”
Dr. Sondike answered the following questions for National Eating Disorder Awareness Week:
WHBC: Tell us a little about yourself and what you do at Akron Children’s?
Dr. Sondike: I am the division director for Adolescent Medicine at Akron Children’s Hospital; commonly know as the Teen Clinic. I moved here in August from Charleston, W. Virginia where I was the founder and medical director of the Disorder Eating Center of Charleston.
WHBC: Tell us what’s going on in your clinic?
Dr. Sondike: Right now Akron Children’s Hospital is growing tremendously. In the Eating Disorders Program we have Dr. Jessica Castonguay, Lindsay Bailey, who is a terrific dietitian, and myself. We are actively recruiting a psychologist so we can have the full interdisciplinary team but in the meanwhile we use community psychologists. (WATCH video here.)
WHBC: What is the medical definition of an eating disorder?
Dr. Sondike: Eating disorders comprise a wide continuum of conditions from the traditional disorders of anorexia nervosa and bulimia nervosa to obesity. Obesity represents about 40 percent of people seen in weight management clinic and often have the diagnosable “binge eating disorder.” Discomfort with food goes beyond the traditional eating disorders of anorexia and bulimia. They encompasses a wide range of eating behaviors and maladaptive relationships with food, body shape, body image and eating.
WHBC: Could you tell us the differences between anorexia and bulimia?
Dr. Sondike: Anorexia nervosa is traditionally seen in people who are restricting food and not eating enough to maintain their body processes. People with this condition either restrict food or binge and purge. Individuals with this tend to be either losing weight or often of a low weight. But they’re not always skinny and that’s a misconception. You can start out being overweight, lose a lot of weight by not eating and still have anorexia nervosa and all the signs of malnutrition. So it’s losing weight, not eating and doing other unhealthy things to lose weight as well as extreme concern about your body size and shape.
The difference with bulimia nervosa is characterized by the binge, not by the purge. So individuals with bulimia eat excessively. It’s usually a large amount of food over a short amount of time. They respond to the binge by either throwing up or excessively exercising or something else in response to the binge. If you binge because you’re so hungry that you’re starving yourself, that’s anorexia nervosa.
WHBC: What about other influences that cause someone to have an eating disorder like genetics, environment, or other?
Dr. Sondike: This is the million-dollar question. If you could answer the question you would be rich and famous. We know that there’s definitely a genetic or brain disease component to eating disorders because of family history evidence – a twin separated at birth is more likely to develop an eating disorder if one of the twins is affected. Beyond the genetics, you need the trigger. For example, you may have a ballet coach tell you that you need to lose weight or a fitness assessment or BMI taken in school, which could be the trigger. A lot of parents blame themselves because they made an offhanded comment and that triggers it. I try to explain to parents that it’s not their fault. We try to do the best we can to take the focus off size and shape and explain that because of the predisposition, and given our societal pressures, it would have happened with another trigger.
WHBC: Does society’s pressure on individuals with eating disorders play a role as a contributory factor?
Dr. Sondike: Absolutely, there’s cultural pressure to maintain a certain body image. Folks who suffer from eating disorders have other things going on like baseline anxiety, personality conditions, and genetic predisposition. Studies suggest that if you have a 1st degree relative with an eating disorder you are 9 times more likely to develop an eating disorder.
High profile individuals who are in the public eye are more likely to have what we would call the “trigger” to continue the eating disorder. Not everybody who’s involved in high profile situations is going to develop an eating disorder – there’s that predisposition, then the triggers, then anxiety. All those things feed on each other. You can sort of think of it as a rabbit hole. Once you get into it, it’s really hard to dig yourself out.
Certain careers have a higher incidence of eating disorders than others including performers, gymnasts, figure skaters, and dancers – careers where body shape and image are imposed on you. We really try hard to train coaches and teachers not to put the focus on body shape but on skills and overall health rather than focusing on size and shape.
WHBC: What is the profile of the typical teen with an eating disorder?
Dr. Sondike: There is a stereotype of the middle class white girl who’s a perfectionist. We certainly see those individuals but we also see a lot of boys who are ethnic minorities. We see it more and more worldwide – in our immigrant communities. It’s everywhere. When I first moved to West Virginia, certainly not a hotbed of rich prep schools, I was told that I would have trouble developing an eating disorder program because it wouldn’t be that common – they were wrong. We were very busy.
WHBC: What is the average age of onset of an eating disorder?
Dr. Sondike: There are 2 peaks we see a lot – around 12 to 13, and another peak at 18 to 19 years old. That 12-13-age peak is during puberty when people’s body shape is naturally changing and leading to some discomfort. When you talk about that older group – they may be out on their own for the first time with a lot of pressures. However, when I see someone around 18 to 19, I ask them when did they first become concerned about their size and shape. They tell me that was a very long time – back to 13 or 14 but they weren’t able to act on it until they went away to college or went out in their own.
WHBC: Do you think that teens’ poor diet and love for junk food has an affect on the high incidence of eating disorders?
Dr. Sondike: I think we have a terrible relationship with food and we see an increase in both eating disorders and obesity. What we’re doing is playing both sides against the middle. People either give up and eat everything they see or they feel they have to restrict in order to maintain a certain size and shape. The number of people who have a comfortable relationship with food is dwindling. Everybody’s either gaining weight or going on the latest fad diet when in fact the best way to trigger an eating disorder is to start a diet. When people are constantly talking about how fat they are and then eating horrible food, and dieting, we’re going to have an up and down relationship with food and in a certain subset of people eating disorders are triggered. We have become a nation of self-hating fat people. Many people I see with anorexia were told they needed to lose weight by a well-meaning individual and fell down that rabbit hole that they couldn’t get out of it.
WHBC: Are there any other conditions you see besides anorexia and bulimia?
Dr. Sondike: Something we see quite a bit of is called the female athlete triad. This is associated with disordered eating, losing your period and bone density. We see this in high-level athletes who may not have a traditional eating disorder. They aren’t obsessing about their size and shape but with their level of intake and the amount of exercise, they just don’t have enough energy to keep their body processes going. So something that would be a healthy diet for someone who is not very active is not enough for someone who for example is running cross-country. I tell some of my patients that Michael Phelps ate 6,000 calories a day when he was training. When you are a high-level elite athlete, a 1,500-2,00 calorie a day diet is not going to cut it and those people wind up having all the signs and symptoms that you see with anorexia nervosa, and we treat them similarly.
WHBC: Is the concern about body size the reason families come to you?
Dr. Sondike: Often because there’s concern that they’re eating funny or differently than they used to. A lot of parents will say they used to eat with the family and now they’re not doing that anymore. They used to go out for pizza with their friends and now they’re doing anything they possibly can to avoid doing those things. They are eating alone, eating in their room, picking crust off the bread and things they’ve never done before. All these things raise concerns.
People with anorexia also make themselves throw-up or take diet pills and laxatives to control their weight. They may also excessively exercise. So there’s healthy exercise like getting 30 minutes of reasonably moderate cardio with some lean body mass workout but these individuals will do cardio for 2-3 hours a day, they’ll sneak in exercise in the shower, they’ll lock themselves in their room late at night. It gets to the point if they miss their workout they can’t go on with the rest of their day. That’s when you can see whose trying to be healthy versus the more sinister reasons.
WHBC: Do you refer these people for psychiatric care?
Dr. Sondike: Yes, and an interdisciplinary team is the way to go. They need a medical doctor like myself or Dr. Castonguay who can evaluate them for medical complications that accompany poor nutrition. They also need a dietitian to reteach them how to eat and a psychologist to work with some of the anxiety that comes with having to gain weight when that’s something you really don’t want to do.
WHBC: Without a parent’s involvement how do you get a 12 or 13 year old to change?
Dr. Sondike: We do get their parents involved and it’s essential for recovery. It’s very difficult to have success without them at every step of the way.
WHBC: A caller asked about Prader-Willi syndrome. How do eating disorders play a role with this syndrome?
Dr. Sondike: Prader-Willi syndrome is a genetic condition in which babies are often floppy, have decreased tone and may be under weight up until 3 or 4 years old. Once they are toddlers there is compulsive eating and these individuals can end up at 300 to 400 pounds. It’s not curable but there are medications or behavioral therapies that can help. That would not be considered an eating disorder so if you need more information I would recommend calling the Genetic Center at Akron Children’s or the Endocrinology Clinic. I know they both see individuals with Prader-Willi.
WHBC: Is there a fine line between the person who is extremely focused on eating healthy and working out and the person with an eating disorder?
Dr. Sondike: That’s a great question, which I get a lot. A lot of individuals who have eating disorders start out just trying to eat healthier. They change they’re eating habits by eating more salads, fruits and vegetables which is in general a good thing. The concern comes when they start not liking foods that they like, eating alone and avoiding social situations where people would be eating. So if someone’s not going out to eat with friends or displaying habits like picking at their food, running to the bathroom after eating that’s a huge red flag. The earlier you intervene with an eating disorder, the better. The longer you wait, the harder it is to pull yourself out of it. Your mood changes and your obsessional thoughts increase as you become more malnourished. Your body changes too – your stomach can’t move food along so it becomes harder to eat. So if you have any concerns at all, come see us. If it’s not a concern, I’ll pat you on the back and say we’re glad you came. If there is a problem brewing, we can intervene early.
WHBC: There’s a lot of talk in the literature about the connection between eating disorders and anxiety; can you tell us more about that?
Dr. Sondike: That’s really hard to tease out because that’s a chicken or the egg issue. We know that one of the signs of depression is decreased appetite. We also know that malnutrition causes lower mood and depression. So when somebody comes in and they’re malnourished and depressed and they’re anxious about food, do they have an anxiety disorder, depression or both? A lot of times when we improve nutrition, the blood gets flowing to the brain and their mood improves. When they start therapy and working about their issues around food, the anxiety gets better. One thing that seems to be true is that the standard antidepressants used for depression and anxieties don’t work well with anorexia nervosa, which implies that, the depression and anxiety is secondary to the eating disorder. So it’s a tangled web and it’s really hard to figure out. That being said, we do treat with antidepressants if people tell us they have been depressed or anxious long before the eating disorder developed. We understand that these medications won’t treat some of the eating issues but at least it might treat some of the other mood issues.
WHBC: You mentioned that you have a dietitian on your team. Does every patient who comes to you get a diet?
Dr. Sondike: The treatment we use is called family based therapy and so what we do is teach the parents how to re-feed their child. It’s particularly tricky with young adults who aren’t living at home. We empower the parents to use their parental authority to make sure their kids eat even when the kids get upset, throw food and yell and scream. That’s part of the disease and we understand that. Anorexia is different from some other condition in that people who suffer from this don’t seem to want the cure. That’s the malnutrition talking. Once the nutrition gets a little better and the mood improves, they get more on board. In the beginning they don’t want to do it so we empower the parents to help. The dietitian is integral in teaching parents to re-feed the kid. We don’t do specific diet plans because we want to eventually teach kids how to eat on their own. If we just give them a piece of paper telling them what to eat every day, then they can’t learn to identify their hunger cues.
WHBC: What’s the most successful model you use to treat eating disorders?
Dr. Sondike: The most successful model is an interdisciplinary program with a medical physician, a dietitian and a psychologist using family based therapy. Sometimes the families just aren’t able to do it for a variety of reasons and then we use some other therapies that also work but family based therapy is the best. More and more evidence is showing that it should be the first line of treatment.
WHBC: How do outcomes in the family based model compare with individual-focus treatment?
Dr. Sondike: They seem to be better. I don’t want to say that individual focus treatment doesn’t work. It works in the hands of an experienced psychologist using it but research shows that with family based therapy the weight gets gained a little quicker and relapses are less common. So that’s why we go that first unless for some reason it’s not possible.
WHBC: Today kids often eat what they want and parents don’t have a sit down dinner for a lot of reasons. Do you think this is part of the problem?
Dr. Sondike: Yes, parents used to say there are 2 choices – take it or leave it. Often if families aren’t eating together, parents don’t know what the kids are eating. It might take longer to realize that there’s something nefarious going on. By the time someone has lost enough weight that it’s noticeable they’ve probably already lost too much. Also, people with anorexia nervosa often wear looser clothes in order to hide the weight loss and by the time the parents have realized that there’s a problem, the kid is already quite sick.
WHBC: What factors contribute to a young person being able to overcome an eating disorder?
Dr. Sondike: The thing that gives you the best prognosis is diagnosing it early and seeing recovery early. There is some good data that shows that if you have anorexia nervosa and you gain 4 pounds in the first 4 weeks of treatment, your outcomes are much better than if it lingers on. That’s why I say if you have any concerns at all, give us a call and come on in. Let’s do an evaluation and if it’s not something that we need to be concerned about, at least you get that peace of mind. If it is something we catch early then outcomes are much better. The other thing that shows a good outcome is good family support. We empower the parent to get involved because nobody knows how to feed his or her child better than a parent.
The mortality rate of anorexia nervosa is around 20% as compared to the mortality rate of acute childhood leukemia at 5%. There’s a 95% cure rate with leukemia so you’re more likely to die from anorexia than to die from leukemia. So, if your kid had cancer and he or she said, “I don’t want to take my chemotherapy,” you wouldn’t say, “I don’t want to upset them and force them.” You’d make certain that they took it. With anorexia nervosa, the medicine is food so we tell parents that as you would not allow the diabetic kid not to take their insulin, you would not allow the kid with anorexia to not take their food.
WHBC: Do you have specific foods that you suggest that they consume?
Dr. Sondike: We aim for a variety of foods. People with eating disorders tend to go for foods that don’t have a lot of energy like salads so we work on making sure they get energy-dense foods. We need to make sure that it’s not a meal unless it has 3 colors. With breakfast, you can’t just have cereal with milk – you have to throw some berries in there to add a color. If there are not 3 colors, you’re probably not having as nutritious meal.
WHBC: What advise can you give to parents about things they should or should not say to their children about living a healthy lifestyle and developing a healthy body image?
Dr. Sondike: The one thing we really want to avoid is what we call “ fat talk.” There is actually a lot of data that suggests that increased “fat talk” in the family can trigger eating disorders. Kids are more likely to have eating disorders if parents are constantly weighing themselves, talking about how much they weigh and how fat they are. We want to avoid any talk about size and shape as it compares to health. We want to just say, we want to be healthy. If you don’t want your kid to eat that second bag of chips don’t say, don’t eat that second bag of chips you’re going to get fat but rather don’t eat it because it’s not healthy. That’s a much better way to phrase it.
WHBC: Tell us about Akron Children’s Eating Disorder Program.
Dr. Sondike: We’ve been seeing children in our program for years. In the past, we’ve had staff leave and had to slow down but now we’re at full strength with Dr. Castonguay, the dietitian and myself. If you have a concern about somebody’s eating habits and you think that there might be an eating issue, you can certainly come see us. Your physician can refer or you can call personally. We like to keep the primary physician involved so that way everyone can stay in the loop. We’re always happy to hear from you. And you can reach us at 330-543-8538 or akronchildrens.org.