The future of eating disorders

0:00Russ:This is Stanford Engineering's The Future of Everything, and I'm your host, Russ Altman. I thought it would be good to revisit the original intent of this show. In 2017, when we started, we wanted to create a forum to dive into and discuss the motivations and the research that my colleagues do across the campus in science, technology, engineering, medicine, and other topics. Stanford University and all universities, for the most part, have a long history of doing important work that impacts the world. and it's a joy to share with you how this work is motivated by humans who are working hard to create a better future for everybody.

0:37Russ:In that spirit, I hope you will walk away from every episode with a deeper understanding of the work that's in progress here and that you'll share it with your friends, family, neighbors, co-workers as well.

0:48Tina Sindher:Unfortunately, I'm seeing some kids who really prefer to use chat GPT or similar platforms as their primary source of therapy so they can actually type in a question and they'll get a response. And often there are some compelling and useful things that will come out, but there aren't the guardrails that you would have with a human therapist.

1:17Russ:This is Stanford Engineering's The Future of Everything podcast, and I'm your host, Russ Altman. If you like what you hear, follow the show. We think your future self will thank you. Today, Jennifer Duran will tell us that for disorders like anorexia nervosa and others, a combination of behavioral therapy and some really interesting new medications, ones that you might not expect, may be useful for helping to treat these very difficult diseases. It's the future of eating disorders. Today, we are continuing our new feature, The Future in a Minute. At the end of my conversation with Jennifer, I will ask her some quick questions and she'll give me some quick answers.

1:55Russ:That'll be at the end. Before we get started, please remember to follow the show. Again, your future self will thank you for all that you're about to learn.

2:09Russ:Adolescence is a difficult time for everybody. It's a time when your body is changing, where your social network changes a lot and friends become way more important, And you're beginning to evolve and become independent and looking towards leaving the family nest. Unfortunately for some people, adolescents can also bring eating disorders. These are diseases where eating becomes pathological and compromises function. That is to say, the physiological function, the health of the individual, physical health, as well as their ability to function in school, at home, and in social groups. These are terrible diseases that are very difficult to treat.

2:48Russ:But Jennifer Duren is a professor of psychiatry and behavioral sciences at Stanford University, and she's an expert at adolescent psychiatry and eating disorders, among other areas. We're going to talk to her about what the status of these diseases are in our society, whether AI and social media have helped or hurt, and what are the new promising treatments that are coming down the pike. Jennifer, to start out, how did you decide to focus much of your work on eating disorders?

3:15Tina Sindher:It's a great question. I went to medical school thinking I was going to be a pediatrician. Psychiatry was not actually on my radar at all. And then when I was doing my rotations, I realized that I actually really enjoyed talking with kids about what was going on for them. And within psychiatry, eating disorders have the reputation for being the most challenging of the diagnoses to work with. And I love a challenge. They're an incredibly rewarding patient population to work with.

3:44Russ:So can you tell me, for people who don't think about eating disorders all the time, can you kind of give a landscape of the types of things we're talking about? What are the diseases? What are the challenges in treating them? Yeah.

3:58Tina Sindher:So, gosh, we have the more traditional eating disorders that people often think about. Like Karen Carpenter was diagnosed with anorexia nervosa back in the 70s and 80s. Bulimia nervosa, where people eat large amounts of food and then compensate by purging in some way. And then binge eating disorder, which is similar to bulimia, but there's no compensatory behavior. We also have a relatively new diagnosis called avoidant restrictive food intake disorder. And that is seen in kids who are having trouble eating, but it's not because they want to be thin or because they're trying to lose weight. And these kids have always existed, but it only has risen to the level of being an actual diagnosis in the last 10 to 15 years.

4:45Tina Sindher:So that's really where we're putting the majority of our effort. Sometimes people say, well, what about kids who are at higher weight, who live in larger bodies? We don't necessarily view that as an eating disorder unless it's the binge eating type.

4:59Russ:So, and you said the word kids a couple of times, and I think it is the case, and tell me if I'm wrong, that these do tend to kind of manifest at least for the first time in adolescence or early adulthood. So, what are the demographics of these diseases in terms of when you're seeing them and making the first diagnoses?

5:18Tina Sindher:Often they present in adolescence. So, really the teenage years is kind of the stereotypical time, but they can really present across the lifespan. So unfortunately, I've seen kids as long as old as five or six who presented with real anorexia nervosa. And then we've also seen people in their 60s, 70s, even 80 years old who present for the first time with symptoms. So it truly can present across the lifespan.

5:46Russ:And so let's take anorexia nervosa just as our first thing to think about. And I know people think about that and worry about that a lot. What are the symptoms and how can somebody tell if they or a loved one really have a disorder versus, I don't know, it's quirky eating habits?

6:03Tina Sindher:Yeah, I'm asked to comment on this all the time because I think in some ways, sometimes disorder is a little bit normal. Most people have been on a diet or been concerned about their weight or shape at some point in their lives. And for a lot of people, they may for a few weeks kind of watch what they're eating. They might exercise a little bit, but it typically doesn't get to the point where they're not functioning across domains. So when someone is unable to attend school, they're no longer seeing their friends, they can't go to work, and they're in a medically dangerous place, then we start to worry that this is really a diagnosis.

6:42Tina Sindher:With anorexia nervosa, it may be that they feel like their weight is too high. They're being very restrictive in what they're willing to eat. They have a lot of weight and shape concerns. So we may all see that they are objectively underweight and in a potentially dangerous space. But they actually don't see that or don't feel that. And so they continue to engage in these problematic behaviors to the point where it can become very medically dangerous.

7:15Russ:Yes. And you mentioned that a lot of this gets manifested in adolescence. And of course, as you know better than most, this is a very difficult time for young people, this transition from being a child to being an adult. And many issues, as we all know, arise. I'm guessing that it's hard to manage these folks because in addition to having these disorders, there's so much else going on in their life, social interactions, the changing body separate from the potential disorder. There's just changes in the bodies happening. So how do you approach the treatment and the communication and creating a bond with the patient?

7:54Tina Sindher:Oh, 100 % true. We always joke that eating disorders are everyone's fault and no one's fault. So it's not one thing. It's usually a perfect storm. And a lot of it is actually first really getting a shared understanding of what it is that we are trying to treat and getting the patients buy in as much as possible, but also a family buy in. We really want families to be equal partners in the treatment process. And then we really, you know, we sometimes say we have an agnostic view that it doesn't really matter if there was one potential reason that this happened. The important thing is that we've recognized that it's a problem and we're going to work together on solving it.

8:36Tina Sindher:So where we get change and improvements and outcomes is around changing eating behaviors, stopping exercise, stopping binging and purging, and really supporting the patient all around rather than spending unlimited amounts of time trying to get to the bottom of why this happened. We don't get people better when we focus on that.

8:56Russ:Yeah. And on the why, and I won't, I promise I won't focus on it too much, but do we have an understanding of the relative contributions of environment versus kind of genetics and kind of nature versus nurture? Is this, are these diagnoses that come because of the experiences and the things that the person lives through or are there innate tendencies towards this or do we understand it?

9:20Tina Sindher:I think it's both and. People far smarter than I am are looking at the genetics and the biologic vulnerabilities, which are definitely passed along within families. But we also know that there are some temperamental factors that tend to be really consistent across the board. A lot of times our patients are very high achieving, perfectionistic, risk avoidant, people pleasers. And then there is the whole element of media and particularly social media in this day and age. We're all exposed to it. We don't all develop eating disorders, But for people who are vulnerable, it can be a really important trigger.

9:58Tina Sindher:And anyone who's been on any of the social media platforms knows you watch one video, the algorithm will start sending you that content over and over and over again.

10:08Russ:Yeah. So since you since you raised social media, I'm imagining that this is a huge part of your practice, even separate from the from the eating disorders. And so can you tell me what what what are you seeing in young adolescent people? There's an informal observation from many of us just on the street seeing that young people are down on their phones all the time that they refer to these, what do they call it, social media natives where the phones, all of this has been since they were born. They really don't remember a world without it. I'm imagining it's created, I don't know if I can use the word earthquake, but some big changes in your practice.

10:46Russ:Is that true?

10:48Tina Sindher:A hundred percent. You know, I feel like when I was a kid, you know, longer ago than I care to admit, I would go to school and if someone was picking on me at recess, I might decide to tell the teacher, but I might also have to try to work it out with my friends. If nothing else, I was going to have to wait till I got home to tell my mom and dad about it. And so there's a lot of natural need to focus on self-soothing, problem solving, working it out amongst yourselves. I think when you add something like a smartphone to the picture, you have constant contact with people in your lives. And I want to be really clear.

11:29Tina Sindher:I am not saying that kids should just figure it out on their own. And at the same time, if you immediately are messaging mom and dad and they're coming in to intervene, you lose some of that valuable ability to practice. And so I think people who are talking about putting restrictions or limitations on smartphone use in this age range, it's not because we just want to take it away. But I think we want to give people practice developing some of the skills that are really important. So face-to-face communication, I find that my patients struggle with. I feel like phones are very often used as soothing tools.

12:13Tina Sindher:And if the phone is taken away for a punishment for some reason, that can cause a very big emotional response. We've seen kids in the emergency room because someone took their phone away and they threatened suicide. So it's definitely a huge part of our practice across the board right now.

12:31Russ:So related to this, I think, is I know that you have a special sub interest in the transition to college or the transition out of the family. And it's really fascinating. And I'm sure all these issues kind of are intermixed. But tell me about tell me about that transition, because it's a big one for families. It's a big one for parents. It's obviously the biggest one. Many of us have vivid memories of the weeks and days around the time where we left our childhood home and went to some new place, if you're lucky enough to be able to do that. So tell me about that particular experience and the kinds of lessons and what you're seeing there.

13:12Tina Sindher:Yeah, I mean, I think in many ways the good news is that we're seeing more kids who are able to make that transition. We've gotten better at identifying mental health conditions, getting people treatment early, keeping them supported. And because parents are so involved, they're providing a lot of scaffolding and support at home. I think one of the top things I see as an issue, though, is that families may not realize how much they are supporting their child. And so all of a sudden, when it's time to go to college, they may assume that the kid has learned some things that we just kind of expect that you do when you're an adult.

13:49Tina Sindher:But no one's actually taught them, how do you budget? How do you do laundry? How do you make an appointment? How do you fill a prescription? And if you have someone who struggles with depression or anxiety or ADHD, that all can be triggered in the context of this big life change. And so I have seen kids who have crashed and burned a little bit with the transition. And so my dream is for every family to really think about, okay, we are making the plans to go to college. We're going to think ahead of time about what do we actually need for there to be in place? And then what are our contingency plans if something doesn't go well?

14:31Tina Sindher:And then how do we give the kids some independence and practice while they're still at home so that transition isn't so scary?

14:38Russ:I love that idea. So it implies that we don't do this a month or two before saying goodbye for college. This might be something in sophomore year, junior year, say, OK, we're headed towards this event. Let's like do some planning for it. A hundred percent.

14:53Tina Sindher:And even small things like if you are waking your child up every morning to get to school, that is wonderful. It's a very caring parental thing to do. And if they don't ever experience the natural consequence of sleeping through their alarm, not making it to school, not being on time for their test and maybe getting a bad grade because of it, they're never going to be able to learn from that and develop skills and strategies to make sure it doesn't happen again.

15:22Russ:Yeah, really interesting. I have to just comment that when I went to college, I took a train to college and I said goodbye to my parents. I got to the campus and the first person I met turned out to be my partner and wife for the next 40, 45 years. And so that transition took one hour. I mean, there was a lot that had to happen. But like when you look back on it, it was bye mom and dad. Hello, partner. And wow, I think lucky, luckily. Um, um, okay. So I wanted to talk a little bit about, um, treatments, treatments, uh, and, and, and I think this will go even into our next segment, but, um, as you make these diagnoses, um, and as you have these, um, young people in many cases who are struggling and they're struggling with many things, um, is there a hierarchy of treatments?

16:09Russ:How should we think about the treatment for these disorders? And I can imagine, you know, therapy type treatments, maybe medications, maybe other things that you want to tell us about? Where are we for treating these disorders? Yeah.

16:23Tina Sindher:So right now, really, it's a team approach and it's multidisciplinary. First off, we need to make sure people are medically stable. So I am lucky enough to work collaboratively with adolescent medicine physicians who kind of share that piece. It's scary.

16:40Russ:Sorry to interrupt, but it's scary to even think. Like, of course, you would want to make sure that they're medically stable. And it's kind of shocking because, of course, it may get to the point where their health is in jeopardy. And then you have to manage both the psychiatric and the physical manifestations. And I'm sure that's very hard. And I mean, thank you for just mentioning that so we can all remember how serious these things can get. Yeah.

17:07Tina Sindher:I mean, the bulk of my time actually is on a medical stabilization unit where we take care of kids who have gotten medically unstable for some reason. So it definitely happens. And then food is your best medicine. So nutrition, re-nourishment, that is by far the most important part of this whole process. And a lot of times kids will say, you're just focused on the food. This is so boring. I don't like this. I want to talk about my feelings and my emotions. And I would love to talk about that stuff, but not until you're out of danger. And so we are working on increasing nutrition, regulating and normalizing eating patterns, and then focusing on getting rid of other eating disorder behaviors.

17:49Tina Sindher:And so we tend to work with a medical provider, a dietician who often consults with the parents around what is the appropriate amount of food that this person needs to recover from their eating disorder, a therapist who specializes in eating disorder. And sometimes someone can play more than one role. So you might have a psychiatrist who is also the therapist. The evidence-based treatments, there's not a ton of them. Eating disorders are tough to treat because a lot of times the individual actually doesn't think there's a problem. They don't want to change. And so actually treatment with someone who is still an adolescent is often a little bit easier because you have the parent involvement and the parents are the ones making the decision.

18:35Tina Sindher:And that actually contributes to improved outcomes over time.