Where’s the Line Between Being Healthy and Having an Eating Disorder?

Ask Lisa Podcast, Ep. 11: Where’s the line between being healthy and having an eating disorder?

The Ask Lisa Podcast does not constitute medical advice and is not a substitute for professional mental health advice, diagnosis or treatment. If you have concerns about your child’s well-being, consult a physician or mental health professional.

REENA: I know we spend so much time on this podcast talking about food, one of our favorite topics, but you know it got me thinking, I know eating disorders are actually a specialty of yours, which is remarkable. You are so knowledgeable about it. Food has given us a great deal of comfort. We’ve done a podcast on food. When is the time to worry that you might have an eating disorder?

LISA: Oof. I’m glad we’re talking about this. I think it’s something we want to be watching really closely right now. I think for a lot of people, adults and kids, their relationship with food feels a little wonky right now.

REENA: We got a letter from a mom and she talks about this with her daughter, that she’s concerned about she says, ‘Hello, Dr. Lisa. My seventeen-year-old daughter has been under some stress lately, which I thought was mainly due to lock down and being a senior in high school, and having to make so many life changing decisions. But it turns out that she’s been stressing over her body image. She’s a tall, pretty and very well proportioned girl with a healthy weight, but she hates everything about her body and think she looks like a boy. She admitted that social media has ingrained in her certain standards of beauty that she’s finding it very hard to get over. Help.’

LISA: Hm.

REENA: I mean, you hear this often, right?

LISA: I am hearing it a lot, and I’ll tell you, Reena, when I was worrying over the summer about what might be coming down the pike with teenagers, and you know, what it means to be under COVID-19. I was worrying about anxiety, I was worrying about depression, and we’ve certainly seen that be you know on the rise, I was worrying about substance misuse and a little bit sort of you know further from the center of it for me was eating concerns. And I have to tell you, in the last couple weeks, I feel like, clinically in terms of what I’m seeing and hearing, what my colleagues are seeing and hearing, eating concerns have come so much to the fore, and then on top of that I’m part of a conversation that’s on that’s on WETA and PBS Newshour about teens and COVID and how their mental health is coming along. The link on how to watch as in the show notes, and as part of that the survey was done asking teenagers like what was top of mind? What are some of the things you’re really struggling with? The number one thing that teenagers said was stressful for them had to do with body image, eating, fitness and the thing that was so incredible to me, though it lines up with what I’m hearing, the boys were really well-represented in this. It was like 55 percent of the girls said that was their main concern and 40 percent of the boys said it was their number one concern. So it’s one of those things, Reena, like you know how sometimes you learn a new word and then you sometimes like start hearing it everywhere?

REENA: Yeah.

LISA: I will tell you, the last couple of weeks for me clinically, everywhere I turn, eating concerns are coming up and that is definitely worrisome.

REENA: I didn’t realize that the boys are represented in that, you know 40 percent that’s huge as well, but you know you look at social media, Instagram whatever it might be, you worry because you can add filters, you can make your waist skinnier, you can do a lot of things that don’t make reality reality right? But what do you think is going on here? Is this because of COVID? Because we’re locked down? Is it just social media in general that’s everyone’s having to deal with it? What is it, really?

LISA: Well, so I think there’s a lot of play, but let’s start with the social media piece. Okay so generally in conversations about social media, I am very slow to blame things on social media. There’s in some ways, I think an over blaming social media for like every bad thing that goes on with teenagers and we don’t really have the data for it, and you know so I’m always really cautious and I’m like, oh it’s not all bad. Okay, on this one I think it’s a pretty significant factor, and I think there’s a couple things at play. One is kids are looking at like you said these idealized images or these you know kind of curated images, very carefully posed images, which they do normally, but normally it’s counter-balanced by seeing kids in real life.

REENA: I hadn’t thought of it like that.

LISA: Yeah, you know it’s one thing if you see a like a kid you know from class, a girl maybe, who has really carefully chosen an angle to present herself with, which they do, they spend a lot of time picking out these angles with it you know sort of most flattering, you know and or you know morphing in one way or another, but then you see her in class and you’re like okay but she doesn’t really look like that, you know that in normal life there’s more of a check against the distortions of social media, so one problem right now is that check is gone. And I just find it, like I have so much empathy around this because like you know how Instagram is now pushing reels? I think it’s like the Facebook version of TikTok?

REENA: Yep, videos.

LISA: So like there’s I’ve been searching like when I go to search for, you know somebody on Instagram, when I open up the search frame the reels start playing because they’re bringing them forward and the reels are invariably like these darling, slim, fit young women who are like roller skating or whatever, and it’s so strange because even at 50 years old I’m like, oh, I don’t look like that, and I mean just how quickly on that reflex is to compare, and so I think here I am at 50 I can’t resist it, like what does it mean for a kiddo?

REENA: We talk about social media, how now do you counter that? What’s the solution in dealing with that?

LISA: Yeah, okay so one is again, if you can get your kids to look at other people in person, you know have their friends over in person I really think that helps to counterbalance. The other thing that we need to do, and this comes from there’s a really smart woman named Jill Walsh who talks about kids and social media and helping them manage you know how they take things in, is to have that conversation. To say look, I mean yes the girl looks darling and very slim, but you know and I know like what do you think? Like how long did she spend taking that picture? How much time was put into that image? And I’m not saying you can’t look at it or don’t look at it, I don’t think that’s very realistic, but to do what we can in parenting to insert that filter to get young people, boys and girls, questioning what they see, because the other thing I’ve seen, I was I was actually looking at something, I think is reading something the New York Times about some Tik Tok hype house, and they showed a pack of boys who were these you know really I guess famous Tik Tokers, all without their shirts on, all with six packs, and I saw that and I thought okay here’s the boy piece, right? Wo we talk so much about the girls but there’s also I think on social media for the boys to see a lot of young men who are putting forward these very very, you know, kind of fit physiques, and if that is what you’re looking at all day and you’re not looking at the kid in class who just looks like a normal person,  it constructor warp your understanding of how you’re supposed to look.

REENA: What else do you worry about?

LISA: Okay this is gonna sound really basic, but it seems to be part of the problem. Kids have too much time on their hands. They don’t have enough distractions. It’s so interesting, clinically, Reena, when I’m talking with kids something is going through my head that is not usually going through my head, which is like, oh my gosh this kid is too much in their head. That they have time to just loop on obsessions almost. You know things that they’re thinking about they can just go down these rabbit holes and get further and further into them because they’re not running off to practice, they’re not over at this house babysitting, they’re not out and about, you know trying to figure out how to get something done. There’s so much of a narrowing of experience for all of us right now, and kids too, that I think you know you can almost start to add these up. Number one they’re looking at a lot of social media with a lot of idealized bodies, whether they’re real or not. Number two they have time to just think and think and think about it, and I will use the term obsess about it because there’s not enough else happening that is pleasantly distracting or even unpleasantly distracting. They’re not their lives are narrow.

REENA: But Lisa, how do I as a parent counter that? Because things are closed, soccer shut down, schools might not be open, and I need to do my work and feed three meals a day, so how do you counter the lack of distractions?

LISA: I’m not entirely sure to be honest, but I think first you name the problem and that gets you toward solving it. I do think we need to find ways to keep teenagers busy, even in the context of the pandemic. And that’s in some ways been a longstanding truism about teenagers, like they’ve better when they’re busy, you know it just kind of keeps them on the right track and out of trouble if they’ve got stuff to do, and so may be the way to think about is, here we are you know late October, whatever the rhythm was of school we probably adapted to it a bit or hopefully it hasn’t changed much,  like kids are starting to figure it out, grown ups are starting to figure it, it’s new and different but it’s less new and different, can we start to have kids you know do more chores or rake more leaves or you know shovel more snow?

REENA: Good luck with that.

LISA: Yeah, but can we just be attuned to the fact that they just don’t have that much happening and try to fit in more that just pulls them away from their own heads, which is such a strange thing as a clinician to say like I don’t want teenagers thinking so much, but I don’t want them going down rabbit holes so much, and they unfortunately have time to do it. Even stuff like you know in school when they’re like there’s like gossip or kids to talk to or you know the funny thing that kid just in class, you know just the loss of that is creating space I don’t think is always helping teenagers.

REENA: It’s also you don’t have control of so many things at this point right?

LISA: Well that’s,  I think, another huge piece of this, and in many ways kind of a traditional and you can feel like a little bit of a pop psychology explanation for eating disorders, but I think it’s really legitimate here, which is it’s something to control, and so okay so first you’ve got the layer of kids looking at themselves, or other kids on social media. Then you’ve got the layer of too much time to think about themselves, their bodies, how they’re looking, how they’re going to come out of this pandemic, and then the third is this overall sense that there’s too little control you know that that things are not going the way they want them to and they can’t control a huge amount. And it does, I mean to use a weird expression here, it sets the table for kids to be like, okay well I’m going to take control of this. I have time, I have inclination and I don’t have anything else I feel in great control of, I am gonna whip myself into the best shape of my life, or I am going to eat the purest diet possible, and it’s one of those maneuvers that happens psychologically of like, if I can’t do that I’ll do this, you know if I can’t control you know what’s happening in my social life i’ll control my body, and it’s problematic because it’s reinforcing. You know that if I feel like, okay everybody’s hanging out without me and I can’t do anything about that, but I can eat salad for lunch and that makes me feel better, you know we have the problem of it being somewhat reinforcing. Like, oh I ate salad and I feel better about my social life, right? I mean it’s sort of one of those tricky maneuvers that kids can get themselves in trouble, and also grown ups too.

REENA: Totally, but when I’m hearing you talk about, you know, this whole wishing for control as as one of the explanations with eating disorders, but I’ve got to tell you I try to work out with get the gang in the neighborhood and I feel like I can see how this is sort of the only thing I can control my life that I look forward to, but at the same time when is it healthy when is it not? I think working on healthy, it’s helping my brain, my mental health, eating a salad every day, what’s wrong with that?

LISA: Right, I mean and that’s actually where I think it’s very tricky from the standpoint of parents because some parents where the kid is not eating all that well and being really lethargic and not getting that much activity, so you know if you see your child or teenager taking a lot of initiative around like I’m gonna eat healthy and I’m gonna make sure I’m getting lots of exercise, to a degree parents are probably like, okay good, like your on it, you’re checking that box I don’t have to worry about that.

REENA: Yeah.

LISA: So the, you know, the broad framework and and I I know we raised this in our earlier episode, we talked a little bit about activity, but it’s really the right framework is, is your kid taking good care of themselves? And especially teenagers, we can really expect the teenagers to see it is their responsibility to take good care of themselves, and just watch that, right? And so if you see a kid who you feel is getting really controlling around what the eat and their exercise, I would start to call the question, and I will call it openly with a teenager, I would say, look I see that you eating less or eating super healthy is a way that you’re trying to make something work right now and it feels like nothing’s working, make something better when it feels like nothing is you know happening the way you want it happen, but I want to make sure you’re doing it in a way that really means you’re taking good care of yourself, which means not taking it too far.

REENA: What really happens in the mind for someone who’s struggling from an eating disorder? Can you talk generally about that? Is it different case-by-case?

LISA: It’s actually a fascinating question. So part of why eating disorders can be so dangerous is they can kind of lock people in. tThat if a person really starts to restrict and isn’t eating enough, what happens is their ability to think in sophisticated ways starts to collapse, and one way to think about it, okay say, Reena, I said to you, okay I will talk to you in two days, but between now and two days from now you are only going to eat 500 calories a day, so you know very restricted diet.

REENA: Oh my gosh.

LISA: Right? Okay, what kind of shape are you going to be in when you and I talk in two days?

REENA: I tell you in six hours I’ll be dead. Forget two days.

LISA: You’ll be thinking about nothing but food, and we would not be able to have a rounded, thoughtful, sophisticated conversation about anything.

REENA: Yeah, I’d be angry. Absolutely angry at you within six hours.

LISA: Exactly.

REENA: I’d bite your head off in six hours.

LISA: Angry. Very concrete in your thinking, very focused on food only. And so one of the ways that eating disorders can really get a grip on people is in the depletion of nutrition, in the loss of just the sustaining nutrition that we need, people’s ability to step back and think, what am I doing? Is this a good idea? Is this really working for me? That actually gets undermined by the lack of nutrition, and so then there can become this very rigid focus on food rules or exercise rules that really can take people down a path that is a dangerous one. So that’s where we will have to be so mindful as parents of teenagers right now, especially teenagers who are doing what may be a perfectly wonderful thing of taking really good care of themselves in terms of how they eat and getting plenty of exercise. I would just say to parents keep an eye. Keep an eye on I would say almost the flavor of how they’re doing it, like does it feel like, this is me loving and taking good care of myself, or this is me taking what starts to feel like an almost punishing stance towards myself.

REENA: You know I wonder under these COVID situations and eating disorders, so many people have gained the COVID fifteen at this point, right you’re locked in. How do you make sure you’re not forming an unhealthy relationship and then could be transferred over to your kid who you might even have an eating disorder right? When you know you’re in trouble?

LISA: Well I I think, like if we go with that idea, you know, do we seek food and exercise or food and activity as part of how we tend to ourselves, or part of how we are hard on ourselves, right? Restricting and high standards for exercise or, I mean that word punishing really feels like it fits the bill here, you know this how we are trying to keep ourselves in line, as opposed to, I feel good when I eat this way, I feel good when I get this much activity. I would just watch that, but we also know what parents say matters, so it’s not just the kids and teenagers who I think are having to renegotiate their relationship with food and exercise and activity, because we all are because we’re in such a different setting than we’re used to, so I would have parents also be cautious about how they talk about their body, how they talk about their eating, and really go out of your way to try to model a sense of this is me tending to myself, as opposed to this is me taking myself to task.

REENA: So you’ve walked us through why you think there may be a rise in eating disorders under COVID right now and you mentioned social media, second it was lack of distractions and the third was a wish for control. Is there anything else that you think might explain why we might be seeing an uptick?

LISA: Okay so this is a little vague, but I have a very strong Scooby sense about it, I guess as you would say. This is such a hard time to be a teenager. School is so weird and so hard no matter how they’re doing it. They do not get to see their friends like they’re supposed to and used to, and it’s becoming a bit normed, like we’re sort of getting used to this idea of like, yes schools looking at a computer and seeing your friends is like this you know tough negotiation, and what I worry in the kind of adapting to, the normalization of it, is that we can forget how crummy this is for teenagers and then we can do something which is really easy to do, which is to sort of flex on teenagers when they don’t like it. You know so when a kid is like, oh my god I can’t do one more Zoom meeting, it’s very easy to be like well, you know it’s important you stay on top of things this year. Or if a kid’s like I really want to see my friends you know for an adult to be like well you know we have to be very careful, and then we can do that and well-behaved be teenagers will sort of put their head down and go along with that. But part of what I’ve worried about is they’re still really mad, and what we’re asking them to do should be making them mad, actually anger is a very appropriate reaction right now to what we’re asking of teenagers, but not all teenagers can or will get outwardly angry. Some will. Some will misbehave, some will you know really go toe to toe with the parent, but I think let’s work with the assumption that all teenagers are deeply unhappy if not angry about what we’re asking of them right now, and rightly so, but some, rather than taking it out on the world, are going to take it out on themselves, and so my other concern is that kids who are angry may manage that anger by pointing it against themselves and being like, well I’m gonna then get myself you know into good shape and only eat healthy foods and really take, again, I’m gonna use this word again, a punishing stance toward themselves. I think that dynamic may be quite a bit at play, to be honest.

REENA: Interesting. So bottom line is we wrap it up here, what should parents really look out for?

LISA: Well I think watch your kid’s relationship with food, but I would also say on this last point take the initiative to talk with your kids about how pissed they must be. You know whether or not they’re articulating it, don’t let them point it in. Help them point it out, right?  So you know even as your wonderful diligent daughter or son if you have one who’s sitting down and just you know making it work anyway, doing the schoolwork under these terrible conditions anyway, take the initiative to say, look buddy I watch what you’re doing and you’re doing an amazing job, but like this stinks and you’ve got to be really frustrated or really annoyed that this is how it’s going down, or, I can’t believe we have to negotiate whether or not you can see your friends, like we do we have to figure out something safe, but buddy like I don’t want to miss for a minute that this is unfair and not okay for you. Don’t let the ugly piece of this go unaddressed. I would name it, I would try to help the kids say it, because if it’s not going out if it’s not pointed out that aggression that frustration can be pointed in, and that is not a good situation for kids.

REENA: And on your point about focusing on on other things and sort of other distractions, charity could potentially be a good distraction, and we have a new series that we launched called For Children Everywhere and we’re gonna mention a charity that we love, and opportunity for you to talk to your family about maybe donating, and these charities don’t know that we’re mentioning them and we get nothing out of it, it’s just what Lisa’s always said, giving back really helps people. And the charity that we’ve decided as we’re talking bout food one that I love is World Central Kitchen by Chef Jose Andres, they are doing amazing work providing emergency food relief, trying to keep small kitchens up and open, and during the election I found out they’re going to be feeding people in the poll lines. They said they don’t care who you vote for, they just want to make sure you don’t leave the polls and you cast your ballots. They are helping in disaster relief areas so we wanna give a shout out to them, provided more than 25 million meals since 2013. If you want to help fight hunger, World Central Kitchen.

LISA: And we’ll put the information in the show notes too.

REENA: Yes, every week we put the information for the charity in the show notes, which is on the description of where you’re getting a podcast, and we’re also going to mention Wellbeing, that’s the show that Lisa will be on WETA PBS Newshour. More information in the description.

So what’s your parenting to-go, Lisa?

LISA: So my parenting to-go is about when kids are pointing it outward, are pointing their frustration outward, and it’s about complaining. Complaining is part of being a kid and a teenager, and it’s for me not that big a deal, it’s sort of how kids manage to be really well-behaved everywhere else, is they come home and complain a lot, and what I am finding and hearing is, okay complaining is a lot right now. Kids are complaining a lot. If they’re not, you know, just sucking it all up they are complaining a lot, and there are two phrases that I think all parents should have handy for when their kid starts complaining. So the first one is, do you want my help? Or do you just need to vent? It’s really useful because usually the kid will say, I just need to vent, and then the parent can sit back and see the complaining as a way that the kid is unloading the burdens of the day, and then just walking away from them, and usually the kid feels much better, and knowing that the kid just needed to vent, the parent doesn’t feel like they were supposed to have done something. If the parent’s feeling like maybe more needs to be done, my other favorite phrase is to say, is there anything I can do that won’t make this worse? And it’s a real light touch. It’s a way of saying, I can tolerate that you’re unhappy. I also can tolerate there may not be much I can do to fix things, but I’m here. I’m trying to be creative, and those two phrases address a great deal of the kind of end of day distress the kids bring our way.

REENA: You always teach us how to rethink things that I think are huge problems that you just want to go away, and sometimes it’s the language.

LISA: You’ve got to have the right phrase, and I think that so much of what you learn in your training as a psychologist, the theory is one thing, but like the words to say it that’s another. So having the words to say it does make it easier.

REENA: Absolutely love it. I will see you next week, Lisa.

LISA: See you next week.

REENA: Thanks.