On a recent trip to the West coast, I met child psychiatrist Huey Merchant, M.D, who went from working at a residential eating disorders treatment center in the Los Angeles area to a non-profit mental health facility in the Antelope Valley, a community at the western tip of the Mojave Desert due north of Los Angeles.
Dr. Merchant had many interesting insights into adolescents, their parents, body image and eating disorders issues, and I was struck by how different the patient populations at his two jobs were from each other.
At the residential eating disorders treatment center, where he worked from 2003 to 2005, patients were primarily white, upper-middle class, some of them with health insurance, and some whose families were paying in cash. "They were very savvy with the pro-ana web sites, and the images they were looking at were People magazine, pop culture images," Dr. Merchant recalled. The center was a step- down treatment facility for adolescents who had been discharged from the hospital; most of the patients he saw were battling anorexia because, he notes, "that's what met the criteria for them to be hospitalized."
The mental health facility where Dr. Merchant now works as a staff child psychiatrist has contracts with Los Angeles County. There, he sees patients from a lower socioeconomic class, the majority of whom are black and Latino. Since he is bilingual, he works with many families of Spanish-speaking parents and bilingual children. As an African-American, many black clients request him as their doctor.
Dr. Merchant told me that he sees very little anorexia among these patients, but he does treat many patients whose secondary diagnosis is obesity. Of the eating-disordered patients he does see, the majority engage in binge eating and purging. Dr. Merchant finds himself ordering lipid panels much more often than most child psychiatrists tend to do, in order to check the cholesterol of even very young patients. "There's more of an ongoing discussion about what healthy weight is," he said, adding, "in a way, my job has become more about psycho-education." Dr. Merchant conducts a lot of non-judgmental, "how-can-you-be-more-healthy?" kinds of conversations. "I've referred many people to a nutritionist to talk about weight issues, healthier choices, and how to build exercise into their life," he says.
Unlike the upper-middle class families he treated in Los Angeles, however, here, when obesity is an issue, the adolescents and their families often don't see the patient's weight as a problem. Among patients with attention deficit hyperactivity disorder (ADHD, fairly common among his patients), when the subject of medication arises, he will often meet with reluctance among parents who are concerned about the possibility that their overweight child will lose his or her appetite. "It's not that parents don't want their child to be healthy, but what is considered a healthy weight and healthy eating habits is different for many of them. Some ‘healthy' foods and cooking are viewed as being a lot more expensive, and a lot harder to do with busy schedules and financial considerations," Dr. Merchant explains. "Just today I saw a patient with a BMI of 29.8. I tried to explain, without being triggering, how this is not within the normal [weight] range, and ways to be healthier."
When he does encounter eating problems, says Dr. Merchant, most often it is a form of EDNOS [Eating Disorders Not Otherwise Specified]. Some patients might restrict occasionally, but not to the point where they are underweight. Or they might binge eat but not purge; others are into cutting, burning (a self-harming behavior involving actual flame, heated objects, or erasers used to inflict pain), or purging, to the point where they "kind of get addicted" to those behaviors as a type of coping mechanism.
Dr. Merchant's experience in the Antelope Valley is interesting in the light of the "Western contagion effect," that has been described by researchers. Studies have shown that even in cultures as remote as the Fiji Islands, when western television programs and popular culture begin to take hold of local imaginations, the incidence of eating disorders rises. But Dr. Merchant points out that even within the U.S., there are regions-his practice area, and the Louisiana culture of his mother's side of the family, for example-where beauty ideals are different from mainstream America. "They're very acculturated and western," he explains, "but their images of beauty aren't the same. Having some ‘meat on your bones' is what's beautiful." Those patients who do binge and purge, he notes, "want to weigh less," but their idea of "thin" is not the same as say, the Hollywood or West Los Angeles idea of thin.
As a side note, Dr. Merchant expresses the concern that in an era when doctors are seeing growing number of patients battling obesity, the underlying psychological causes might be getting short shrift. "Appetite can be a symptom of a lot of different things," he explains. When a severely underweight patient comes in, it "raises the red flag," he says, and it's more likely that psychological counseling will be part of the treatment. Overweight patients, on the other hand, whose parents are often overweight as well, are more apt to be considered genetically prone to overweight, or simply following in the unhealthy eating patterns of their parents. They are less likely to be asked about a variety of possible underlying causes: body image; their relationship with food; other disordered behaviors such as restricting, purging, or cutting, or mood disorders such as anxiety and depression. Dr. Merchant would like to see mental health practitioners make it a habit of asking patients about these practices in a non-judgmental way.
Marcia Herrin and Nancy Matsumoto are co-authors of The Parent's Guide to Eating Disorders. Marcia is the author of Nutrition Counseling in the Treatment of Eating Disorders