Disordered eating in higher weight children

Disordered eating is prevalent in our society, and when we discuss health, we want to approach conversations in ways that promote healthy relationships with food.  Learn from our expert, Dr Michelle Boyd what to ask and what not to ask, and what red flags you should keep in mind when discussing health behaviours with families.

Host Dr Sam Manger chats to Dr Michelle Boyd, a general paediatrician based at the Queensland Children Hospital and CYMHS Greenslopes Eating Disorders Program. She currently leads the inpatient care of the eating disorders cohort at QCH and currently contributes to many local, state-wide and national eating disorders training and education forums. 

Transcript

Health and Wellbeing Queensland acknowledges the Yuggera and Turrbal people and the traditional custodians on the lands on which this podcast was recorded and the traditional custodians on the lands of borders on which you are listening. We pay our respects to the Aboriginal and Torres Strait Islander elders past and present, for they hold the memories of the traditions, cultures and aspirations of Australia's First Nations people. 

[upbeat music] 

Dr Michelle Boyd [speaking over music]: And now that they're exposed to comparing themselves not only to their immediate peer group but to the online world in written and video and photo form, I think our teenagers are up against it in being able to filter out for themselves what is natural and achievable. 

Sam: Welcome to the Clinician's Guide to Healthy Kids, a podcast series for health professionals brought to you by Health and Wellbeing Queensland's Clinician’s Hub. I'm your host Dr Sam Manger and in this series, we'll be diving deep into the topics that matter most in childhood weight management. We'll be talking to Queensland experts across a variety of topics including sleep, disordered eating and higher weight children, prevention and healthy growth with healthy diets.  

Let's get started. Today we are discussing disordered eating in a child or adolescent living with overweight or obesity. To help us with this is our expert guest Dr Michelle Boyd. Dr Michelle Boyd is a general paediatrician based at the Queensland Children’s Hospital and Child and Youth Mental Health Service, Greenslopes, Eating Disorders Program. She has been working in paediatrics for over 20 years and specifically with young people with eating disorders for 12 years. 

She's passionate about providing compassionate and holistic care to young people and their families, using a strong, evidence-based approach to treatment and assessment. She currently leads the inpatient care of the eating disorders cohort of the Queensland Children’s Hospital and currently contributes to many local, statewide and national eating disorder training and education forums. So, thank you so much for joining us, Michelle. 

Dr Michelle Boyd: Excellent. Thanks for having me today. 

Sam: So, tell us a little bit about why you got into this area? 

Michelle: I'm a true clinician at heart. So, many, many years ago I had a young boy whose heart rate was in the low 20s at night-time and on every subsequent night on call, somebody dealt with his low heart rate differently. So, I set about answering the clinical question of what's safe and that opened up my whole world to the knowledge of Starvation Syndrome and how Starvation Syndrome affects children with all different types of eating disorders. So, my passion grew from there, and I kept working at the Mater Children's Hospital and now the Queensland Children's Hospital in this space. 

Sam: Oh, that's wonderful to hear. I mean, there's certainly a lot of good work clearly that you're doing there. So, what is disordered eating and how is it different from an eating disorder? 

Michelle: So, if we think about disordered eating and eating disorders, clearly, they exist on the spectrum and they're not different entities. If we think about disordered eating, it is any behaviour that may result in irregular eating or insufficient eating. And it may be based on wanting to change weight and shape or it may just be through having some feeling of distress or wanting to change how you're eating.  

They're pretty common in childhood, but when it evolves into an eating disorder is when there is more distress and a refusal to maintain health despite having weight concerns. So, I think we're really looking at one end of the spectrum to actually have a diagnosable eating disorder, which can encompass a range of things from binge eating disorder right through to anorexia nervosa. 

Sam: And so how common is disordered eating in children and adolescents generally, and in those specifically living with higher weight, where we should be perhaps more aware of that being part of the presentation? 

Michelle: I think they're surprisingly and scarily common. So, in Australia, if you think at any given time point, we might have about 4% of prevalent eating disorders. In your lifetime, you might have about a 9% chance of developing any sort of eating disorder. And within that group about 50% may have something called binge eating disorder and at least half of those people will live in a higher weight. And we know that people who are of higher weight are in the fastest growing group of people with eating disorders, which includes children and young people. So, this really is the group to watch in terms of prevalence and what we're going to experience over the next couple of years. 

Sam: And so, you mentioned there some of the sort of diagnostics of anorexia and then binge eating disorder. It is important to recognise, because it may not have those compensatory behaviours with it, like you might see in a bulimia – the purging or restrictive eating. So, you might just have the binge eating disorder, so, people may think that it's not disordered, that's a behaviour – and so, there's some confusion there. So, it's quite important, I think for us to identify how can these present. You've highlighted a few symptoms that may present around, say, emotional disturbance around foods, but what are some of the ways that it presents? 

Michelle: So, I think in all children that I meet, it must start with a change in eating patterns. So, if they go from eating regularly and eating a certain energy density, then they start to restrict – whether that be restricting food times, eating regularly, skipping meals or eating different food groups, that is, cutting out food groups. I think that's got to be the catalyst because without that sense of restriction or dieting, you're much less likely to develop disordered eating.  

But moving on from there, as those behaviours intensify, we'll start seeing things like preoccupation around food and eating, and food rules. There may be an increased focus on exercise and activity that's not there for enjoyment, but really to control weight or shape. Then that may come with some more emotional change where there may be some withdrawal from previously enjoyed activities or some irritability and things like that. So, you often see many more of the emotional characteristics coming out first before we start seeing some of the physical characteristics which may be dizziness, obvious weight loss, right through to fainting, collapsing or losing muscle mass and things like that. 

Sam: So obviously a number of things there, a clear change in diet, a change in a psychological or emotional response to other lifestyle behaviours may change as well. Like you said, physical activity, and then as we progress, you then will potentially start to see physical symptoms and are these some of those alarm bells or red flags that you that really make your eyes wide that the clinician should be aware of?  

Michelle: Yes, as a paediatrician, if you see rapid weight loss in a child, it should ring alarm bells immediately and that does not matter what they're starting weight is. So, if they started on the 97th centile and within a couple of months have dropped 2 centiles, we cannot be congratulating that child for their weight loss. We must be worried about how they've achieved that level of weight loss. The other alarm bells that we see are any of the more extreme methods to control weight or shape. So, there may be fasting for prolonged and excessive periods, the child may be following food rules, they may be calorie counting, or they may be doing things like purging and at the extreme – using laxatives.  

I think if there is a major preoccupation – so that the family can say that their child is only thinking about food or exercise – that would ring alarm bells with me. And if there's any major deterioration in the young person's mood, if their academic performance and friendships are failing, or if there is the emergence of any new mental health concerns like anxiety or depression, that has coupled a change in their eating – they would all be big alarm bells for me. 

Sam: And what are the common things you might see in children who have higher weights and disordered eating? 

Michelle: So, I actually had a chance to ask my colleagues at the eating disorders’ services this question, and we came up with 3 things that we see commonly. The first – from an experiential point of view – would be a sense of trauma. So, our young people of high weight who are experiencing disorder will always recount a history of some sense of worthlessness or shame or guilt about their weight. And they say that this comes about by bullying by their peers. The perception of weight stigma from all aspects of society and social media. They also point out to us that it comes from health professionals. So, I think they tell us the trauma of their experience is often not addressed or identified.  

The second thing they talk about with those similar things is being invalidated by health professionals, in particular, who might say there's nothing wrong with them because they look fine when they've actually taken those steps to disclose that they've got a problem.  

And the final thing we see is back to those physical characteristics. If we see major fluctuations away from previous growth trajectory, then that would be a common theme that someone actually has an eating disorder evolving – even though they may have been a high weighted body. 

Sam: And if young adults or children living with the higher weights do develop concerns around their shape and weight, it often leads to, as you've mentioned, attempts to control their weight through your disordered eating behaviours – bingeing we've mentioned, food restricting and total food group avoidance. So, what are your thoughts on how we approach that and manage those restrictions? 

Michelle: Number one, as a clinician, we must take that seriously. So, we can't dismiss concerns about eating or health, based on appearance alone, because essentially, we would be perpetuating weight stigma, if that's the approach we take. So, we actually need to take the time to discuss normal growth in childhood and adolescence. I also think we also need to educate families and the young people about the dangers of extreme eating or dieting practices.  

And then one of the practical things we need to do is think about a return visit. You actually need to specify with the young person that you're worried about their health because they veered from their previous growth trajectory. Talk about a check-up as a priority and give a specific timeframe. And I just think they need to understand that you're going to look at all aspects of their health, not just their weight.  

From a family perspective, one of the things that you can do is ask the family to eat together and that can be really challenging in a busy household. But if the family are eating together, they can really assess the regularity and adequacy of the intake to work out how big a problem the young person is facing.  

And the final thing that I think is most important is don't wait until someone's lost a lot of weight to intervene. I think if we can recognise it early, what we see in the development of an eating disorder is often a young person grumbles along a little bit. They get a lot of positive reinforcement from the weight loss and thus their eating disorder cognition strengthens. The families always tell us – it's like flicking a switch – and then suddenly they’ve fallen off a cliff and they no longer will eat. So, if you can capture a child in that sort of phase before they fall off the cliff, so to speak, you may prevent the development of a full-blown eating disorder, like anorexia nervosa. 

Sam: We'll be back after this short message. 

[Community message – male narrative]: The food and drink options available for purchase outside the home and the incentives provided to drive sales have a big impact on customer selection and ultimately on longer term health. That's why Health and Wellbeing Queensland is working with our hospital and health services to meet targets for healthy food and drink supply in retail outlets, vending machines and staff catering. We are proud to support Queensland Health to provide a healthier range of food and drinks, enabling hospital staff and visitors to live healthier lives. Find out more by searching A Better Choice at hw.qld.gov.au 

Sam: Now. Back to the show. It's interesting because as healthcare professionals, we're faced with this difficult conundrum. We know 50% of our children and adolescents have higher weights that will put them at significant risk in the short and long term of developing a chronic disease. Yet as a health professional, we don't want to instigate an eating disorder by raising the topic of weight or being too fixated on it. As you said, the weight stigma is very strong, and you mentioned before that people who do struggle with disordered eating have reported their health professionals could have been part of the perpetuation of that for them. So, we really don't want to be part of the problem. So sometimes we're a little bit frozen as to how we go about this. What's your advice around that? 

Michelle: I think it's quite simple that if the conversation around their health starts with weight, then you have a problem. So, you actually need to be able to have a conversation about growth. And just go back to what we know when we see an infant or a toddler, we're very comfortable in talking about growth. We will measure their height and weight; we'll do it routinely and it is a natural part of the health check. And that's really important that you carry that on to your adolescents and young people – that they understand that growth is a normal part which includes weight gain as well as height growth.  

And I think you then can lead that conversation if they're veering upwards and their weight is increasing at a trajectory higher than they used to, then you can have a conversation about what are the factors that are changing that trajectory? Have they changed their exercise or their input or the types of foods they're eating? And how do they feel about those changes? And then similarly, if their weight is veering down, you have that same conversation and so you normalise that without focusing health completely on the number on the scale. 

Sam: That makes a lot of sense and looking at the whole person and thinking about the whole health and wellbeing of that person, and as you said the growth. Let's say we've developed that relationship and that rapport is quite good, and we're having these conversations – you can sometimes see in clinical practice that natural reaction for the parents of a child. So, we'll talk about the parents now of a child when we're having this conversation, and when their child is experiencing unhealthy weight gain. It is then that the parents themselves will start to restrict food. So, what's your advice to listeners to then help families and parents with that? 

Michelle: Well, I think maybe in this series we've already talked about the dangers of dieting and diet culture, and it's absolutely proven that dieting or short-term food restriction does not lead to good weight maintenance or normal growth. In fact, you're more likely to gain excess weight when you go back to normal eating patterns. So, we very much need to be very clear to your families and young people that eating regularly is one of the key aspects to good health.  

I think it's okay to focus on a modest restriction of really high energy foods or lots of soft drinks, but we need to make sure parents know that their child should never feel hungry or deprived because it's more likely that they may lead to disordered eating behaviours. I think we also need to be mindful not to single the child out from the rest of their family, so both healthy choices need to be made together. 

And I think you need to suggest practical ways to increase activity, acknowledging that a lot of our young people living with a higher weight are quite self-conscious and they might feel that they're not good at sport or be reluctant to participate. So, then the family need to problem solve – so that they go for a walk after dinner, they increase playing in a park or the backyard on weekends and physical activity needs to be fun, not for the purpose of weight or shape control. So, the idea for parents that restriction is a way to their child's health needs to be dispelled and we need to talk about eating core food groups regularly and adequately. 

Sam: So not responding with ‘extreme with extreme’ so to speak. And this is really relevant to the modern context and what a lot of children and adolescents going through now because of the online world and the pressures – peer pressures. But then just the constant, you know, the ‘FOMO – Fear of missing out’, and the other aspects of seeing these perfect artificial lives and bodies on the online world. And you'll be no stranger to it – and I’m certainly no stranger to it – the number of restrictive diets that come up all the time and the supposed amazing benefits that one will receive upon these restricted diets. So, how do you – because you must come across this all the time – how do you help young people and families navigate that world?  

Michelle: Yes. Well, I love that we're acknowledging the minefield that our teenagers face at the moment. So, the amount of information and misinformation that they're subjected to is astonishing. If you think about past generations, often family members were the source of truth. And whilst they may be some mistruth from those family members at least it was a limited source of information.  

In teenage years, obviously comparison of self to others is one of the most important aspects of that neurological development. And now that they're exposed to comparing themselves not only to their immediate peer group but to the online world in written and video and photo form, I think our teenagers are up against it in being able to filter out for themselves, what is natural and achievable.  

So, I think as medical professionals, we can be leaders and we can champion the message that those fad diets and short-term restrictive diets don't work. And we can arm ourselves with the knowledge that we need to understand correct nutrition for different ages, so that we don't get into the trap of giving a dietary overlay for adults and say that that's alright for teenagers.  

We need to acknowledge and let teenagers know that it's okay to be hungry, that it's okay to want to eat, because they're fuelling their growing body. In terms of actually looking at websites, I'm really curious with my young population. I find out what are they looking at. Who's your favourite person on Insta? And you get a sense, as to whether their world is just full of influencers and impossible beauty ideals, versus somebody that may actually be helpful and nourishing to them.  

I'm not really one to create rules for families because I think that needs to be done within the family itself, but I'm forthright in challenging a family – if constant looking at a particular site or cruising recipes or following someone is creating negative body image and perpetuating weight and shape concerns – then I'll say to the family why don't you talk about it? Work out some change in the structure of how they use their social media. Think about turning something off for a while and certainly, trying to limit contact with other unwell young people at that time. Because whilst they probably feel like they enjoy being part of a community, we rarely find that 2 unwell people can become well together. 

Sam: Interesting. The pointer on curiosity, is I think is a common thread we've seen through this podcast, but really crucial on the social media side of things. As you said – I like how you said Insta – so, you're obviously up with the lingo. So, who are you following on Insta and TikTok and other avenues? Because – one you build rapport, which is great, you're genuinely interested – and you may learn things. I mean, sometimes I've asked my patients, what are you watching? And you're go ‘okay, actually, that's not that bad. That's kind of interesting’. And then you'll find that – ‘there’s this one and this one’ – that is not that good – and you can then demonstrate your reasoning, which is good. So, it's sort of making your own thinking transparent, which is much better for them because it's there’s this patronising, ‘don't do it, should not do it, should do it’ – it's like, well, here are my concerns about this and this is how it's relevant to you and they go, ‘okay, now I understand you're talking to me like I'm an intelligent person’. It's respectful, you're showing dignity and you're just being curious. So, it's a really important clinical tip that just deserves to be highlighted again and again. 

Michelle: I think if you keep your ear to the ground as well, you can actually try and get some additional messaging in. I'll often say, have you heard about the ‘health at every size’ philosophy and movement, and they’ll say, ‘no, I haven't heard about that’. I'll just say look, there's this whole community out there that you can actually look at different ways of thinking about weight and shape. 

Sam: That's another very good insight in the sense of being curious, and then just helping where appropriate and where reasonable to redirect and say, ‘you know, there are the other sides of things, and other channels that you could check out’. So, you're utilising the online world rather than just denying it’s not going to work.  

So, you've sort of answered my next question already and I suspect I know your answer. But you mentioned there about the risk about sometimes adult diets being translated to children and adolescents. And one of those is fasting is very common in the adult world now, and you see it spilling into the younger populations. So, what what's your opinion around that, which is fairly topical? 

Michelle: I loved my response to this. I have been asked, ‘Are fasting diets safe?’ My answer is: No, simple. But I would like to expand on that if that's okay. So, every time I meet a young person in hospital, I actually give them a little science lesson about what's happening to their body. And I'm very clear and explicit around what's going on from a hormonal perspective. So, whilst they all kind of hear about their puberty hormones, what they don't know about, is all those biological determinants of growth. So, they've got growth hormone, insulin like growth factor, thyroid hormone and their stress hormone – all interplaying with pubertal hormones. So, if you starve yourself in that phase of growth, that's what puts you at risk of the consequences of the Starvation Syndrome acting on the brain to change your thinking around food.  

So, if teenagers are at risk of irritability anyway, you put starvation on that, and so ‘hangry’ is the layman's term but there are neurobiological processes happening there. Then we're actually getting our teenagers to be really at risk of significant changes in emotion and mood. So that can then impact on their friendships because they're really cranky all the time with their friends. 

They're at risk of really poor school performance because they can't concentrate, they're at risk of not doing as well at sport and they might really want to make a team or do well. Also, they miss out on regular and social eating at school if they're fasting and so they're getting further away of all those messages that we're going to try and promote about regular and adequate intake.  

So, we also know that I think that starvation or that feeling that you're starving yourself probably leads you to a risk of bigger binges when you're really hungry, and that cycle is a definite risk factor for setting up disordered eating. So, for anyone out there, I'd have to strongly say that fasting diets are not appropriate for children or young people at any weight. 

Sam: We'll be back after this short break. 

[Community message – Woman’s voice]: Unhealthy weight is one of our greatest public health challenges. Two in 3 Queensland adults and one in 4 children live with overweight or obesity. We need to shift the dial. That's why Health and Wellbeing Queensland has created Clinician's Hub for you, our clinical workforce. Clinician’s Hub is a digital ecosystem of initiatives, resources and tools, including this podcast series for multidisciplinary health professionals to support best practice prevention, identification, treatment and management of overweight or obesity and it offers a wide variety of clinical tools and training to help you transform health for children, adults and families. Find out how Clinician's' Hub can help you at hw.qld.gov.au/hub. 

Sam: And now back to the show. So given all of this, and that the listeners are people mostly working in primary healthcare settings and obviously we work with a lot of child and adolescents, I'm wondering about your approach overall. We've touched on lots of elements and encourage listeners to maybe listen to this once or twice because there's loads of really good insights throughout this episode. But how do you approach a child or an adolescent with a higher weight? And what would you recommend in a primary healthcare setting given what we know around the limitations around time? 

Michelle: So first of all, you acknowledge that their thoughts and behaviours are really common, so you can normalise for it. The second thing, you must validate the distress that comes with those thoughts and behaviour, and then you can give that consistent and practical advice on what is healthy eating. I think we can never reiterate enough, eating regularly with a wide food group, which includes all those core food groups and being mindful of our body’s hunger and satiety clues, is key to good nutrition and health.  

And then if you think that that person may be engaging in more serious, disordered eating behaviours, then I actually am really open, I'll acknowledge that, and I'll go on to a physical examination just to let them know that I'm really hearing them. But I'm actually looking at all the aspects of eating disorders and that it's a serious issue and it can affect their health in really negative ways. So, I'll always take that, validate it and then go on to actually let them know what I'm assessing for, so they understand that there are consequences to their disordered eating behaviours. 

Sam: Yes, that's a good way to do it. Again, explaining your clinical reasoning, not necessarily saying not doomsaying, because that usually doesn't go down well with teenagers. But saying: ‘this is what I'm doing, I'm asking these questions because of this, I'm doing this physical assessment, and we might do these investigations for these things’. So, you're letting them know that there are serious consequences here that are affecting them personally, as opposed the ethereal potential of it. Yeah, that makes a lot of sense. And your advice there around the importance of regular whole foods or guideline 5 food groups like diet is very important to just to have consistency and regularity there.  

So, we're trying to reduce a lot of the associations and potentially negative associations with food and even if it's – and please correct me if I'm wrong – but sometimes in practice the patients will be resistant to that and say: ‘Do you want me to eat regularly, that's, you know, that's hard’.  

But what I have found working with some of my patients with eating disorders is to encourage regular eating, even if it's a small amount – but it could just some nuts and a little bit of this, a little of that – but we want it to be regular. We want to almost desensitise the brain to the fear response that's occurring around all of this, as opposed to not eating for 12 hours, then having a big meal, then not eating again for long period, but we want these regular small meals. Is that a sensible bit of advice? 

Michelle: That's really sensible for the children who may actually have more of the lower category disordered eating patterns. But once you do get to a DSM [Diagnostic and Statistical Manual] diagnosed eating disorder, that may not be adequate. They may need to actually complete the entire meal. So certainly, for somebody who's reaching out to you in early stages of disordered eating, that's absolutely sound advice.  It just depends on whether they actually need to regain weight, in which case they'll need to be eating greater quantities. 

Sam: And they made need a specific meal plan and caloric intake, yes, absolutely. That's very good. So, for healthcare professionals though working away from metro areas – and obviously we're in southeast Queensland at the moment – what sort of support exists in Queensland if they have concerns around a child or adolescent with an eating disorder, who can they call, and what are they're referral pathways to follow? 

Michelle: Yes, there's lots of help out there. So first of all, we need to acknowledge that if a child has a diagnosed eating disorder, they do need somebody who's expert in their field, so you might find a general psychologist may shy away from some of these patients. So, you do need to know that you're referring to someone with experience in the eating disorder field.  

So, in centres outside of southeast Queensland, you should know if there's a local child and youth mental health service and whether those services are face to face or telehealth. So, the more remote regions will have telehealth to those areas.  

I think I'd like to acknowledge that the unit that I work in, which is a child and youth mental health, which we call ‘The Greenslopes Eating Disorder Program’, it just happens to be housed in the suburb of Greenslopes, is a statewide service, so that's accessible to any GP in the state that could want to ring in for phone advice or get some help us to where to refer a young person.  

From a GP's perspective, many of you look at the health pathways. So, I've been involved in looking at the adolescent component of health pathways. I understand that's not universal to every Primary Health Network, but certainly the health pathways are a very good source of information, if yours has an eating disorder site.  

And then just be aware of the many local and national eating disorder organisations that are mostly NGO [non-government organisation] based. So, we've got Eating Disorder Queensland in Queensland, which focuses on carers and parents and for people 16 and above – so, all parents and carers and then older individuals. And then Australia wide, we've got The Butterfly Foundation, the National Eating Disorders Collaboration and the Inside Out Institute. And there is a wealth of training material for GP's, mostly free, some paid for service, but incredible training packages on many of those national sites. 

Sam: That's excellent for our listeners to know about the training and then obviously within places like you said, the Butterfly Foundation, there's some great resources, some for patients as well. There are peer support programs, there's good books to recommend, podcasts to recommend that they can really empower themselves as well, which is absolutely a key part of all of this. Well, thank you so much, Dr Boyd, for your time today and your expertise. It was very interesting, and on a very important topic. 

Michelle: Excellent. Thanks for having me. 

Sam: Today, we've been talking to Dr Michelle Boyd from the Queensland Children's Hospital. For more information on today's topics, visit the Health and Wellbeing Queensland website at hw.qld.gov.au We’ll see you next time on the Clinician's Guide to Healthy Kids.