Nutritional Deficiencies That Can Cause Eating Disorders – Dr. James Greenblatt – HPP 60
In today’s modern culture it’s no surprise that what we consume is largely influenced by what we see around us either in the media, internet or within the workplace. There are hundreds, if not, thousands of factors that affect our mental well-being and having a deficiency in nutrition can massively impact our capacity to think and make sound decisions that can ultimately multiply other factors that help worsen a fragile mental state.
In today’s episode, we discuss the lack of a push and awareness on the importance of nutrition and why providers should look more into incorporating this idea in their day to day practice. We discuss the role that the media plays on how it influences us and our children around nutrition and eating disorders.
We are very excited to be joined today by Dr. James Greenblatt, a revolutionary mind and expert on the treatment of eating disorders. Join us as we dive deep into issues involving imbalanced nutrition and how we can apply effective strategies and solutions to help avoid or combat existing symptoms of an eating disorder that you or someone you may know is experiencing.
Origins: Adapting the Integrative Approach – 02:11
“But I kind of came into it by accident about 20 years ago. And for me, it was kind of a perfect way of bridging my interest in traditional psychiatry and integrative because I got to talk about nutrition and brain function because all of our patients were malnourished and I could do grand rounds, and I could talk to colleagues about nutrition”
Dealing with difficulties: Food Allergies – 08:32
“I mean, as an outpatient physician and integrative psychiatrist, I’m looking at diet as an important part of the treatment plan. With our patients with anorexia, particularly in the hospital, you have to be really careful recommending restriction of any food group as part of this illness to kind of obsess and hold on to that”
Diet Restrictions and Eliminations: Why you need to be cautious – 10:00
“And if you’re worried about the patient that you’re working with, I would be really cautious about making broad recommendations about eliminating all these foods. Again, I’ve seen it many, many times”
Treating Eating Disorders – 13:49
“The kinds of therapy that has been shown to be somewhat helpful, there’s like DBT and CBT. And you mentioned the word meaning. I think so many of our patients with anorexia have this obsessive perfectionist personality. And then that often can be used for academic success and success in employment. But when it’s just focused on food and weight loss, it becomes destructive“
Anorexia and Celiac disease – 16:18
“We would recommend to adhere to a strict gluten free diet. So for celiac disease, we can document and absolutely, because that would impair recovery and nutrient malfunction. It’s kind of big food allergy panels that are just hard to substantiate the clinical relevance as well as relating risk of eliminating diet”
Treating Anorexia – 20:33
“And I believe there are models of prevention. So if we can treat it aggressively and treat it early, some of the nutritional supplements, as well as there’s something called FET family based therapy, helping the parents get more involved and monitor their kids as if they have a life threatening illness is probably the most important thing we can do”
Managing Children with Eating Disorders and the Truth about the Vegan diet – 25:29
“Well, this is going to be hard to hear some parents appreciate but probably the most important message I can share with you today and parents is my concern that a vegetarian or vegan diet, in preadolescents is one of the major causes for eating disorders”
Understanding Zinc and the effects of a deficiency – 30:01
“They’ll have many of the symptoms that you and I would see in our patients with anorexia. So, zinc is required for our taste buds. So most of our patients with anorexia have a lack of sense of taste. So food is not pleasurable. And zinc is also required for digestion”
The impact of Social Media – 34:00
“Some of the social media stuff about helping people lose weight, helping people hide their anorexia from the parents, and then the kind of social media support and comparison absolutely fuels this illness. You know, we described it as the gasoline on the fire that sometimes can tragically precipitate”
The future of treating Eating Disorders – 36:32
“I think the new areas that we need more work on are some of the infections like pandas. So these infections create some kind of autoimmune disorder with eating, restricting the major component. So I think there’s an autoimmune component that we need to do better to address. There are no current medications that we have for anorexia nervosa”
Full Episode Transcript
Dr. James Greenblatt, Keith Kurlander, Dr. Will Van Derveer
Dr. James Greenblatt 00:01
We have thousands of articles demonstrating that a vegan vegetarian diet, higher risk to develop an eating disorder, slower rates of recovery and much more likely to relapse. And for me, it just reflects a zinc deficiency that I was talking about earlier because a higher need for zinc in puberty, vegan diet, which is small, so little zinc is kind of that perfect storm.
Dr. Will Van Derveer 00:35
Thank you for joining us for The Higher Practice Podcast. I’m Dr. Will Van Derveer with Keith Kurlander and this is the podcast where we explore what it takes to achieve optimal mental health. Welcome back, everyone. Today’s episode of The Higher Practice Podcast is on eating disorders. The origins of eating disorders is not something we really talk much about in this field. It’s not something that was discussed in my training as a psychiatrist, and it’s a really interesting question. What are some of the possible underlying causes of eating disorders? Are there nutritional deficiencies? Are there other issues? And I learned some very surprising new information from our guest today, Dr. James Greenblatt who has been treating eating disorders for 30 years. For the past three decades, Dr. Greenblatt has devoted his career to educating his colleagues, clinicians and patients. How integrative medicine can have profound effects on mental wellness and how to employ balanced integrative strategies in the treatment of eating disorders. So we’re really excited to get to share with you this exploration of what may underlie the symptoms of an eating disorder.
Keith Kurlander 02:07
Hi, Dr. Greenblatt, welcome to the show.
Dr. James Greenblatt 02:09
Great. It’s great to be here. Thank you for inviting me.
Keith Kurlander 02:11
Yeah, it’s great to have you. We’ve both been following your work for a long time. So it’s exciting to get to talk more to you and more about it. We wanted to start off by just really hearing a little bit about, because you’ve been involved in integrative psychiatry for a really long time and functional psychiatry and eating disorders, and we just wanted to hear a little bit in the beginning here about how did you get interested in integrative psychiatry? It’s always such an interesting story to hear how people get involved in these types of things.
Dr. James Greenblatt 02:43
Sure. It was actually in college where I read a book, Mark Vonnegut’s book on how he became psychiatrically impaired and cured his illness through orthomolecular medicine. So in college, I was interested in orthomolecular medicine and treatment of schizophrenia. I went to medical school and came out many years later as a psychopharmacologist, child psychiatrist, and then eventually, as I got into practice, probably about 35 years ago, renewed my interest in nutrition and brain function. And the eating disorder career really is only about 20 years. Like many psychiatrists, I avoided eating disorders, because nobody taught me how to treat them. But I kind of came into it by accident about 20 years ago. And for me, it was kind of a perfect way of bridging my interest in traditional psychiatry and integrative because I got to talk about nutrition and brain function because all of our patients were malnourished and I could do grand rounds, and I could talk to colleagues about nutrition.
Dr. Will Van Derveer 03:47
That makes a lot of sense. You know, I guess it’s so obvious that people with eating disorders are going to have malnutrition and going to have deficiencies in micronutrients and macronutrients
Dr. James Greenblatt 03:57
It’s so obvious, but it’s been missed by the eating disorder community for many, many years, we got to embrace the concept of malnutrition and we’re not to use supplements, although in front of you is a malnourished, starving patient. So it’s slowly changing. But there’s still a lot of need for better integration of nutrition.
Keith Kurlander 04:20
I’m curious and maybe you can talk a little bit about your current clinical setting, and how you’re implementing these integrative techniques with eating disorder patients and how does it work in a more clinical setting? I think that’s really interesting too, for people to hear.
Dr. James Greenblatt 04:37
Sure. I mean, at this time, I’m the medical director, Chief Medical Officer at Walden behavioral care, which is an eating disorder continuum. So we have a hospital, residential day programs, evening programs, and those patients are quite medically ill and some psychiatrically compromised. And not everyone is embracing an integrative approach. My medical staff is trained in using nutrients and checking for vitamin levels. It’s more along the outpatient continuum. We’re looking more closely at some of the functional medicine testing, as well as some of the little more aggressive nutritional supplements.
Dr. Will Van Derveer 05:19
That makes sense. So it sounds like there’s probably more of a traditional and medical, more traditional anyway, on the inpatient side, and then you’re able to do a little more of the functional testing as people move through that spectrum.
Dr. James Greenblatt 05:34
Absolutely. But in the inpatient unit, part of the refeeding process is micronutrients, zinc and essential fatty acids are critical. Most of our patients are complaining of G.I. distress because of the diet and the malnutrition. So probiotics and digestive enzymes are pretty much given to every patient and I think we’re unique in that respect and at least acknowledging that there’s digestive problems in treatment starts in the hospital.
Keith Kurlander 06:06
In the eating disorder population when you’re taking a really integrative functional approach, what are you thinking about in terms of differential diagnosis, in terms of an expanded spectrum of root causes and what’s happening for these people, and how are you approaching your treatment plans with that framework?
Dr. James Greenblatt 06:28
Sure, I mean, it’s a complicated answer there. There’s different eating disorders, anorexia, bulimia and binge eating. I think most of us think of anorexia nervosa when we think of eating disorders, which is kind of low weight, malnourished, you know, body dysmorphia. And in those patients, there’s a large psychiatric comorbidity. So we’re worried about anxiety, OCD, depression, ADHD, and some statistics suggest 70-80% have trauma. So we’re dealing with significant psychiatric comorbidity. But I think one of most important things that are often missed are some of the medical comorbidities like celiac disease. There’s very high correlation between celiac disease and eating disorders as a cause, and as an effect. I believe every adolescent presenting with an eating disorder should be tested for celiac disease. And anybody with celiac disease, we should be careful monitoring for the onset of the eating disorder.
Keith Kurlander 07:29
You said something very interesting. You said celiac disease is a cause and as an effect. How is celiac disease an effect of an eating disorder?
Dr. James Greenblatt 07:37
Well, if we think of celiac disease as an autoimmune disorder, destroying the intestinal villi, you’re not absorbing nutrients. So zinc, folic, amino acids and my model of eating disorders such as anorexia is this malnourished mind. So there’s a 12 year old who has a higher need for zinc going through puberty and they have celiac disease and they’re not absorbing zinc. It’s kind of that clash if you play with the genetic vulnerability, that they’re in much higher risk for some of the eating disorder symptoms.
Keith Kurlander 08:11
Yeah, that makes a lot of sense.
Dr. Will Van Derveer 08:13
It’s really interesting.
Dr. James Greenblatt 08:14
In my model of eating disorders, which is off the path from traditional conditions really is any path that leads to malnutrition. We see it with anorexia and post bariatric surgery. We see it with celiac disease, and we see it with just restrictive eating.
Keith Kurlander 08:32
I think that leads into an interesting thing that Will and I were talking about when we were thinking what would be some really great questions to ask you. What do you do with somebody who has an eating disorder and they have a food allergy or food sensitivity, or many of them when we’re already working with people who are already struggling in their relationship with food and now we’re getting into elimination diets and things. How do you work with that?
Dr. James Greenblatt 09:00
Yeah, that’s a really great question. I mean, as an outpatient physician and integrative psychiatrist, I’m looking at diet as an important part of the treatment plan. With our patients with anorexia, particularly in the hospital, you have to be really careful recommending restriction of any food group as part of this illness to kind of obsess and hold on to that. And I can’t tell you how many patients I’ve seen where this illness was triggered by a physician recommending a restrictive diet, eliminating dairy or wheat, and then the next food group and then they’re eating very little. So we often have to ignore some of the food allergies to treat someone in the hospital. If somebody does have celiac, or some specific food allergies, we might be able to work into a meal plan. But you have to be really careful recommending restricting major food groups with patients who are struggling with a disorder of starvation.
Dr. Will Van Derveer 10:03
Right. It sort of brings up for me the bigger question about food sensitivities and elimination diets. I’ve seen so many patients over the years who come with a printout of their large list of foods that they quote unquote, can’t eat from another practitioner, and it’s 20 different foods. It brings up the question for me of how much bang for the buck there is when you have an obsessive, especially in the context of an anorexia and already with restricting. What would be your big message to practitioners out there who might make the mistake of missing the sensitivity in that patient when they’re making those recommendations?
Dr. James Greenblatt 10:49
I think with eating disorders, like most of our psychiatric disorders, you know, genetics and family history is important. So I think if a clinician who does have a practice of integrative or a naturopathic practice looking at food allergies as a family history of an eating disorder. And if you’re worried about the patient that you’re working with, I would be really cautious about making broad recommendations about eliminating all these foods. Again, I’ve seen it many, many times, someone who was struggling with food but not malnourished and requiring hospitalization. Taking one of these food allergy print-outs in over six months ending up in the hospital as they eliminate various foods.
Dr. Will Van Derveer 11:30
There’s another question that comes up from this area of the exploration, which is, can you tell us a little bit from your broad experience with eating disorders in particular anorexia? What are the common, I guess, do you see more broad deficiencies in micronutrients? You mentioned fatty acids and zinc and I’m curious, what are the common things that you would see in terms of deficiencies?
Dr. James Greenblatt 11:56
I believe those are the two most common. My theory is that, particularly the adolescence that is essentially as a deficiency, again, that clash of genetic vulnerability, puberty with a high need for zinc, and just zinc deficiency being common. So zinc to me is the most important and there’s actually research to support it; ignored by our medical colleagues, but research to support it as much research on zinc as we have for any psychrotrophic. So zinc to me is the most important and essential fatty acid and then amino acids. Again, most of these men and women with anorexia have been restricting for so long that I’ve found essential amino acids, essential fatty acids, and zinc in just core treatments that really will help somebody regardless of testing.
Keith Kurlander 12:53
How do you relate to more of the macros and food plans and what’s the perspective at your clinic and you’re holding in terms of helping people with different types of food issues and how to guide them on how to help them eat in a healthy way?
Dr. James Greenblatt 13:13
Yeah, I mean, they’re dieticians that are integral to the program, working with patients and helping them with a meal plan. Ideally, our goal is that patients are going to be able to choose food and not have a meal plan. But sometimes that structure is really important. The macronutrients are critical because so many of our patients are choosing foods that are low in fat, and not looking at a broader range of balanced meal plans. So our dietitians are working with the patients developing meal plans. And for the adolescents, working with the parents.
Keith Kurlander 13:49
And in terms of more holistically looking at psychotherapies, I know there’s some research out there that meaning-making and values and approaches with psychotherapy for eating disorders has been important to help people generate meaning in their life. What are you seeing over there in terms of psychotherapies that have been particularly useful?
Dr. James Greenblatt 14:14
Well, with anorexia, it’s been challenging because oftentimes we’re dealing with a distorted image. Many of the thoughts from our patients with anorexia are delusional, you know, almost a fixed false belief about weight and distorted body image. So oftentimes psychotherapy does not move the needle. It’s supportive, but it doesn’t kind of help. The kinds of therapy that has been shown to be somewhat helpful, there’s like DBT and CBT. And you mentioned the word meaning. I think so many of our patients with anorexia have this obsessive perfectionist personality. And then that often can be used for academic success and success in employment. But when it’s just focused on food and weight loss, it becomes destructive. So helping our patients find meaning in other areas of their life is critical for recovery.
Keith Kurlander 15:11
You also mentioned the comorbidity of trauma and some of the statistics there. Are you doing trauma therapies? Is that often recommended to many of these patients?
Dr. James Greenblatt 15:23
Yeah, I think a large percentage of our patients that end up in hospitals, or we might call treatment refractory are not getting better, typically trauma, would be the powerful variable that’s not getting addressed or why it would slow treatment down. So yes, absolutely. Trauma informed treatment, and trauma based therapies are often the most important part once we start nourishing the patient.
Dr. Will Van Derveer 15:50
I have another question for you, Dr. Greenblatt about, I want to go back for a second to the food eliminations and the specific diets. Just to clarify something. So if you have a patient with anorexia, who also has celiac disease, would you be more likely to not intervene with a gluten free diet until after some of the other recovery pieces are in place
Dr. James Greenblatt 16:18
For celiac disease, absolutely. We see it all the time. We would recommend to adhere to a strict gluten free diet. So for celiac disease, we can document and absolutely, because that would impair recovery and nutrient malfunction. It’s kind of big food allergy panels that are just hard to substantiate the clinical relevance as well as relating risk of eliminating diet.
Dr. Will Van Derveer 16:43
Right. That’s really helpful. Thanks.
Keith Kurlander 16:45
Yeah, along similar lines. I’m curious about what type of functional specialty lab testing are you looking at gut health and in these individuals, and what types of things do you see in this population with gut health and do you address that?
Dr. James Greenblatt 17:03
No, my practicing career is utilizing testing, functional medicine testing to make all my decisions. But with our patients with anorexia, there is actually much less testing because the malnutrition is so profound and global, that recommending amino acids, essential fatty acids and zinc and digestive enzymes and probiotics for three months might be sufficient before I even look at testing. You know, I like to look at MTHFR variants. A lot of times we see the TT variant of patients not getting better, so that is helpful. I look at organic acids for dysbiosis in the gut. But I don’t need to draw a lot of labs because I’m just assuming they’re malnourished. And I’d like to get some nutrients in them before we do a lot of testing, which is different than almost every other psychiatric illness I treat.
Dr. Will Van Derveer 17:57
Makes sense. And in regards to the amino acid deficiencies are you fond of the broad spectrum freeform amino acid, you know, the multi ingredient kind of amino acid approach or more for specific?
Dr. James Greenblatt 18:14
No. My go to for years, you know, across depression, fatigue and children with anorexia is the broad spectrum, you know, free form amino acids. It was a period where they took out tryptophan. And so there’s still some of the market that don’t have all the essential amino acids. Now, many do. But yeah, all the essential amino acids and some kind of powders are just easily absorbed. People feel better quickly. And that’s been a core part of our treatment. Absolutely.
Keith Kurlander 18:43
We returned back to earlier in this conversation, the different types of food disorders, maybe just starting with anorexia and binge eating. What are you looking for in terms of how the body’s been potentially injured between those two different disorders?
Dr. James Greenblatt 19:00
Sure, I mean, the anorexia, which is just a profound malnutrition, driven by rigid perfectionist thought. But bulimia is actually probably the most dangerous because patients are purging so we see electrolyte abnormalities, potassium can be dangerous and binge eating disorder, which is the most common. It’s actually more common than anorexia and bulimia combined, which now has a DSM five diagnosis. You know, the medical complications for those that tend to be overweight, tend to be the type two diabetes and blood pressure. But the binge eating, the complications tend to be more psychological kind of the shame, the humiliation and not really seeking out treatment. So there’s less kind of acute medical complications. Bulimia is dangerous and we see very significant abnormalities in patients that are purging.
Dr. Will Van Derveer 19:53
And with those electrolyte imbalances I’m sure you can see, you know, even more serious complications like cardiac arrhythmias and with the stomach acid, Barrett’s esophagus and a lot of different secondary medical issues.
Dr. James Greenblatt 20:11
Yeah, most people, you know, don’t realize I didn’t finish training and it’s like on the scale that our patients with eating disorders have the highest risk, highest mortality of any psychiatric illness and highest risk of suicide within psychiatric illness. So we have profound medical complications that increase mortality, as well as suicide.
Dr. Will Van Derveer 20:33
With the breadth of decades of clinical experience, how do you see the arc of recovery for someone with anorexia in terms of, you know, the prognosis and the length of treatment? Do you see people putting those kind of more obsessive perfectionist character traits into, for example, work and being able to put the interaction behind them, or do you see people more struggling over decades?
Dr. James Greenblatt 21:04
You know, there’s a cohort of both. It’s the model. And I think the most important thing we can do is treat these kids early, typically adolescent onset. And I believe there are models of prevention. So if we can treat it aggressively and treat it early, some of the nutritional supplements, as well as there’s something called FET family based therapy, helping the parents get more involved and monitor their kids as if they have a life threatening illness is probably the most important thing we can do. The longer someone has anorexia nervosa, the higher mortality rate goes up. So my world in the hospital, I’ve seen chronically ill patients that struggle with recovery 20-30 years and we’ve seen patients recover. I believe those that can embrace a more integrative functional model, meaning lifestyle and nutrition, can absolutely recover and then not relapse. Like substance abuse, eating disorders are kind of a chronic relapsing illness. And that relapse prevention model is lifestyle and nutrition.
Keith Kurlander 22:09
There’s the biological components to this and then the psychological. I’m curious to hear a little bit more about your thoughts on the psychological components of eating disorders. And at this point in all the time you’ve worked with this, what are you seeing in terms of some of these components?
Dr. James Greenblatt 22:29
Well, I mean, I think my career is focused on trying to get people away from thinking of the psychological because, you know, every 10 years, we had a new theory, you know, we blame the mother, then we blame the father and we blame the models, and nobody ever addressed the malnourished patient in front of us. So I think we really can’t blame anybody. It’s a clearly genetic vulnerability and an environmental insult. What we can do and what’s been the most effective psychological therapy have to do with the family based model, one for adolescence, and less research for adults, but helping the family system understand the role of eating, the role of relationships and struggles. Control can be the most important path to recovery on that psychological aspect.
Keith Kurlander 23:22
How was your work received in the eating disorder community where you’re really, you know, you’re pushing the needle forward on the biological components and addressing malnutrition in a new way. How have you been received?
Dr. James Greenblatt 23:34
Well, I think it was 2010 when I wrote the book on anorexia. It was 10 years ago, and I talked about zinc and fatty acids and many parents really appreciate it because nobody addressed it. And then a couple years later, you know, going to conferences and I started hearing people talk about essential fatty acids, and zinc. So things have changed and people are much more involved and understanding the role of malnutrition and with the rest of medicine changing, it’s hard to argue, you know, with some very simple concepts about less salad nutrients are important for our health.
Dr. Will Van Derveer 24:12
I mean, it sounds like your center is very forward thinking. And I’m just curious if are you aware of other centers that integrate so much of the micronutrients and, you know, the fatty acids and seeing this more comprehensive approach?
Dr. James Greenblatt 24:33
You know, I think that again, over these 10 years since we first started talking about more and more positions, internists and some psychiatrists are able to kind of appreciate the role of many of these nutrients. So they’re dabbling. I’m pretty excited that in the fall, we’ll be opening up a center an 82 bed facility, just on eating disorders, where the philosophy will be based on this integrative model, working with naturopaths, as well as some physicians on a much more integrative holistic model.
Keith Kurlander 25:09
That’s really exciting. Where’s that going to be?
Dr. James Greenblatt 25:11
The outside of Boston. In Massachusetts, it’ll be hospital level care and residential, but just an opportunity to provide some of the functional medicine testing, as well as a much more holistic program that’s challenging to do in a typical medical facility.
Keith Kurlander 25:29
We have some parents who listen to the show, I’m curious what you would tell them if they have a child who has an eating disorder and some tips and ways to think about their child having this disorder and how to help their child.
Dr. James Greenblatt 25:45
Well, this is going to be hard to hear for some parents to appreciate but probably the most important message I can share with you today and parents is my concern that a vegetarian or vegan diet, in preadolescents is one of the major causes for eating disorders. You know, I’ve seen it in my entire 20 years I do parent support groups. And one parent will say, my son or daughter started becoming a vegetarian. And then the next parent till everyone in the room to share that story. And we have research to support it. We have thousands of articles demonstrating that a vegan vegetarian diet has a higher risk of developing an eating disorder, slower rates of recovery, and much more likely to relapse. And for me, it just reflects a zinc deficiency that I was talking about earlier, because a higher need for zinc in puberty, vegan diet, which has little zinc is kind of that perfect storm. So the most important thing I can share is that there’s absolutely good research to be very cautious about your adolescence on a vegan diet. I think you can do it on a vegetarian diet with supervision and dietary consult. On a vegan diet, it is not adequate to get through puberty unless someone is aggressively, you know, supplementing. And certainly many people can have a healthy vegetarian vegan adolescent. But if you have a family history of an eating disorder, and I think it’s really important that parents aggressively supplement or work with a dietitian.
Keith Kurlander 27:23
I think that’s really, really insightful. You know, I think, actually, in a lot of the patients I’ve worked with not just eating disorder patients. I’ve seen issues with vegetarian and vegan diets in general and some of the mental health issues I’ve seen. Not always, but it’s really insightful to hear to just be cautious. If a child is doing that and if they’re doing it without supervision, then they don’t know what they’re doing and you’re obviously messing with the chemistry of your body at that point.
Dr. James Greenblatt 27:55
Yeah, there are early studies calling vegetarians, some international studies, and they developed an eating disorder like 12 to 18 months later. This was in the late 80s. We’re now seeing much more rapid, and six months later developing symptoms of distorted body image and poor digestion, restricting more and more.
Dr. Will Van Derveer 28:20
It’s interesting, it kind of brings up, for me, the question of the chicken or the egg and I guess what I’m hearing you say Dr. Greenblatt, is that the malnutrition from the vegan diet without supplementation at that age, where there’s such a high need, entering puberty, for zinc and the other micronutrients can actually be involved in the bringing forward of the disorder as opposed to being a symptom of the disorder.
Dr. James Greenblatt 28:50
Yes, it’s that kind of two way street. And again, I believe, it comes back to that genetic vulnerability. You know, I always tell a story here It can be 10 kids at camp that decide to be, you know, vegetarians. And one stops after two days, the next one three days, but one is going to just keep going and develop a serious eating disorder. Surely we’re going to find that individual has some genetic vulnerability to obsessive compulsive disorder, or eating disorders in the family.
Dr. Will Van Derveer 29:21
So it sounds like outside of the attention to the family history and kind of carefully watching the child who wants to be vegan, and then, hopefully counseling them about the need for supplementation like a multivitamin. Is that what you have in mind? If the child insists?
Dr. James Greenblatt 29:42
Yeah, one of the chapters in my book is, if your teen comes home or preteens, saying I’m going to be a vegetarian. And, absolutely. Multivitamins, they might have 10 milligrams of zinc, could be really helpful in preventing the onset of these disordered thoughts.
Keith Kurlander 30:01
Can you say a little bit more about a zinc deficiency and how that is related biochemically to this issue?
Dr. James Greenblatt 30:07
The chemistry is fascinating. But the simple version, if you starve an animal in the lab, you know, a monkey becomes zinc deficient. They’ll have many of the symptoms that you and I would see in our patients with anorexia. So, zinc is required for our taste buds. So most of our patients with anorexia have a lack of sense of taste. So food is not pleasurable. And zinc is also required for digestion. So to make acid in the stomach and all of our digestive enzymes are zinc dependent. So as you become zinc deficient, you don’t digest food, we get full very quickly and we get bloated, and then patients will say I don’t feel like eating and go on and on. And sleep disturbances are common. Zinc is required to make melatonin. So zinc just isn’t such a critical coping factor in so many of the chemical or neurochemical enzymes that look like the symptoms of anorexia nervosa.
Dr. Will Van Derveer 31:14
And one of the complaints that I’ve worked with a lot in my practice with supplementing people with zinc is the nausea that can come from a zinc supplement. I’m curious how you work with that in your practice.
Dr. James Greenblatt 31:26
Yeah, so doctors get a little too zealous and give too much zinc. So absolutely. It’s not high doses. It’s pretty low dose zinc, and it always should be after food. Yeah, on an empty stomach, someone’s going to get very nauseous and never take it again. And if they take it after food, it’s usually called.
Keith Kurlander 31:48
You mentioned a little bit about the prevalence of eating disorders. I’m curious about what’s happening over a number of decades now. Are we seeing an increase in eating disorders, a decrease in eating disorders?
Dr. James Greenblatt 32:01
Well, I think we’ve described eating disorders since the 1600s so it’s been around, but certainly the time that we’re keeping track of incidents, there certainly has been an increase in the major eating disorders. But if we flip the term around and talk about disordered eating, I think that those numbers are just astronomical. So we talked about 90% of college women on diets who don’t like their bodies, and so the body image issues, starting very young and continuing and the disordered eating, but there’s a new diet for every illness and disease. So as a culture, we’re obsessed with diet, and we have many variations of disordered eating from restricting to eating too much, but for those genetically vulnerable, it becomes a life threatening, you know, road to serious illness.
Keith Kurlander 33:01
Do you speculate on the biological side? Because the psychological side, we obviously don’t know what’s what, but are we seeing an increase in certain issues over decades now with low zinc or are you seeing anything that is pointing towards that?
Dr. James Greenblatt 33:19
Yeah, I mean when I started, we were treating adolescence, 16 and over, and now we’re treating 11 year olds, 10 year olds with classic symptoms of anorexia nervosa. So the age of onset is younger. And if we think about every year someone has the illness, higher mortality rate, so it is becoming more disabling. We’re seeing more males. We’re seeing across all races and ethnic groups, socio economic groups. So the research is showing an increased incidence and clinically we’re seeing dramatic increases and lower ages of onset
Dr. Will Van Derveer 34:00
One of the questions that comes up for me around that of earlier onset is the issue of social media and apps like Snapchat that adolescents are using quite a bit, like Instagram. These platforms where you show your, quote unquote, best angle of your picture that you take of yourself and you don’t show the way you look every day, let’s say. I’m curious what your thoughts are about the role of this body dysmorphia epidemic. And I mean, 90% of college women are really so intense to hear that. Do you think that there’s a significant connection there between kind of addiction to social media and this increased prevalence?
Dr. James Greenblatt 34:52
Absolutely. There’s research to support it. Many have major psychiatric illnesses, depression, suicide risk for one, but for the community, there’s been these websites before. Some of the social media stuff about helping people lose weight, helping people hide their anorexia from the parents, and then the kind of social media support and comparison absolutely fuels this illness. You know, we described it as the gasoline on the fire that sometimes can tragically precipitate.
Dr. Will Van Derveer 35:32
I’m wondering how you would counsel, just as a parent with a teenage daughter myself and thinking about some of the battles around using those platforms for communication and as a psychiatrist myself, knowing the potential risks there. How do you talk to the parents about this?
Dr. James Greenblatt 35:54
You know, it’s hard I think I’ve been sharing with you the parents that remove the phone or restrict phones whenever you have a kid in school who has one. That does not work. And so we’re dealing with the reality. And I think it’s a token of communication. It’s limiting. There’s limits around, you know, X and Y being done first. But we can’t control this complete onset of social media. So it’s really kind of balancing it with a healthy relationship, either around food or body image.
Keith Kurlander 36:32
Where do you see the future of eating disorder treatment and what type of, are there any novel approaches you have your eye on? Or where do you think we’re headed? Is it just really moving more of this integrative methodology into the mainstream?
Dr. James Greenblatt 36:50
Yeah, I think 10 years ago, we were talking about taking a supplement, people looked at me cross eyed. Now it’s easy to talk about in many clinics and problems of doing it. So I think the nutritional pieces are moving in the right direction. I think the new areas that we need more work on are some of the infections like pandas. So these infections create some kind of autoimmune disorder with eating, restricting the major component. So I think there’s an autoimmune component that we need to do better to address. There are no current medications that we have for anorexia nervosa. A lot of people prescribe a lot of medicines, but there’s no FDA approved medicines. So I believe we’ll be able to kind of look at a role of nutrients and maybe medications to address some of the more life threatening illnesses.
Keith Kurlander 37:45
What else would you say, as we wrap up here, to all the listeners in the world right now listening, what would you really want them to take away about eating disorders and you have a lot more to say about integrative psychiatry. So what are some of the takeaways you would want them to hear?
Dr. James Greenblatt 38:04
I think it’s really being cautious of a particular approach because the names appeal, which my medical colleagues and psychiatric colleagues have kind of ran away from. So it’s appealing that there is not a lot of medical support. It’s dieticians and counselors. And so the biological substrate or foundation has been ignored. And I focus on that not to neglect the dietary or the psychological, but it has to be part of the treatment. So I just urge parents and clinicians to understand that there are three legs to the stool, there’s the psychological illness, the nutritional support, as well as understanding where the role of medicines or other comorbid psychiatric illnesses fit in.
Dr. Will Van Derveer 38:56
I just want to thank you for the stand that you’ve taken and you keep taking for nutrition as a key element of brain health. You know, it’s such a no brainer when we talk about it that way, it sounds so obvious. But I totally agree with you that in the psychiatric community, we don’t think about it enough. So the work that you’re doing, I think is revolutionary. And I’m really excited for your new center to open up so that more people can be served in this way.
Dr. James Greenblatt 39:29
Great. Thank you. I think our medical colleagues avoided eating disorders because, you know, we don’t have a pill. And it’s challenging. And so we ran from that. And I think if clinicians understood that nutrition, food is medicine, then nutrition can provide relief, that hopefully more doctors will be involved in the care of our patients with eating disorders.
Keith Kurlander 39:55
Yeah, I love the statement food is medicine. I think that’s such a powerful thing for providers to hear and also for patients to recognize that some of their best medicine is in the supermarket or growing in the fields around them. It’s a powerful message. Well, Dr. Greenblatt, thank you so much for coming on the show and sharing all your wisdom and all the decades you’ve devoted to moving the field forward. You’ve done a lot there for everyone.
Dr. James Greenblatt 40:25
Great. Thank you for having me. I appreciate the opportunity.
Dr. Will Van Derveer 40:30
Well, it’s such an informative conversation, I learned a lot of new things from Dr. Greenblatt. I want to thank him for being on the show. And you know, oftentimes we think about eating disorders, causing significant nutritional deficiencies. And that is part of the problem, but really thinking now more broadly about nutritional deficiencies that can actually spark the beginning of an eating disorder is a whole new way of thinking for me, so I hope that you enjoyed that episode. It was very interesting for us. And if you enjoy learning about the lesser known root causes of mental illness, and you enjoy listening to this podcast, please leave us a review. This is how others can easily find us. And if you would like to get more information about these topics and you’d like to join our community, please go to email dot psychiatry Institute dot com. That’s EMAIL-dot-psychiatryInstitute, all one word, dot-com (email.psychiatryinstitute.com) and enter your email there and we will then be able to send you our newsletters, and videos to keep you up to date on these fascinating topics. We look forward to connecting with you again on the next episode of The Higher Practice Podcast where we explore what it takes to achieve optimal mental health.