23. Eating Disorders in Pediatrics with Dr. Jenn Goetz

How can we identify kids at risk for eating disorders  in pediatrics? How can we promote healthy relationships with food and with eating?  Our guest, Dr. Jennifer Leah Goetz, a double board-certified psychiatrist specializing in eating disorders, discusses:

·      the variety of eating disorders in kids, 

·      the prevalence, and risk factors for developing an eating disorder

·       how eating disorders come in bodies of all shapes and sizes 

·       questions that pediatric clinicians can ask to see if a child/teen is at risk of developing an eating disorder

·      Positive ways to talk about food with children to mitigate their risk of developing an eating disorder

Jennifer Leah Goetz, MD: is double board certified in general psychiatry and child and adolescent psychiatry. She completed her internship in pediatrics at Massachusetts General Hospital and her general psychiatry and child/adolescent psychiatry training at MGH and McLean. She previously served as medical director of the child and adolescent inpatient unit at Johns Hopkins Hospital and helped run the eating disorder clinical service. She is an attending psychiatrist at McLean hospital and an Instructor in Psychiatry at Harvard Medical School. She specializes in the care and treatment of those with eating disorders. 

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Transcript

Dr. Elise Fallucco: 0:21

Welcome back to PsychEd4Peds. The child mental health podcast for pediatric clinicians- helping you help kids. I'm your host, Dr. Elise Fallucco, child psychiatrist and mom. Today, we're going to be talking about eating disorders in kids and teenagers. What can pediatric clinicians do to identify kids at risk or kids who've already developed eating disorders. We're going to go over specific screening questions you can ask. And finally how we, as clinicians, as parents, as trusted adults, can model healthy relationships with food and eating. Today's guest is Dr. Jennifer Leah Goetz, who is double board certified in general psychiatry and child and adolescent psychiatry. She did her residency and fellowship training through the Harvard medical school system at Massachusetts general hospital and McLean. She worked at Johns Hopkins to help run the eating disorder, clinical service and worked as medical director of the child and adolescent inpatient unit. And currently she's in Boston. Affiliated with Harvard and working on various inpatient units at McLean hospital. When we say eating disorders, there's this broad category. So what do you mean, Dr. Goetz, when you talk about eating disorders?

Dr Jenn Goetz: 1:37

Eating disorders are a broad category encompassing the things that we often think about, which are disorders like anorexia nervosa, bulimia nervosa, and binge eating disorder, but they also include the eating disorders that don't fall into one of those nice little boxes. So things like other specified eating disorder things like Avoidant Restrictive Food Intake Disorder and actually more people fall into these categories that aren't nice, neat boxes of anorexia or bulimia nervosa than don't. So I'm referring to all of these different eating disorders.

Dr. Elise Fallucco: 2:08

So it's like the larger picture of having a disordered relationship with food, with eating plus or minus with body image, depending upon which one you're talking about. A Lot of times when people think of eating disorders, they immediately think about adults or young adults. But eating disorders are common in pediatrics. Could you tell us a little bit about which types of people are at risk for developing an eating disorder?

Dr Jenn Goetz: 2:32

Yes. 9% of the population will have an eating disorder at any given time. There are lots of different risk factors for the development of eating disorders, ranging from a perfectionistic or obsessive or anxious type of temperament, all the way to things like poverty and food scarcity that also place individuals at risk for developing different types of eating disorders. Of those who develop an eating disorder, there's almost always a diet at the beginning in some fashion. And by diet, I just mean a restrictive practice of eating. And so there are lots of different ways that individuals come to develop an eating disorder, but they often take root in that sort of childhood, adolescence period, even if they don't come to like full attention during that time. It's a really crucial time.

Dr. Elise Fallucco: 3:10

Wow. I just heard you say eating disorders affect 9% of the population. So close to one in 10 of the kids, the pediatric clinicians see in their practice may have eating. disorders. What can pediatric clinicians do to identify those kids who may be struggling with And eating disorder, or who may have, disordered eating and maybe on their way to an eating disorder, how do we identify the kids as early as we possibly can?

Dr Jenn Goetz: 3:38

There's a couple different ways to think about screening for eating disorders right. One is, if you have kids in your practice who's really falling off their growth curve, that should actually spark a workup for lots of different causes for weight loss, one of which could be an eating disorder. But in addition, a lot of eating disorders don't actually show up with significant weight loss. And some might show up with weight gain and most show up with absolutely no changes in weight and go on secretively for years and years, simply because no one has ever asked the question. So it's really important to get at whether there's eating pathology present because early intervention and treatment saves life. The longer somebody goes with an untreated eating disorder, the harder it is to treat because these patterns become so entrenched.

Dr. Elise Fallucco: 4:15

So similar to other disorders across pediatrics, early identification is key. And I want to highlight, you said most children with eating disorders have no major changes in weight, making it even more critical to screen all kids and teens, regardless of their weight. What questions would you recommend the pediatric clinicians ask kids to screen for possible eating disorders?

Dr Jenn Goetz: 4:36

I recommend that pediatricians incorporate a series of different questions into their screening that they're doing for general health conditions. And so asking about things like food insecurity and whether or not kids have access to regular food and what that looks like. Again, if kids are scared that they're, they don't know when they're getting their next meal from, they're going to store up food. Because they don't know, and that leads to these cycles of binging and restricting. You want to know whether kids are intentionally going for long periods of time not eating certain foods. So one of the easiest ways to get at that question is do you eat lunch at school? now kids could not eat lunch at school for a variety of reasons, but it's a great entree because it's a really easy way for kids to go under the radar, because there aren't usually adults in the cafeteria. So I ask kids a lot tell me what lunch looks like. And if they answer I don't usually eat lunch, that leads into questions about, like, why? Are you intentionally skipping? Are you skipping other meals? Ask kids screening questions about whether or not they eat large quantities of food and feel like they can't stop themselves or feel like out of control to get it, whether there's binging going on. And if they do anything to get rid of food, make themselves throw up or use different types of pills like laxatives or diuretics. Some kids know what those are. If they don't, that's usually a sign that they're probably not engaging in that behavior. I also will ask kids and teens about exercise Exercising a ton actually could be a sign of a developing eating disorder. So understanding actually like the amount of movement that someone's getting and the relationship to their body and sort of their food intake is really important.

Dr. Elise Fallucco: 5:58

Okay, so asking about food insecurity, asking about what do they eat for lunch, as an example asking about, eating large quantities at a time and feeling like you're out of control and can't stop, and then, compensatory behaviors like trying to get rid of food, using laxatives or diuretics or even potentially excessive exercise in an effort to lose weight or get rid of calories. I'm thinking about our pediatrician colleagues that how hard it is to be standing in the gap because obviously are the end goal for all of our kids if they're struggling with obesity and health consequences related to overeating, we want to be able to help them in a way that doesn't send them off in the other direction and predispose them to developing disordered eating.

Dr Jenn Goetz: 6:43

Right. I would actually encourage our pediatric colleagues to think about individuals who are what we consider overweight or obese, I would actually encourage them to look for restrictive eating practices in those individuals. Because oftentimes individuals who look like they're overeating, and we even tell you they're overeating, are oftentimes restricting as well. biNge eating disorder at its core is actually a restrictive eating disorder. It's because Individuals restrict their intake that they actually feel out of control and can't stop eating during these binge episodes for many individuals who are overweight or obese, they might actually be struggling with something similar and it just goes under the radar, but the people don't think of these as restrictive eating disorders.

Dr. Elise Fallucco: 7:27

without assigning morality, like good and bad to certain foods, how do you talk about eating in a way that is healthy In an effort to keep people well balanced

Dr Jenn Goetz: 7:37

how do you teach kids that there are foods that have more nutritious value than others? It's a great question. It's twofold. So one is through modeling and I think the way that parents and adults in kids and teens lives talk about food and interact with food is really important. The way that we talk about our bodies and about what we're putting in our bodies is really important. What I share is actually both really simple and very complicated. And that is there's room for literally every type of food you could imagine In a diet of what you're putting into your body. The key is variety, right? And so making sure that the foods that you're putting in your body come from lots of different sources. Protein, carbohydrate. Fat, dairy, vegetables, fruits, all these different categories are really important. but it's equally as important that we include things like sweets, whether that's M& Ms or Snickers bars or ice cream or yogurt. If we don't limit these foods in terms of access to them and that they have a place in our world, then we don't create a restrictive mindset for kids and teens. The minute we put those things on restriction, what do kids want? They want them more. So liberalizing our approach to letting kids eat what they want. Eat when they're hungry. Stop when they're full. They actually know how to regulate their system better than we do as adults. And reminding kids that they can have all these different foods, exposing them to a wide variety of foods, letting them see that we eat a wide variety of foods and aren't restricting what we put in our bodies is so important. I kind of like to explain it to parents and kids is that no food is off limits. Unless you have an allergy to something and then you should probably stay away from it. And food shouldn't be earned either. Food should be something that your kids and your teens are learning about putting in their body so that their body can do the things that they want it to do, whether that's dancing or gymnastics or soccer, or walking up the stairs, or, food just allows us to fuel our life. It's nothing more than that.

Dr. Elise Fallucco: 9:32

I Like how you're emphasizing, food is a source of energy and it helps fuel our lives and helps us do the things we need to do and helps our brains think at school or at work.

Dr Jenn Goetz: 9:41

Food is fuel. You put gas in your car, you got to put gas in your body.

Dr. Elise Fallucco: 9:44

You've talked a lot about modeling a healthy approach and a healthier relationship with food and with eating. Part of what we can do in our own families, friend circles, communities, practices, is to try to model a Healthy attitude with food that recognizes that all of these different foods, when consumed in a variety are really helpful to keep our body running and to help us do the things that, that make us special and that bring us a lot of joy and hopefully help other people. I love this. So as we wrap up, do you have a take home message that you want to share with pediatricians to help the kids and teens in their

Dr Jenn Goetz: 10:21

practice? Yeah, I think it's really easy for us to think we can identify folks with eating disorders by looking at them. Actually, you can't really tell who has an eating disorder just by looking at them. There are a variety of reasons that somebody could have lost a lot of weight. And so it's not clearly an eating disorder, if that's what's happening. But most eating disorders actually don't have a certain look. They don't have a specific racial, ethnic picture. They don't have a certain socioeconomic status that they hit. They really exist in all bodies, in all sizes, and occur across genders. And so I would just encourage pediatricians to ask the questions regularly of all of your patients because a lot of folks are really suffering and struggling in silence. And it can be decades. Some folks come to clinical attention and people suffer a lot in that period of time. And we can really get folks back on track with relatively simple interventions early on that you can do in your office.

Dr. Elise Fallucco: 11:08

Thank you so much. You are so welcome. And I love all your creative and practical ideas for what can we do to promote healthy eating habits at all ages and try to combat that in our various circles.

Dr Jenn Goetz: 11:19

Thank you. This was so fun.

Dr. Elise Fallucco: 11:20

And is a brief recap of what we talked about. eating disorders are common in pediatrics affecting up to one in 10 kids, and they're often difficult to detect. Because the majority of kids with eating disorders do not present with major changes in weight. So we really have to ask the questions about food insecurity, about a history of binge eating, food restriction, and excessive exercise or other compensatory behaviors. In our next episodes, we're going to dive deeper and talk about specific screening tools that may be helpful and practical for use in primary care to detect eating disorders, as well as what pediatric clinicians can do to help kids with eating disorders in their practice. Thanks again for listening. If you have any questions, comments, or ideas about future episodes, please message us on the website at psyched. The number four paeds.com. Or. On Instagram at psyched for paeds. See you next time.