Eating disorders affect people year-round — in the U.S. alone, about 5.5 million people will develop an eating disorder and over 10,000 will die from one in one year’s time — but the holiday season can be particularly hard for many. With the stress of family gatherings, food-centric events, travel, social pressures, and more, the winter holidays offer up challenge after challenge to people who may be struggling, and the families supporting them.
As a healthcare professional, your guidance can make a huge difference for these families in making it through the holiday season.
Contrary to pervasive myths, lasting recovery is possible for all people with eating disorders. By providing support during this fraught season, you can help guide your patients and their families toward the treatment they may need or help them protect the recovery they worked so hard to achieve.
So how can you best support patients with eating disorders during the holiday season? Tanna Vayon, MPAS, PA-C, a Physician Assistant at Equip, answered some of the most common questions providers have on this important topic.
Why is it so important to look out for signs of eating disorders during the holidays?
It’s vital to increase awareness around screening for eating disorders during the holiday season, as the level of eating disorder behaviors are often heightened. The holidays involve stressful circumstances for many people, regardless of whether they have an underlying eating disorder — and for those who are living with one, these stressors can cause an uptick in behaviors. Family members can come with unwanted anxieties, disagreements, and triggers of past trauma, and a lack of control around foods and the timing of family meals can be detrimental to a patient with an eating disorder.
Patients might attempt to “numb out” the anxieties that come with family and counteract their perceived lack of control around food with compensatory mechanisms. These include, but are not limited to food restriction, purge behaviors (vomiting, laxatives, diuretics), overexercising, and more. The medical complications are vast when it comes to these behaviors. They can lead to dangerous electrolyte imbalances (hypokalemia, hypophosphatemia, hypoglycemia, metabolic alkalosis), cardiovascular compromise (bradycardia, arrhythmias), vital sign abnormalities (hypotension, orthostatic tachycardia, hypothermia), and acute, rapid weight loss.
Often, medical providers are the first to bring eating disorders to the attention of family members. The holidays are a time where pediatric patients are out of school, and have time to follow up with their primary care providers. It's the job of the PCP to screen for eating disorders and their related medical complications. It’s also their job to empower families to address the underlying disorder and seek treatment for their loved one.
If my patients are in the midst of eating disorder treatment, should I advise that they sit out their holiday plans this year? If not, what guidelines should I provide for managing treatment while participating in holiday events?
Each patient in eating disorder treatment is unique, and the recommendation you make on this decision will need to be individualized. Some questions to think about when discussing restrictions on holiday plans may include:
- Will the family be traveling? If the patient is struggling to complete meals at home, it may be best to avoid an increased risk of food restriction in an unfamiliar environment.
- Will there be increased physical activity in their holiday plans? Some patients who need weight restoration are placed on complete activity restrictions, and shouldn’t be engaging in added physical activity (for now).
- Is the patient on a meal plan consisting of scheduled meals and snacks? Most patients in eating disorder recovery are on a scheduled 3 meals and 2-3 snack plan to provide adequate nutritional rehabilitation. Large holiday gatherings where one meal is planned the entire day is typically not ideal for a recovering patient.
If the patient will be participating in holiday plans as usual, it might be beneficial to recommend adding some precautions. This might include having family members plate and supervise meals and snacks, monitoring the patient before and after meals to guarantee the patient isn’t engaging in eating disorder behaviors like purging or compulsive exercise, and checking in on the patient's emotional status to ask if they need additional support during or after family gatherings.
This time of year, it’s common for people to talk a lot about weight loss and gain. Should I talk to my patient about holiday weight gain and/or New Year’s resolutions around weight? If so, how?
This is an excellent question and a valid concern for many medical providers. Before you answer, I would suggest you assess your own internal biases and stigma around weight. Although many medical providers are educated on the “dangers” of weight gain and the “health risks” associated with fat, the medical details of these claims are rarely discussed or proven. In fact, research shows that weight stigma and shame around weight gain worsens an individual’s health through increased cortisol production, elevated blood pressures, weight cycling, and fears of seeking medical attention at the risk of weight shame.
In my experience, it is not beneficial to address holiday weight gain or encourage New Year’s resolutions around diet or weight loss. When I discuss New Year’s with patients, I tend to ask questions like:
What are your joy goals for this coming year?
What core value do you have that you want to live out more this coming year?
What was one positive experience you had this previous year that you want to bring into the next year?
Goals that are directly related to an individual’s positive attributes will help them establish higher self-esteem and encourage a more positive trajectory for the new year.
How do I know when to refer a patient to treatment for an eating disorder? If I’m worried, can I wait until after the holidays to get them help?
The first step to establishing the urgent vs emergent need for eating disorder treatment depends on the medical status of a patient. We use the following criteria to determine if a patient is in need of emergent hospitalization for medical stabilization:
- Vital sign instability
- Heart rate < 50 while awake, <45 while asleep (bradycardia)
- Blood pressure < 90/45 (hypotension)
- Temperature < 35.6 degrees Celsius or 96 degrees Fahrenheit (hypothermia)
- An increase of > 20 beats per minute in heart rate upon standing, or a decrease of 20 mmHg (systolic) or 10 mmHg (diastolic) blood pressure upon standing
- Body weight less than 75% of median BMI for age and sex
- Electrolyte abnormalities
- Potassium <3.5 (hypokalemia)
- Phosphorus < 3.0 (hypophosphatemia)
- Magnesium < 1.8 (hypomagnesemia)
- Sodium < ~135 (hyponatremia), which may be sign of water loading
- EKG abnormalities
- Sinus bradycardia (HR < 50 while awake)
- Prolonged QTc interval (> 450 ms)
- Other acute complication of malnutrition
- Examples: pancreatitis, heart failure, kidney failure, syncope, severe dehydration, GI bleed
- Acute food refusal (<500 kcal consumed per day for over 3 days)
If your patient meets any of this criteria, I would recommend you send them to the nearest emergency room (preferably one with eating disorder specialists) for further evaluation.
For your patients who do not meet any of these criteria, the decision about whether to refer them for treatment is ultimately up to you as their provider. However, I would recommend starting treatment as soon as possible and not waiting until the end of the holidays. The physical state of an individual facing malnutrition can deteriorate rapidly. A patient can have stable vital signs one day and a heart rate under 40 beats the next. I’ve seen it happen.
I sometimes use the analogy of a patient who has an acute infection: If you had a patient with bacterial pneumonia present at your clinic, would you send them home without treatment and expect their infection to resolve by the end of the holidays? I would hope not! Rather, you would probably think about the most common bacterial etiologies, consider the antimicrobial resistances in their area, and ultimately start your patient on an immediate course of antibiotics with ER instructions at the ready.
A patient with an underlying eating disorder and malnutrition is no different. Any delay in treatment can be detrimental. I would advise you to sit the patient and family members down to express your concerns, and reach out to local treatment centers for support. Eating disorders never take a holiday, so treatment shouldn’t either.