A Rise in Eating Disorders with Elizabeth Wallis, M.D.

Eating disorders in young people have spiked during the COVID-19 pandemic, according to several U.S.-based studies. But there is hope and effective treatment for those with these serious conditions.

In this episode of Advance with MUSC Health, Elizabeth Wallis, M.D., explains warning signs of eating disorders, effective therapies and the different paths young patients and their families take to make a full recovery. She is the Director of the Division of Adolescent Medicine at MUSC Health and Medical Director of the Friedman Center for Eating Disorders at MUSC Health.

“I think one of the misconceptions (about eating disorders) is that people don't recover from eating disorders, and that's not to say that everybody recovers or that everybody recovers quickly, but the truth is, there are effective treatments. I see adolescents get better and get all the way better. This isn't something that they carry around for the rest of their life.”
- Elizabeth Wallis, M.D.

Topics covered in this show:

• Like other healthcare systems around the country, MUSC Health has seen an increase in young eating disorder patients during the COVID-19 pandemic.
• The most common eating disorders are OSFED or other specified feeding and eating disorders, which are sub thresholds of anorexia or bulimia.
• There was a common misconception that parents “cause” eating disorders. Wallis says that is not true and eating disorders are multifactorial and may include genetics, environment and mental health.
• Social media may contribute to the problem by normalizing disordered eating.
• Many children present with eating disorders at the onset of puberty (age 12/13) and in young adulthood (ages 18/19).
• Treatment at the Friedman Center for Eating Disorders at MUSC Health typically lasts six to 12 months.
• Treatment is typically called family-based treatment and is an outpatient weekly therapy in which a team of healthcare providers engage parents very closely in terms of helping their adolescent recover. This is the treatment used most often at the Friedman Center for Eating Disorders.

Read the show transcript below: 

Erin Spain [00:00:04] Welcome to Advance with MUSC Health, I'm your host, Erin Spain. This show’s the mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Eating disorders and young people have spiked during the COVID-19 pandemic, according to several U.S. based studies, but there is hope and effective treatment for those with these serious conditions. Dr. Elizabeth Wallace is here to explain warning signs of eating disorders, effective therapies and the different paths young patients and their families take to make a full recovery. She is the director of the Division of Adolescent Medicine at MUSC Health and director of the Friedman Center for Eating Disorders at MUSC Health. Welcome to the show. You're a general pediatrician by training, but you've been working with young eating disorder patients for much of your career. What led you to working with these specific patients?

Elizabeth Wallis [00:01:00] I did my training in pediatrics and went out and was practicing in the community for a little while. And what I realized was that so much of what general pediatricians are seeing is actually mental health, and as part of that is eating disorders. And, you know, pediatricians are really the front line in terms of who parents may access for issues, whether it's anxiety, depression, eating disorders, whatever. And so that's sort of how it led me to doing more of that work, such that now that's the majority of what I do.

Erin Spain [00:01:30] So let's talk about these recent times. Has the Friedman Center for Eating Disorders noticed an uptick in patients over the pandemic?

Elizabeth Wallis [00:01:37] We definitely have. We are struggling to keep up with the demand. I think we've also seen more visits to the emergency department and also more visits, more inpatient admissions. There was actually just a recent study in pediatrics looking at rates of hospital admission for adolescents with eating disorders and also seeing that's really increased during the pandemic.

Erin Spain [00:01:56] Why are those hospitalizations of what's happening with these patients who are coming in through the E.R.? What are you seeing and what state are these children in?

Elizabeth Wallis [00:02:04] We really prefer to treat eating disorders, not in the hospital, if possible. You know, they really are best treated at home if we can. But patients who have significant medical complications or significant psychiatric complications sometimes are only safe in the hospital. So medically, that might be a patient who is, you know, a dangerously low weight such that their heart rate or their blood pressure is very low or a patient who's got other organ systems that are complicated as a result of malnutrition or electrolyte disturbance from purging behavior. The other thing to think about that definitely can happen, too, is as these patients can have significant suicidality. And so sometimes that can be such that they need to be hospitalized to be kept safe.

Erin Spain [00:02:46] So what are the common and not so common eating disorders out there?

Elizabeth Wallis [00:02:50] So the traditional eating disorder is that people think about are typically anorexia nervosa, which is primarily restrictive eating such that a person's weight becomes significantly lower than it should be and they're significantly, well, malnourished and bulimia nervosa, which is where patients will potentially typically binge eat or eat a large portion of food in a small amount of time and then get rid of it in some way, whether that's vomiting or excessive exercise or laxatives. Honestly, the most common eating disorder is actually what we call OSFED or other specified feeding and eating disorder, which is subthreshold anorexia or bulimia. And then there's also OSFED, which is avoidant, restrictive food intake disorder and OSFED sort of simply defined as it's a relatively new diagnosis. It's kind of restrictive eating in some way, but without the associated body image disturbance. So, it's not driven by body image or desire to lose weight. It's driven by either issues with texture or appetite or types of food, that type of thing. So, it's a little bit different, but also falls into the cluster of eating disorders.

Erin Spain [00:03:55] So those are in the most severe cases. What are other common complications of eating disorders?

Elizabeth Wallis [00:04:01] I tell people all the time that eating disorders affect every organ system in the body. So, when you think about restrictive eating disorders, whether it be anorexia or something else, those are typically our body kind of goes into starvation mode or hibernation. And so, everything slows down your heart, slows down your lungs, slow down, your gut slows down, your brain slows down. The majority of the complications that you're seeing are a result of malnutrition and a result of kind of your body trying to conserve what energy it can, you know. In contrast, whereas the purging disorders or bulimia nervosa, those disorders, typically the complications are more the result of whatever the purging behavior is. So, if it's vomiting, it may be changes to your electrolytes or problems with your gut, your esophagus, your stomach. If it's taking diet pills or laxatives, it may be related to the side effects that those medications have.

Erin Spain [00:04:50] Are there certain demographics of children who seem to develop eating disorders such as, you know, at a certain age or boys versus girls? Are there certain demographics that are more affected?

Elizabeth Wallis [00:05:01] We do see a couple of age peaks 12 to 13 right around puberty and then 18-19 sort of young adulthood, like early college for many students, are kind of the times where we see the most likely onset of illness. One of the misconceptions about eating disorders is that they only affect a certain type of person. So typically, people think about high achieving girls, typically Caucasian. And the reality is that eating disorders actually affect every population. So yes, they are more common in girls, but a significant percentage of boys are affected. We see eating disorders in all various like racial and ethnic backgrounds. It is not only a certain type of adolescent.

Erin Spain [00:05:44] You mentioned puberty and then young adulthood seem to be those timeframes. But what are some of the factors that can lead to eating disorders?

Elizabeth Wallis [00:05:53] Well, the truth is we don't know everything that contributes to eating disorders. We know that it is something that is multifactorial. There is certainly a genetic predisposition for many people. This is a disorder that runs in families. We know that there are environmental influences that may impact. But how all those things exactly work together, we're not completely sure. Yes, there are certain people that are more at risk than others, but we don't know all the causes. One of the things that I do tell families often is that, you know, parents don't cause eating disorders. That was a commonly held belief for a very long time. And the approach to eating disorder treatment was to separate children from parents and because parents were the problem. And we have since learned in the past 20, 30 years that that's really not the case and that parents can actually be a really powerful tool for recovery. And so, you know, if people take nothing else away from this, parents don't cause eating disorders.

Erin Spain [00:06:46] Well, something that could contribute to eating disorders, perhaps, is social media. Social media such as Instagram has been in the news lately for reports of it being toxic to teenage girls and their body image. What role do you think social media plays?

Elizabeth Wallis [00:07:02] I certainly think that social media plays a role in the sense that there is a lot of disordered talk that is very much normalized in our society. It is very much normalized to talk a certain way about your body or to talk a certain way about wanting a certain, you know, physical attribute that's different or talk about dieting or even disordered eating. So, things like intermittent fasting is really restrictive eating. But many of those things are kind of normalized and sort of acceptable in our culture, such that especially for teens who might be more influenced than others, it can seem like perfectly normal, and that's something that they should do.

Erin Spain [00:07:39] So you talked about some of the myths out there, such as parents contribute to eating disorders or cause eating disorders. What are some of the other myths and misconceptions out there that you would like to clear up?

Elizabeth Wallis [00:07:50] So probably the biggest one I've already mentioned, and it's that eating disorders only affect Caucasian teenage girls, and that is not true. It can affect any age, any background. We only treat up to about 24 at the Friedman Center, but we get calls for all ages relatively often. I think one of the other misconceptions is that people don't recover from eating disorders, and that's not to say that everybody recovers or that everybody recovers quickly. But the truth is, there are effective treatments, and I see adolescents get better and get all the way better, such that this isn't something that they carry around for the rest of their life.

Erin Spain [00:08:27] So tell me about the treatment plans offered at the Friedman Center for Eating Disorders.

Elizabeth Wallis [00:08:31] So we try very hard to follow and think about what the evidence base is in terms of how we treat eating disorders. For a long time, there actually was not a lot of good evidence, but there's quite a bit more now. The main treatment that we offer for adolescents is something called family-based treatment, or CBT that is an outpatient weekly therapy in which we engage parents very, very closely in terms of helping their adolescent recover. There are a number of professional societies that say that should be the first line treatment. It has the most evidence supporting it. And so that's the lion's share of the treatment that we do. We do also offer other therapies for young adults. For example, they may not have family or parents available to do something like FBT. We do actually also offer an intensive outpatient program that's three days a week. But the lion's share of what we do is is called FBT or Maudsley is the is the other term that people will will potentially know.

Erin Spain [00:09:27] So parents, you you talk about this family-based treatment and parents are often the first to notice symptoms. And so, tell me, what are some of the common symptoms that parents notice that bring them to the Friedman Center for Eating Disorders?

Elizabeth Wallis [00:09:42] Parents may notice that a kid's eating pattern changes really significantly. You know, they cut out a whole food group, or they start only eating at certain times of day, or they start really limiting their portions or engaging in behaviors around food, whether it's cutting food, really small or moving food around the plate or disappearing to the bathroom. After meals, for example, one of the big things that that occurs with malnutrition and restricting is that people's mood changes. So many parents, most parents will notice that their kid is more irritable or more anxious or not sleeping as well, or all of a sudden as is exercising excessively. These are absolutely things that sneak up on you. You know, kids don't wake up one day and say, I'm going to start eating 600 calories a day and exercising for three hours. So, parents will often have a lot of guilt when they come in that they've waited as long as they have. In reality, it's like it's paying attention to these things. If your gut says something is off your, you're probably right.

Erin Spain [00:10:40] Well, should parents ever take a wait and see approach if they notice something like a restrictive eating, for example?

Elizabeth Wallis [00:10:47] I would typically say no. I think their first line would typically be their pediatrician, so they don't necessarily have to start with us. But I think starting with their pediatrician, is this something I should be concerned about talking with their kid? It is much easier to treat eating disorders early in their course or before patients are significantly underweight. We would always rather treat them at that point. It's much easier. And the truth is, too, is that there are a lot of misconceptions among providers about eating disorders, too, and parents do reach out to their pediatrician or their family practice doc. And that person says something or gives them an answer that doesn't seem like they're still concerned. Again, I would go with your gut. Probably the biggest thing we see is that people get dismissed because they're not necessarily underweight yet.

Erin Spain [00:11:35] Well, that's what I was going to ask. Can you be diagnosed with the eating disorder if your average weight or even overweight

Elizabeth Wallis [00:11:42] OSFED eating disorders is probably about 60 percent of our patients. And so those are patients who have symptoms of anorexia or bulimia but may not meet full criteria so may not meet full weight criteria. For example, with anorexia, a teen who started out on the higher end of the growth spectrum or overweight. Potentially, you got to look at how quickly they've lost weight if they've lost 45 pounds in three months, that's not normal. And unfortunately, you know where we are in a society where weight loss is praised and so many of those kids will be seen by somebody who then gives them reinforcement for what they're doing. But yeah, you can absolutely have an eating disorder and not be quote unquote underweight. In fact, it's the more common thing.

Erin Spain [00:12:25] How involved should a child's school system be, and should they be even aware of the treatment?

Elizabeth Wallis [00:12:30] I think that's something that we sort of tackle on a case-by-case basis. Absolutely. One of the core tenants of family-based treatment is that kids need supervision and accountability for meals because the eating disorder is telling them not to eat. And so, in some cases, that may be taking a break from school or in some cases, that may be a parent coming to school to eat lunch with them. The school system actually helping to supervise or provide accountability around lunch nutrition and getting these kids healthy has to be the number one priority. And so that often takes priority over school. And so, you may need to engage the school in a way of saying, I need you to be a little bit flexible right now while we're doing this. These are typically hardworking kids who want to be in school and are getting their work done, but you know the most important thing has to be getting them healthy.

Erin Spain [00:13:17] So how long is a typical course of treatment? And you said recovery is possible? So how effective are the treatments as well

Elizabeth Wallis [00:13:24] in terms of duration of treatment? I would say the average that we typically see is like six to 12 months. That varies a ton, though, in terms of how ill the kid is at presentation, how quickly they are able to get on board with treatment. What other complications they have. You know, there are lots and lots of factors that go into that. There are certainly families that we follow for a significantly longer time than that in terms of effectiveness. We don't have perfect data. What I would say is if you look at eating disorders across the lifespan, there are some things that predict potentially a more complicated course. Patients who are older at presentation or very young at presentation, patients who have significant psychiatric comorbidities are more likely to struggle long term. I tell people on average, you know, probably a quarter of patients will have a longer-term course and the other three quarters in terms of the adolescents that we're seeing do pretty well. But again, there's a lot of variability. We tell people the earlier we get kids engaged in treatment, the earlier we get them to a healthy weight, the better our odds for that kid having a good long-term recovery.

Erin Spain [00:14:32] Why should parents consider the Friedman Center for eating disorders if they're in the area?

Elizabeth Wallis [00:14:37] Well, I think that what's nice about our team is we are all in one place, so we're all under one roof. So, we have therapists. We have medical doctors with dietitians. Nursing staff were all housed in one place, and I think the advantage of that is we also communicate very closely in terms of treatment course and what they need. And it's very easy for one of us to pop into somebody else and say, hey, what do you think about this? Or, you know, hey, this is going on or parents can get multiple appointments done on the same day. I think the other piece is that that we really do try to follow the evidence base and try to stay very up to date in terms of what the best practices around the treatment of eating disorders. Families are typically looking for what is the best evidence in terms of of X, Y or Z, whether it's a medical or a psychiatric diagnosis?

Erin Spain [00:15:23] Well, before we wrap up today, my final question that we ask everybody, what do you do to optimize your health and live well?

Elizabeth Wallis [00:15:30] One is I am fairly rigid about getting enough sleep and exercising with my dogs. I'm really, really fortunate to in that I see patients get better and that's really satisfying as well. We've been open five years now and I've seen a number of patients in the past couple of weeks who are getting ready to go off to college, who've been well for several years and are getting into places like Clemson and the Air Force Academy and things like that that have come just a tremendously long way. And that's that's very satisfying.

Erin Spain [00:15:55] I love that. Well, thank you so much, Dr. Elizabeth Wallace for joining me today.

Elizabeth Wallis [00:15:58] Thank you for having me.

Erin Spain [00:16:03] For more information on this podcast, check out advance.muschealth.org