Complex problem is part of a national crisis in mental health

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Eating disorders have one of the highest mortality rates in all of psychiatry with 12 times higher death rates in 15- to 24-year olds than any other cause. It's a crisis that's part of the nation's mental health crisis. Here to talk about care of patients with eating disorders is Davia Moss, who is a family nurse practitioner specializing in adolescent medicine at Upstate. Welcome to "The Informed Patient," Davia Moss.

[00:00:40] Nurse practitioner Davia Moss: Hi Amber. Thank you so much.

[00:00:42] Host Amber Smith: Let's start by defining what qualifies as an eating disorder. What are the main types of eating disorders?

[00:00:49] Nurse practitioner Davia Moss: So the diagnoses that people have probably heard of are anorexia nervosa, bulimia nervosa, and binge eating disorder. There is also a newer diagnosis that the letters we use are A R F I D, (Avoidant/Restrictive Food Intake Disorder.) Sometimes we see this in younger patients. We see it with patients who have maybe sensory difficulties with different foods and they can have a very restrictive eating, without the body image concerns. So those would be the most common diagnoses that you would hear.

[00:01:20] Host Amber Smith: You mentioned anorexia, bulimia, and binge eating. Do those all have body image tied up in them, or how do they differ from one another?

[00:01:28] Nurse practitioner Davia Moss: Anorexia nervosa is probably what everyone pictures when we think of eating disorders, when we see an emaciated body, that's sort of our stereotypical eating disorder, which actually does not apply to majority of people with an eating disorder, that sort of visual that we have.

Anorexia nervosa has restrictive patterns of eating. Also very significant body image concerns. Bulimia nervosa has a binge and then intentional vomiting, which some people call purging after eating. So that would be the difference there.

And then a binge eating disorder is where people actually feel out of control with food and often are not able to control how much intake they have.

[00:02:13] Host Amber Smith: How prevalent are these eating disorders?

[00:02:17] Nurse practitioner Davia Moss: The numbers are changing rapidly. You can look at a hundred different sources anywhere from 5 to 10% in the general population. However, we know there that there are certain populations that are underdiagnosed significantly, in particular males. Populations of color are often underdiagnosed. And certainly as you spoke to during this crisis, we will see those numbers change rapidly as more data comes out in the next few years.

[00:02:46] Host Amber Smith: Is it mostly adolescents? Are you seeing a lot of this in your patients?

[00:02:51] Nurse practitioner Davia Moss: We are seeing an enormous increase in our patients, both in our outpatient clinic and in the hospital. The number of patients that we have had to hospitalize has gone up by about four to five fold throughout this crisis.

[00:03:07] Host Amber Smith: Do we know what this is all about or what is causing it?

[00:03:11] Nurse practitioner Davia Moss: Eating disorders thrive on isolation. Often it starts as a matter of control. And as we all know, these teenagers lost a lot of control in their life, and they were home and had more time to pour their energy that typically would've gone into school or socializing, maybe into exercise. Then you add the social media piece to things. It often started as, I will quote, because I hear this from a lot of my patients, they will say they were "just trying to get healthier and then somewhere along the line things, you know, became out of control."

[00:03:48] Host Amber Smith: Are student athletes more at risk for eating disorders because they focus on the performance of their bodies?

[00:03:55] Nurse practitioner Davia Moss: There are certain sports that we know for sure are at higher risk. There are certain sports that actually require a weigh-in. So wrestling, rowing, those things are certainly a higher risk. And sometimes you'll see more eating disorder behaviors during the season. And then there are other sports that actually, focus on body image -- cross country running, dance, ballet. Those are definitely higher risk activities that we see in our population.

[00:04:25] Host Amber Smith: And the ones that got started trying to eat healthy, were they trying to lose weight or trying to bulk up and be more muscular? Because I hear a lot about protein powders, and "health food" stores are popular with adolescents now.

[00:04:42] Nurse practitioner Davia Moss: Yeah, our diet culture is really, really incredible. And to be honest, there's no reason for any adolescent to be on a, quote, diet. Their brains are not capable of balance, so it often can get very quickly out of control. The other tricky part is they often get a lot of positive feedback when their body starts to change. And for an adolescent, they really thrive off that, and that's when things can get very out of control pretty quickly.

[00:05:09] Host Amber Smith: Are close friends at risk? If you have someone that you're close to who's dealing with an eating disorder, are you vulnerable to developing this disorder as well?

[00:05:20] Nurse practitioner Davia Moss: That's a great question. I don't know any particular data on that. I would say I don't see it anecdotally. There is a huge genetic component. We do know that if a parent had an eating disorder or a grandparent had an eating disorder that that does put you at risk for an eating disorder.

[00:05:37] Host Amber Smith: Eating disorders are the third most common chronic health condition for children and adolescents, behind asthma and obesity. It was not always that way. Is the pandemic to blame for this?

[00:05:50] Nurse practitioner Davia Moss: The pandemic, combined with social media, combined with our diet culture has sort of been a perfect storm to create this crisis of eating disorders. Absolutely.

[00:06:01] Host Amber Smith: How is it that eating disorders have such a high mortality rate, though? You said a lot of your patients end up hospitalized. How do you go from binging and purging or whatever to needing to be hospitalized?

[00:06:15] Nurse practitioner Davia Moss: So the patients that are hospitalized are often the ones that are restricting to very, very significant under 500 calories a day, over exercising. They can have long-term cardiac, when I say sequelae, those are sort of symptoms that you could deal with for a very long period of time. So cardiac (and) things having to do with the gut, with the GI (gastrointestinal) system. We have patients that abuse laxatives, which can actually impact the ability of your GI tract to even function correctly for the rest of your life.

Patients will have frequent, the term is syncopal episode, where they pass out. Unfortunately sometimes it's seen as normal for a teenage girl to pass out. If that's happening more than once, that should be followed by a medical provider. It can go downhill very quickly, and they're at a time of rapid growth in their life.

[00:07:11] Host Amber Smith: How would a person know they have an eating disorder?

[00:07:16] Nurse practitioner Davia Moss: I'm going to focus in on the adolescent population for right this second because that's what I work with. And I think we really depend on the caregivers, parents, teachers, guidance counselors to be able to hone in on if something is changing in a child, if we notice that their body is changing. That's a red flag. If we notice that their attention concentration is changing, their fatigue levels, if they're starting to isolate themselves more, suddenly wanting to exercise more often. All of those are red flags that should be followed up on.

[00:07:51] Host Amber Smith: Is it normal though for teens to have concerns about their appearance or weight? I thought that was sort of part of growing up?

[00:07:59] Nurse practitioner Davia Moss: It's very normal to have concerns of our body. Unfortunately, actually, the concerns about weight are really this diet culture that we currently live in. You know, the other crisis is obesity. And unfortunately sometimes when our medical providers really hone in on obesity being a weight issue, depending on how we discuss those things with our teenagers, that can actually send the wrong message.

So you know, medicine is constantly evolving, and changing how we communicate with our kids about their bodies is very important.

[00:08:34] Host Amber Smith: So are eating disorders usually diagnosed by the primary care provider, someone like yourself?

[00:08:40] Nurse practitioner Davia Moss: I'm not a primary care provider. We're the specialty, so usually we receive the consult from the primary care providers. But certainly in a well child check, if an adolescent has lost weight since their last visit, there needs to be a conversation.

Often parents notice these things before the pediatricians because teens don't go to the general provider often. It can be once a year. During Covid, it was even less than that. So it can depend. Sometimes it's a teacher, sometimes it's a guidance counselor, sometimes it's a coach. But certainly yes, we definitely depend on our primary care providers to make that call.

[00:09:19] Host Amber Smith: Is this something that can be handled without medical intervention? Can a family solve this on their own?

[00:09:27] Nurse practitioner Davia Moss: Family-based therapy is actually the strongest evidence for healing an eating disorder, but also you need a mental health provider to help guide you through that.

There are certainly books out there, and I'm sure there are families that have made this happen on their own and helped their child turn it around. But support for the family and the patient is really important to help those relationships stay intact through a really difficult time.

[00:09:56] Host Amber Smith: How would you recommend someone prepare for a medical appointment if they're coming to talk about eating disorders? What should they bring with them or be prepared to answer?

[00:10:07] Nurse practitioner Davia Moss: We hopefully will have records from their primary care provider or whoever referred them, which shows weights, which is not all the information we need, but that is a huge indicator and often the first sort of red flag that will bring them into our office.

We do it's called a blind weight. So our patients step onto the scale backward, and we do not show them what their weight is in our office. And if, honestly, if there's any question, even if someone was sent to us for a different diagnosis, if there's any question that this might be a difficult topic for the patient, we do a blind weight.

This is followed by orthostatic vital signs, which is a heart rate and a blood pressure in different positions. Often when we have malnutrition, when we go from laying to sitting to standing, our body doesn't do what it's supposed to do, so we can have dizziness, our blood pressure can drop, our heart rate can change significantly, and those are really big indicators that we're not getting enough nutrition.

[00:11:07] Host Amber Smith: Is there any other medical testing that has to be done, or imaging, or blood work?

[00:11:12] Nurse practitioner Davia Moss: There's no imaging. We do have some blood work done on our patients. Our bodies are very, very good at keeping us stable. So often, blood work can look normal, and that's a good thing.

For patients that are hospitalized, when we start refeeding them -- meaning start giving them nutrition again -- there is a syndrome called refeeding syndrome that can be fatal. It's rare, but because it can be fa fatal, we're very careful to watch what happens to their electrolytes. That's things like magnesium, phosphorus, sodium that's in our bodies, and we keep an eye on those things to make sure they stay within normal limits.

[00:11:50] Host Amber Smith: Can eating disorders be successfully treated, or can they be cured?

[00:11:55] Nurse practitioner Davia Moss: They can. It's actually only about a third of our patients are truly cured. Some providers say it's similar to addiction, where you say you're continually in recovery. Some patients that I'm still in touch with that are in adulthood say that they truly are cured, and they don't -- what we refer to as the "eating disorder voice." It really can be a pretty cruel voice in their head -- and they find that that voice truly goes away. But it is a small, small amount of people that have true recovery. Some deal with this chronically through the rest of their lives, and some do succumb to their illness.

[00:12:37] Host Amber Smith: So what's involved generally in the treatment?

[00:12:41] Nurse practitioner Davia Moss: The most important thing is nutrition. We always say food is their medicine. Sometimes it involves SSRIs (selective serotonin reuptake inhibitors) or other antidepressants, anti-anxieties. These medicines actually don't work if you are malnourished. You need a chemical called serotonin, and when we're malnourished, we actually don't produce enough serotonin.

So that can be really, really discouraging, especially for parents that, it's just terrible to watch their child getting sicker and sicker. And unfortunately, food is their main medicine, and the food is the most difficult part for their child.

[00:13:16] Host Amber Smith: So is nutrition education... are there classes or guides that the patient learns?

[00:13:24] Nurse practitioner Davia Moss: We have a couple of dieticians that we work with that have experience with eating disorders. You really want to make sure that your dietician has experience with eating disorders because unfortunately, there are dieticians out there that do focus on weight loss and are more focused on the diet culture. So you want to make sure that your dietician has that knowledge so they're able to help with nutrition counseling as you're going through that process.

[00:13:48] Host Amber Smith: What about psychotherapy? Is that always a component of this?

[00:13:51] Nurse practitioner Davia Moss: Always, both for the patient and the family. The more that the family can be involved and help understand what the underlying symptoms that have led to this eating disorder, the better the patient can do.

[00:14:06] Host Amber Smith: Are there therapists that specialize in eating disorders?

[00:14:10] Nurse practitioner Davia Moss: Yes. We work with a number of therapists in our region that are specialized in eating disorders. And it's so crucial that as a team we collaborate. We often are emailing after every appointment, so we are all on the same page. Eating disorders are very, very, very powerful, and they can almost convince the patient that one part of the team, one provider and the team, is bad versus another member of the team. So it's really important the team is on the same page to make sure we can provide the best care for the patient.

[00:14:44] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with family nurse practitioner Davia Moss, who specializes in adolescent medicine at Upstate, and our subject is eating disorders.

What happens to someone who has an eating disorder that goes untreated?

[00:15:04] Nurse practitioner Davia Moss: The longer a patient stays in an active eating disorder, the likelihood that they will recover from their eating disorder actually quickly declines. So the faster that we can find the eating disorder and treat the eating disorder, the better they do. The younger that we can address it, the better that they do.

We do have some patients that if they are not doing well with outpatient, which is what I do, they may need something called either partial hospitalization, which is like a full-time day program or residential treatment, which was when they lived there for anywhere from six to 12 weeks while they're recovering.

[00:15:45] Host Amber Smith: When you have someone that you're treating, do you ask them to limit their social media usage or television, or are there things in the home environment that you try to shape for them?

[00:15:58] Nurse practitioner Davia Moss: We try to find the balance of quality of life for teenagers. Social media is a huge piece of quality of life for them. So I think that piece is for the therapist to discuss what might be, we use the word "triggering" for a patient, and what is helpful. I think it's the same as, are these friendships toxic to your life, or are these friendships helpful? So those conversations are definitely important.

Exercise can be the same thing. Finding the balance of pulling a patient from their activities that they love so much, but recognizing what's actually helpful to their body at that time.

[00:16:35] Host Amber Smith: Well, I want to ask you also about some of the medical side effects that come along, often, with eating disorders. Electrolyte imbalances, is that something that can be managed in the outpatient setting?

[00:16:48] Nurse practitioner Davia Moss: Yes. So depending on how sick a patient is guides us on how often we might be doing blood work, or if we have patients waiting for a bed and residential treatment, especially through this crisis right now, we will do blood work more often. Sometimes we have them replacing electrolytes with things like Gatorade, eating foods with more salt, such as pretzels, what we know they can tolerate. That's sort of more like crisis management while we're waiting to get them to a higher level of care. EKGs, meaning we actually put stickers on the chest so we can get a picture of the electrical activity in the heart, is also something very important that we keep an eye on, in the outpatient setting.

[00:17:27] Host Amber Smith: How common are digestive problems like constipation or diarrhea?

[00:17:32] Nurse practitioner Davia Moss: Very, very common. Constipation is much more common. Obviously the less you eat, the slower your gut is working. And then our patients that have abused laxatives or maybe diet pills can impact our gut for long-term use.

[00:17:50] Host Amber Smith: For the female patients, do they typically have menstrual problems as well?

[00:17:55] Nurse practitioner Davia Moss: They can. They can lose their menses for numerous months, which can impact their bone density. After losing their menses for about six months, we will do a bone density scan. Although truly bone density scans, we can't read them very well for adolescents because their bones are different. We only gain our bone density until about 22 years old. So if we don't treat that eating disorder and get them back on track and get their hormones such as estrogen back to the healthy levels, they can impact their bone density for the rest of their life.

[00:18:30] Host Amber Smith: What about tooth erosion, cavities? Does this impact dental care as well?

[00:18:35] Nurse practitioner Davia Moss: Absolutely. That's something we look at in our physical exam. That typically happens in our patients that are self-induced vomiting. And there are also patients that, if they're trying to decrease the amount of laxatives they're using, they actually can have unintentional vomiting. So dental care is very important.

[00:18:56] Host Amber Smith: Well, knowing that this is such a risk for adolescents, is there anything that parents can do to try to prevent an eating disorder from developing in the first place?

[00:19:07] Nurse practitioner Davia Moss: I think 1. the culture we create in our house, how we talk about food, how we talk about good foods, bad foods, how we talk about dieting. If our parents are dieting frequently, throughout their lives, that's a huge risk factor for these kids. And then it makes you wonder, does the parent themselves just have an eating disorder that was never addressed? So absolutely creating the culture, being careful of how we talk about bodies in general.

I have a number of patients that were told as they, when they were young, that they were so skinny, and the minute they hit adolescence, which is very normal, all of a sudden they stopped hearing that, and that was the trigger. That was all they needed to go down the path of an eating disorder.

[00:19:51] Host Amber Smith: Are there triggers like that -- for someone who's treated as an adolescent and 10 years later, 20 years later -- are there triggers that may make the eating disorder return?

[00:20:02] Nurse practitioner Davia Moss: Yes. Especially in the female population, think pregnancy, body changes, even just stressors, going off to college, being in another environment that's full of diet culture, being surrounded by other people that may have an eating disorder that was never addressed. Absolutely those are things that we try to prepare them for as they move into the recovery phase of their eating disorder. We then try to move into having conversations about the triggers that will happen throughout their life.

[00:20:35] Host Amber Smith: So someone who's in recovery from an eating disorder, does that set them up for other medical problems later in life? Not the ones that you would treat actively, but later on. If you have a history of eating disorders, would your primary care doctor need to be thinking about other things that might come up?

[00:20:54] Nurse practitioner Davia Moss: It would be very important for a primary care provider to know if an adult did have an eating disorder as an adolescent.

We can certainly see from a mental health perspective, you can see O C D (obsessive compulsive disorder) symptoms, significant anxiety. We can see fertility difficulties, again, bone density difficulties. And of course those need to be addressed, maybe in a 30 year old, where typically an internal medicine provider would not think to address that until much older.

[00:21:23] Host Amber Smith: Do you see support groups for people with eating disorders?

[00:21:27] Nurse practitioner Davia Moss: There are support groups. There's not enough. as we know in this mental health crisis in general, there's just not enough.

I think the biggest thing to look out for, for support groups, especially if you're a parent looking for a support group for your kid, is to know what stage of recovery the other members of the group are in. Because, of course, this could be very triggering if one patient is not in a state of recovery and maybe not healthy, doesn't have that support at home. That's definitely something to be aware of.

[00:22:01] Host Amber Smith: It's got to be tricky to learn, if you've dealt with an eating disorder, to then learn how to eat healthy because you're focusing on food again to do that, right?

[00:22:13] Nurse practitioner Davia Moss: Yes. So I think there's a balance. People use the term "intuitive eating," and that is sort of, I would say, the end of the road in recovery, to truly learn how to intuitively eat.

I know there's a lot in the diet culture world about what's not healthy on our shelves, what is healthy on our shelves, and so knowing that there's a balance. And if your body is craving something, typically that means that it wants it. And often if we withhold it, eventually you end up eating more than maybe you would have if you had just given your body what it was asking for.

[00:22:49] Host Amber Smith: Davia Moss, thank you so much for making time for this interview.

[00:22:52] Nurse practitioner Davia Moss: Thank you, Amber.

[00:22:54] Host Amber Smith: My guest has been family nurse practitioner Davia Moss. She specializes in adolescent medicine at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.