Half a day.
That’s the amount of time future doctors spend learning about eating disorders over their four years in medical school.
According to Christina Tortolani, Ph.D., associate professor and program director of Bryant’s Doctor of Clinical Psychology program, eating disorders are the second most lethal of psychiatric illnesses — trailing behind opiate addiction. While the National Association of Anorexia Nervosa and Associated Disorders reports that an estimated 28 million Americans will have an eating disorder in their lifetime, many of these brain-based illnesses develop in adolescence — making it the third most common chronic medical condition amongst youth.
“People think about eating disorders as something that happens infrequently, but they occur more often than the public believes,” says Tortolani, noting that these disorders range from restrictive eating to binging and purging.
As a licensed psychologist and eating disorder specialist, Tortolani has spent 15 years working with families and youth and 10 years studying the dissemination and implementation of evidence-based practices for pediatric patients with eating disorders across treatment settings. Collaborating with graduate students, medical residents, clinicians, and educators, she’s heard the same message across disciplines: “We are not getting trained in eating disorders, we don't understand them, and therefore, we don’t feel comfortable caring for these patients.”
“It became my mission to change that,” Tortolani says.
Understanding eating disorders
A pediatrician or primary care physician tends to be the most trusted person in our circle of providers.
“When your child is sick with a fever, you call your pediatrician because they know what to do next. That gets flipped on its head with eating disorders because pediatricians often inadvertently downplay or misdiagnose the symptoms of eating disorders. As a result of a lack of education and comfort, diagnosis and treatment can often be delayed; this has dire consequences as the best outcomes are associated with early, intensive intervention,” Tortolani says.
Eating disorders are the result of a "perfect storm" of many factors, including biological predisposition, personality, temperament, trauma, and sociocultural components. Warning signs may include weight changes, falling off one's growth curve, compulsive exercise, purging behaviors (vomiting, diet pills, and laxatives), and restrictive eating behaviors — such as cutting out carbohydrates and fats.
“Physiologically, eating disorders impact the body head to toe and can lead to dangerous medical complications such as a low heart rate and blood pressure shifts,” Tortolani says. “These are signs of the effects of starvation on the brain and body.”
Tortolani notes that there's a misunderstanding that eating disorders typically impact white adolescent females. On the contrary, eating disorders touch every demographic, race, ethnicity, gender, and sexual orientation.
“Unfortunately, if you're looking for an eating disorder within only one group, you will be missing it in others,” Tortolani says. “We all known that pediatricians and other healthcare providers have their patient’s best interests at heart, and providing education on eating disorders empowers them to meet that goal of optimizing health and wellness."
Taking action
Adolescents may try protecting their eating disorder by keeping it secret, which is why parents are usually blindsided by the illness’s onset. Tortolani adds that youth may not be forthcoming about their eating disorder because they like it and don’t believe it's harming them.
“As a pediatrician, don't wait for the adolescent to be ready for treatment,” Tortolani says. “There are effective, evidence-based treatments available to empower parents to help re-feed their child.”
She suggests providers, as well as parents, take advantage of free, online resources, including Families Empowering and Supporting the Treatment of Eating Disorders, and read memoirs like Brave Girl Eating, which was written by a mother who helped her child reach recovery.
“A lot of parents carry blame and shame either for missing the illness’s onset or for not understanding it and then feeling overwhelmed as to how to help their child,” Tortolani says. “Parents are the number one agent of change for their children reaching recovery.”
Planning for the future
Working with families and youth on eating disorder recovery, Tortolani gravitates toward family-based treatment — an outpatient behavioral approach focused on weight restoration and normalization of eating. Through National Institute of Mental Health grant-funded work led by the University of Pittsburgh’s Andrea Goldschmidt, Ph.D., Tortolani has brought this treatment into home-based settings, which give caregivers the opportunity to learn treatment strategies to help their child.
Shifting attitudes toward eating disorders and building provider confidence will take time; however, Tortolani, alongside Goldschmidt, and Dori Steinberg, Ph.D., vice president of research at Equip Health, are already taking action.
This summer, the three academics hosted a Research Optimization for Addressing Eating Disorders Management in Adolescent Primary Care (ROADMAP) conference in Providence. Over two days, psychologists, primary care doctors, nurse practitioners, physician assistants, social workers, nutritionists, and people with lived experience from all over the country gathered to understand the state of the field, including research and clinical gaps and priorities. The conference covered four major areas relating to pediatric eating disorders in primary care: screener development and implementation; optimizing the pediatrician’s role on the treatment team; developing training and education curricula for pediatricians; and recognizing and managing eating disorders in diverse populations.
While attendees mapped out the next 10 to 20 years of work needed in this area to provide guidance for primary care providers, one idea became most apparent: partnership.
“One of my mentors taught me early on that you cannot treat eating disorders alone — it takes a village,” Tortolani says, noting that funding for the conference was made possible in part by a grant from the Agency for Healthcare Research and Quality*, Equip, Be Collaborative Care, and Every Page Foundation. “We get the best outcomes for patients when we bring together a knowledgeable, compassionate, and unified interdisciplinary team and take a collaborative approach."
*The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.
