Recognize, Prevent, and Recover from Anorexia and Other Eating Disorders, with Dr. James Greenblatt

Welcome to the five Journeys podcast live. Like you matter. We're very privileged today to be joined by Dr. James Greenblatt, a pioneer in the field of functional medicine and psychiatry. He has been treating patients since 1988 and he is a founder of Psychiatry Redefined, an educational platform dedicated to the transformation of psychiatry. He is the author of eight books, including his latest one called Answers to Anorexia. And we've known Jim. Yeah, welcome. And we've known Jim for what?

At least not since 1988.

Also not 88, but I'd say five, eight years. And it's been really a privilege to know you and get to know you personally and better and professionally better and helping us treat our patients. So thank you.

Thanks.

Thank you. Thanks for inviting me and nice to see you guys again.

You too. So let's dive in.

Yeah. So anorexia, I mean, that's a scary subject, truthfully, especially with people. We have four kids between us and anorexia is definitely scary. So let's first go in and talk about that.

Makes it sound like you brought two and I brought two. We actually had four kids together.

Oh, yeah. So let's define. Find anorexia. Let's. Would you mind?

Sure. But I'm going to use your word. Scary, you know, is a word that we need to kind of understand because this is. Anorexia nervosa is the most life threatening illness of any psychiatric diagnosis, highest risk of suicide of any psychiatric diagnosis, highest stress on caregivers, and more importantly, we have no treatment model in the traditional medical community, in the traditional psychiatric community and in our integrative and functional communities. So, yes, scary is a good word. You know, by definition it's a psychiatric diagnosis in the dsm and it has to do with a disorder of restricted eating that results in distorted thoughts. So this perceptual distortions where someone continues to lose weight and likely mostly underweight and, and feel that they're overweight and obese. And it is that kind of distortion that results in really unrelenting turmoil and medical complications that our medical community has really just ignored.

Yeah.

So I just had this thought. Is this the epitome then of a body dysmorphic syndrome that what they're seeing is not what is real?

Absolutely. You know, it, it. Yeah. Talking to, you know, any anorexic patient that they believe and their brain believes it. We understand how the brain is tricking the body and there's probably some genetic origins to that, that when they do look in the mirror, they do look at their Body parts. They do see something different than you and I would see.

Interesting.

I imagine even if people do okay and get through this, there's some long term impacts to this.

You know, for some. My goal and mission is to address the young teens. You know, we're now seeing kids 8 to 10 years of age, but if we can address this, you know, before young adulthood, I think it's a treatable illness and completely to remission and resolution.

So I have a question, Jim. So if you. As a. So we have a lot of parents in our practice and obviously, you know, a lot of parents. How would a parent even identify that their child is either at risk or may have developed an eating disorder or some kind of body dysmorphic? What are the cues that parents should look for? Because.

Right.

I'm thinking I'm always on alert, but I don't really know what to look for. I'm just, you know, a parent.

Yeah. I think the most important thing is in the back of our minds as parents to understand family history. So if there is a family history and it could be a first degree or second degree relative of an eating disorder, that's a red flag. Just put it in the back of the. It doesn't mean your child will develop it, but higher risk and pretty significant highest heritability of almost any psychiatric illness. And then also family histories of ocd. So obsessive compulsive disorder. And then the first thing we just want to identify is a change in diet. And the sad reality is some of our pediatricians are telling kids they need to lose 10 pounds. And for some kids, they might watch what they eat or exercise. Other kids, they start this path of a diet and they can't stop and it results in weight loss. So a change in diet, either because the BMI report card at school or the pediatrician or a parent said something can be the trigger. And then to me, one of the most important messages of this book that I just wrote, which might be a little controversial, is that a vegetarian vegan diet in adolescence is a risk factor. So it's not just trying to lose weight. It is this vegan diet in adolescence that has been shown in the literature for almost 20 years now to be a risk factor in onset, slower recovery and higher relapse rates.

Hold on. So the earth is round.

Yes.

And there's data to support this. So I mean, you say it's controversial, but if there's data to like, if it's borne out in the literature.

But I want to know why.

Now I know Now I'm curious, but, but he said it was like, you know, sort of asserting it. But you're asserting, oh, I.

My professional career. There's nobody who's seen any sort of patient because 90% now are coming in on a vegan vegetarian diet. The only controversy is our, you know, our vegan vegetarian community has shifted into the traditional medical world. There are now vegan diets and hospitals across New York. And you know, our culture, eating a vegan diet is a higher spiritual, you know, entity. So that's the controversy. The science is clear. In adolescence, our kids need higher amounts of zinc to get through puberty. And our kids need fat and certainly B12 and amino acids. And you know, my premise is this perfect storm, again, genetic vulnerability, a vegan diet lower in zinc. And that zinc deficiency, again with good research to support it, is one of the triggers for some of the physical symptoms. The poor digestion, the depression, the lack of sleep, and some of these perceptual distortions that start early on in puberty and just snowball into anorexia nervosa.

You haven't even mentioned social media. Social media, glaring omission.

Well, we kind of. I use the frame, the gasoline on the fire. Someone asked me a question, you know, based on all the Facebook stuff that's coming out, does social media cause eating disorders? And, and I don't believe it does. It certainly aggravates and precipitates and for all across, all the mental health disorders and eating disorders in particular, when these kids are just comparing themselves and self esteem just plummets.

I know we're going to duke it out for who gets to ask their question first.

Yeah, because I'm first. You're saying a lot of this is precipitated by zinc deficiency. B12. So how much do you believe what percent? And I know this is going to be an impossible question to answer, so I'm going to preface this, but what percent do you believe is biochemical versus social, emotional, psychological?

Well, I've been trying to say this for 20 years.

I want to know.

I don't know. I think that's crazy. For 50 years we've been blaming parents and blaming magazines and models and social media, but what's happened in the past 10 years is the, the medical community at least has provided the research. International genetic studies, brain studies, MRIs, everything is now clearly pointing that this is a brain based illness. Okay, so what might trigger these changes in the brain? They could be, you know, family dynamics. It could be trauma is significant and kind of the social media, bullying, stress, all those things contribute, but eventually those things impact a genetically vulnerable kid and triggers this biochemical process. And the treatment for kids that end up in hospitals or residentials, the psychological has just not been helpful. And that's the model. And that's why I'm so passionate, because for 50 years, we have barely changed our treatment model and our outcomes are terrible. Highest relapse rate of any psychiatric illness.

So it's not the vegan or vegetarian diet per se. It's not the special diet part. It's the that it's missing critical ingredients that developing brains and bodies need. Is that accurate?

Absolutely. Yeah. So if for somebody, for religious reasons. Most of these kids aren't coming in for religious reasons, but if they are and they need to restrict, then absolutely we need to monitor zinc B12amino acids, and we can prevent some of this downward spiral. So I'm not asking everybody to eat meat. I'm making sure that they have these nutrients that are much more bioavailable in animal products.

So is that your treatment at this point in terms of looking at their micronutrients, looking at their amino acids, I'm assuming looking at omega 3 fatty acids, omega 6 fatty acids, and really giving them back what they need.

Exactly. I mean, if you asked me, the two most important, let me say three, would be the omegas, the zinc, and likely the amino acids, because they just don't eat sufficient protein to get through puberty. But fat, I mean, some of these kids have avoided fat for six months, some of these six years. And again, the brain's not developed until our late 20s.

Yeah, you need fat to get the brain going. So that makes complete sense. How about. Because I know one of your favorite nutrients is lithium orotate. Of course.

Yeah.

Does that play a role?

Yeah, important part, because so many of our kids with anorexia, again, restricting intake of foods, mood lability is common, irritability is common. So we typically recommend 1-2mg of lithium orotate as well. Absolutely.

How does this transmit into other disordered eating patterns? So we're speaking about anorexia, and you have your new book, Answers to Anorexia, but are there parallels between binging, purging, other things?

Sure. I mean, I think in the old days when I started there used to be really clear. Someone walked in with anorexia nervosa, someone had bulimia, someone had binge eating. And now, you know, the diagnoses emerging and they're changing. Someone might have anorexia at 14, bulimic at 16 and binge eating at 18. I think bulimia is much harder.

Let's define that for a second.

Yeah, those are patients that might restrict calories but also use this compensatory purging behavior. So oftentimes it's vomiting, so vomiting up the food. And this could be once a day to people purging every time they eat could be 10 or 15 times. And then there are individuals that are binging, binging on massive amounts, thousands of calories at a time, and then purging and then that their other group, which is actually the most common, a lot of people don't know this. The most common eating disorder is binge eating disorder. It's probably more, ten times more common. And in my experience, it's much easier to treat. We have medicines that do work, we have nutritional interventions that work, and we actually have therapy, cognitive behavioral therapy that works. So if we combine those programs, we can support patients with binge eating disorder.

Okay, and are the cues the same for parents when they are concerned? I mean, because eating disorders is just this huge bucket. Anorexia seems a lot clearer that the child's restricting losing weight. But then how would parents know to look out for purging or binge eating? I mean, binge eating might be clear, but the purging seems like, because it's occurring often in the bathroom where the parent isn't. How would a parent identify that?

Yeah, it's really important. One is just to listen and to ask the questions and listen. A lot of this would start from body shaming or feeling bad. Either peers at school or parents. I mean, parents are culprits for this. And so it's really the open relationship and asking the question. And I think the hardest part is stories we hear about parents, you know, getting their, you know, 10 year olds signed up for Weight Watchers and making them go to the gym and making them do this, which is kind of humiliating and, and just shaming. So I think parents need to really be in touch with their issues around food and body image.

So there's some definitely clear things parents should not be saying. Right. So you're fat or you look fat, or you need to lose X amount of weight, I think would go into pretty easy buckets. Are there more subtle things that we're doing as parents that we should not be doing that we might not even recognize?

Yeah, I mean, I think it's, you know, making good and bad foods, you know, is really important that, you know, the concept of moderation is, has to be built in, as parents are always struggling with what we know as bad, you know, refined sugar. It's hard to come up with a good reason, but these kids are functioning in a social system where kids are eating different foods. The other part, which. Which I see, which is the tragic one of the kids that are hiding foods. So those kids with binge eating disorder, that they're not allowed to have candy, but they're sneaking it, and the parents are finding wrappers in the drawers and, you know, hidden in cracks in the house. And one of the things that I've learned over the years where the research has supported it is kids with adhd, particularly girls with adhd, often struggle with eating disorders, more likely binge eating disorder. So if you have a young girl with adhd, I think it's important to talk about eating because the same impulse control that might interfere with school sometimes would interfere with controlling intake of foods and second and third and fourth helpings. And oftentimes treating the ADHD can be helpful.

No, that makes sense.

All right, so I have a question for a friend. Our kids are obviously perfect. Obviously, yeah. They eat perfectly well and they behave perfectly. But let's say theoretically, hypothetically.

Hypothetically speaking, asking for a friend that.

We do find wrappers and food, how would one address that? Like, how would be. Is that a direct. What's going on? How would you recommend parents speak to their kids?

I think to prevent a problem down the road, it would have to be letting them know, you know, we found the wrappers. I don't want you to hide this. It's fine, you know, for you to eat it at the kitchen table, and. Because if that doesn't happen soon, it just becomes a secret. And then that secret plays out with many different parental dynamics and. And then emotional eating, you know, just kind of snowballs into places you don't want it to be. Sometimes, you know, the most helpful, you know, if it's, let's say it's, you know, it's candy, and in your house, you don't really have, you know, buckets of M&M's, and it's not something that you do, which, you know, many of our families and friends aren't doing. I think if the kids are craving it, then, you know, participating, making sure that they understand that. That. That you can do that with them. You don't have to do that every day, but, you know, to have something that they would want to enjoy, whether it's a healthy dessert that you made at home just to. Anything you can do to Eliminate the hiding and the sneaking. Yeah, yeah.

I can see parents having issues with, well, those aren't foods that we eat in our home. Or those aren't foods that we have. Or that's not how we eat. So how do you send that message to kids? Like, we don't want you sneaking. We're here to support you. We understand you might really want it. And then what? And then you like, then what?

Then you eat it with them.

You eat it with them.

No, it's challenging. It's challenging. My kids still one's 30 and the other one's 20. They. They'll make jokes about not having a house full of junk food compared to their other kids.

Yep. Yep.

So I have a couple.

I have a thousand. You can go. I have a thousand too.

So again, not that this would be real, but let's say, for example, have eating disorders increased in percentage or per thousand or because it seems like from our friends, our kids. Friends seem. That seems to be a relatively common diagnosis.

Super common. No, the. In 10 years ending up into 2018, the incidence has doubled.

10. Wait, what? 10 years?

Yes, from 208 to 2018 was the last big study. So incidence has doubled. Doubled.

That's crazy.

And then.

And Covid, I'm sure, helped a little bit.

You know, right now you cannot get your child into an eating disorder treatment program anywhere in the country. There's waiting lists for residential, for inpatient, for outpatient therapists. So it really has exploded. Relapse during COVID For people that have recovered, we see all the time, but also new onset people are home struggling. I've heard stories from someone just trying to get healthy and exercising. Others that are on social media comparing themselves and decided to again try to lose weight.

So as parents looking at their children, what are some of the things, the diseases that parents might confuse anorexia for? It's not anorexia, it's whatever. What are some of those things?

Well, no really important question because also I think missed by our medical community is too, that you guys are familiar with is celiac disease and pandas. So I think that if you have a 12 year old who's just losing weight and getting thinner and no GI problems. I mean there's, you know, half the celiac cases are non GI related, so. And celiac disease is this rapid road to nutritional deficiency, certainly zinc, and the incidence is common. I forget the statistics, but we're not. We're talking about high numbers of crossover, but nobody's checking for celiac and then pandas as well. Is Pandas kids are having strikingly severe eating disorder symptoms that come and go. So those are two medical conditions that are often confused and not always addressed by our pediatricians.

So go to your local functional medicine doctor to find out, correct?

Absolutely. Yeah. It's critical because again, if we treat this at age 12, you know, we can really eliminate the illness. If we wait till 22, it gets harder. And then at 30 and 40 every year, the mortality rates increase pretty dramatically every 10 years if someone has this illness.

So you said there was hope before we started filming, you said there was hope and we wanted to focus on that.

Well, yeah, actually that goes to my question of do you have an example or two of real people of where they started and how long it took and what were the interventions and just kind of. Can you give a few examples? Is that.

Sure.

No, but putting you too much on.

The spot with Wendy's word hope, because that really is what keeps me in, you know, this kind of trying to share this message on eating disorders. And the hope is understanding the risk factors, which would be genetics, a change in diet, stress, trauma, and treating early. So absolutely. With many kids and, you know, I've been working with in hospital and residential and I don't know, about six years ago we stopped counting, but we had over 10,000, you know, patients come through our treatment center here at Walden. So I've seen a lot. So the kids that we can treat at 12, 13 and 14, we get them on a nutritional program and it's not aggressive, it's just, you know, a little zinc, fatty acids, amino acids, digestive enzymes. So the food that they're eating and then probiotics, so small kind of nutritional interventions with, for these younger kids, family based therapy because the parents have to be part of the solution. Kids get better and they get better quickly. The older, you know, as we get to 19 and 21 and the 30 year olds, those are patients that are challenging in that the nutritional repletion takes more time. Right. They've kind of neglected their bodies. Their malnutrition has been embedded for so much and the brain changes are significant. So these are patients that we've treated over a year, but again, they're faithful with their nutritional supplements. Oftentimes they're on medications, but over the course of that year, they at least can use words like recovery and remission. So there's clearly hope for anorexia, the binge eating, you know, it's much more quickly. We can find results. We have good medicines that work for those that need immediate Relief. And we also. With binge eating disorder, we see classic nutritional deficiencies, B12 and vitamin D, and those get repleted quickly. And we can use nutritional supplements and. Or medicines.

Got it.

They raised hope.

So it sounds like a bar. It's like a barstool. So there's the cognitive therapy for the binge eating, along with the medication and the family participation. And then for the anorexia, there's the.

There's always the nutritional repletion and the nutritional repletion.

So there's a number of components you put together for each of them?

Yeah, the bar.

If people do the work.

Yeah, it's a great analogy for the binge, and that's treatable. And I use the term food addiction with binge eating disorder. So now whenever I talk about it, and some people don't like the concept. How can you be addicted to food? We can't live without food. And I agree, you can't be addicted to broccoli. But so much of the food.

But sugar, you can.

Exactly. And, you know, MSG sugar, abnormal breakdown products, and dairy and wheat. So the. The food addiction is to process food. And. And we understand that chemically. So binge eating and food addiction, the stool analogy is great. Cognitive, behavioral nutrition and medicines for anorexia. Probably need a table, probably need four legs to organize treatment.

A dining room table.

Dining room table, maybe even six legs. But it can be done. And I think the medical community, you know, has to be better equipped to. To treat our patients with anorexia once people recover.

So it sounds like the vast majority of people who work, work within your system and your approach do end up recovering. Is that accurate?

Well, I wish that were the case. Again, the hospital work that I do, not everyone is willing to take supplements and do this approach. My outpatient work, where people are coming and looking for help, Yes, I see very high recovery rates. But in our hospital setting, we're still utilizing some of the traditional models.

So once people have recovered, what are things that might set people back.

And.

What are things people can do to prevent having a relapse?

Yeah, I mean, one of the last chapters in the book that I recommend sometimes parents read first is relapse prevention, because. Absolutely. Like any illness, things are fragile. So any kind of stress, any change in diet, any medical complication, someone goes in for surgery and they don't eat for a few weeks, someone who's routine around exercising and has a knee injury, and then mostly stress can precipitate this illness. So we have kind of a list of Things that parents can do. And the order to me would be, you know, one thing we talk about is the listening, which I mentioned earlier. So, you know, active listening. Make sure you talk to your child and understand what's going on. Get them kind of back into therapy if they're not, get them back on supplements if they're not. And you know, if they need a treatment program for a brief period of time. The goal is to kind of get them back on path as much as you can. But I think that relapse prevention has to be in the back of parents minds all the time.

All right, so you're one person, unfortunately.

Sounds like you're one very effective person though.

So what are some resources that people can find that can help them? Where can you point people to help this kind of approach? Because obviously this is so powerful.

Yeah, no, I think that for these disorders is just such a as, you know, growing number of integrative and functional clinicians, you know, across the states, you know, and when we started, it was just kind of a few, and now there are well trained pediatricians and family doctors and specialists. I talk to new docs every day who are doing it. So I just urge parents to look for that integrative and functional practitioner because this is not as challenging as some of the other disorders that, you know, we might treat, you know, including Lyme and mold and things that take some effort. We're talking here about, you know, three basic nutrients, zinc and essential fatty acids. We're talking about basic screening tests. So I think for parents just looking for someone who can support them in an integrative and functional approach.

Awesome.

Got it, Jim. This has been great. For those of you who are listening, we're with Dr. James Greenblatt, who's the author of eight books. The latest one is called Answers to Anorexia. Dr. Greenblatt, do you have a website you want to point people to or Facebook or book link? Is there something you want to tell people about?

Sure. My website is james greenblattmd.com and that's where there's information on the books and on Amazon. And then we have a training program mostly for professionals, but some parents can appreciate some of the courses on anorexia. And that's psychiatryredefine.org Got it.

Awesome.

Thank you so much for joining us today. This has been fantastic. We're really grateful.

It's been truly a pleasure inviting me. Nice to see everyone again. Take care.

Dr. James Greenbot. Thank you.