A Devastating Disorder, Poorly Understood
James Greenblatt, functional psychiatrist and chief medical officer at Walden Behavioral Care in Waltham, MA, has noticed a disturbing trend in the patient population he sees. “We didn’t take 11- and 12-year-olds, five or 10 years ago,” he says. “They were much fewer, and they could be treated outpatient. But the ages of onset are getting younger and the symptoms are getting more severe.”
Greenblatt, assistant clinical professor of psychiatry at Tufts University and Dartmouth College (Figure 1), is on the front lines when it comes to treating eating disorders. Working in what is one of a growing number of facilities in the United States dedicated solely to treating anorexia nervosa, bulimia, binging, and other eating disorders, Greenblatt oversees the care of patients who grapple with the often devastating consequences of an unhealthy relationship with food. In 2020, to meet growing demand, Walden expanded to 82 beds (36 residential, 46 inpatient), admitting over the course of a year more than 5000 patients.
Given the fact that researchers in the field have discovered genetic markers for eating disorders which may be triggered under the right conditions (see also “The Biology Behind Eating Disorders” in this issue), Greenblatt’s observation that kids seem to be developing eating disorders at younger ages raises questions of whether there is something about our environment today that is setting the stage for these kinds of problems. Other clinicians have theorized that several factors may be in play, including an earlier onset of puberty (onset of puberty is associated with eating disorders) as well as the increased popularity of obesity-prevention programs in schools which may cause younger kids to begin dieting sooner. In some cases, a restrictive diet may even activate genetic changes that push kids into anorexia. (Interestingly, clinicians also report treating a growing number of older patients, which they say may be triggered by pressures older adults feel to maintain a youthful figure into middle age.)
“Every gene is just this potential,” says Greenblatt. “It’s not our destiny. So, I think it’s the environmental factors. Some of those are stress, some of those are dieting, some of those are cultural. And some of my work has to do with dietary changes.”
Greenblatt believes that one of the primary “stressors” triggering anorexia is as basic as a vegetarian diet in adolescence. And if that’s the case, a growing incidence of eating disorders might be explained by a rising interest and acceptance in both vegan and vegetarian eating. (While a Gallup survey says that only 5% of Americans identified as vegetarian in 2018, unchanged from 2012, it also cited booming sales of plant-based foods in recent years, concluding that overall, more people are reducing their intake of animal products. Another U.K. survey suggested that veganism has risen 350% among those age 15–34 in the decade leading up to 2016.)
“An adolescent eating a vegan diet is not [eating a diet] necessarily nutrient dense enough to get through puberty,” says Greenblatt. “I believe that’s a trigger. Zinc and the deficiency of B-12 that is not adequate in the diet triggers a number of the symptoms that sets this course of restricted eating, not being able to digest food, and eventually affecting distortions of body image.”
Greenblatt points to robust clinical and epidemiological research suggesting a bidirectional relationship between zinc deficiency and anorexia. More than half of anorexia patients have been found to be zinc deficient, and more teens and preteens are avoiding meat these days, potentially explaining declines in zinc levels. A 2001 study of 45 Israeli teenagers with anorexia reported rates of meat avoidance 6.5 times that of those without anorexia. If teens are getting less zinc because more are eliminating animal products from their diet, it could cause changes in the brain that might potentially lead to an eating disorder.
“There’s like 20 things that zinc does,” says Greenblatt. “Everything from our taste receptors to our ability to digest food. These are all zinc-dependent enzymes. Without zinc you don’t digest what you eat, you get bloating, you get indigestion, you don’t taste food, and then you slip into eating less. Zinc is critically important for all the major neurotransmitters in the brain. I might get carried away and say it’s the factor, but it’s certainly a powerful factor in some kids with this genetic vulnerability.”
At Walden, the treatment protocol relies on a combination of therapies meant to address both nutritional deficiencies and psychological factors. As in many eating disorder clinics, “family-based treatment” (FBT) is a mainstay. In FBT, parents are required to plan, prepare, serve, and supervise patient meals. If purging is an issue, parents supervise teens after meals to make sure it doesn’t happen. In addition, Walden touts an integrative approach incorporating yoga, mindfulness, and even dance. Certain eating disorders, like binge eating disorder, are sometimes treated with medications. But the most important treatment from Greenblatt’s perspective is aggressive nutritional supplementation with zinc, B-12, and essential fatty acids, because, as Greenblatt says, “some of these kids have avoided fats for five, ten years.”
“Once a patient becomes so malnourished, the brain becomes distorted,” he says. “It takes many ways to change behavior and change the underlying biology, nutrition, and food being the core… And we know eating healthy fats can change brain chemistry and brain structure.”
Greenblatt’s message to parents is this: “If your child wants to be a vegan, please, understand zinc and B-12 requirements and work with somebody to get those supplements because we can do it early before this illness becomes quite relentless and life threatening.” (Greenblatt also serves as a medical consultant with Pure Encapsulations, the Canadian purveyor of science-based natural supplements where he’s worked on a line of products designed to support neurotransmitter function and integrative mental health. None of those supplements are used in the care of patients at Walden.)
He has a message, as well, for the medical community: Medical schools need to spend more time educating doctors about eating disorders. He cites an online survey of psychiatry residents in which 45.7% reported receiving less than 3 hours of formal training in eating disorders . “It’s just frightening that our medical community, with this life-threatening illness, does not even have programs or training,” he says.
In an effort to address this missing piece, Greenblatt has founded Psychiatryredefined.org, an educational platform dedicated to encouraging clinicians to embrace an integrative functional approach to mental illness, dropping an overreliance on pharmaceutical interventions and considering instead how factors like mindfulness and nutrition can play an important role in mental health.
“The prevalence of eating disorders is increasing,” he says. “It’s doubled over the past 18 years. So, we have increased incidence. We have a lower age of onset. And I know I’ve said it a bunch of times, but the highest mortality rate. Our patients with anorexia nervosa have the highest risk of suicide across any major psychiatric illness, and that’s just not common knowledge and not aggressively treated and understood. But it’s just devastating. And I think our medical community, our research community has really ignored it and not addressed it.”
- A. Klott, J. Hagman, and M. Schiel, “Eating disorder clinical experience and comfort level among current psychiatry residents, fellows, and attendings,” in AACAP Nat. Conf. 2020, New Research Posters Forum.