Ask the Expert: What You Need to Know About Eating Disorders

Angela GuardaEating disorders are serious complex illnesses that stem from a mix of biological, psychological and social factors. The Eating Disorders Program at Johns Hopkins, established in 1976, offers comprehensive evaluation, treatment planning and ongoing care for patients with eating disorders. It was the first behavioral specialty program for eating disorders in the United States.

Located at The Johns Hopkins Hospital, the program aims to restore the functional capacity, normalize the eating patterns and improve the quality of life of its patients.

Dr. Angela Guarda, Director of the Johns Hopkins Eating Disorders Program since 1997, is a Board Certified Psychiatrist and Associate Professor at the Johns Hopkins School of Medicine. She talks about what makes the Eating Disorders Program at Johns Hopkins stand out and what we know about eating disorders today in this edition of Ask the Expert.

To make an appointment with the Eating Disorders Program, call 410-955-3863 or visit for more information.


What separates the program at Johns Hopkins from any other program or center that treats similar disorders?

Several characteristics set us apart.

First we are located within The Johns Hopkins Hospital and have access to experts in all fields of medicine, allowing us to treat patients with a wide range of concurrent medical or psychiatric conditions and disease severity, including those patients with unusual or atypical presentations. We additionally treat both adolescents and adults and both males and females.

Second, the Hopkins Program has superior rates of weight gain and weight restoration for anorexia nervosa that are nearly double those reported by most programs. As described in a recent study currently published online* in the International Journal of Eating Disorders, our average inpatient rate of weight gain for anorexia nervosa is 1.98 kg (4.4 lbs) per week and the majority of our patients leave the program weight restored to a BMI of 19 or above. This is very important as weight restoration is necessary for recovery from anorexia nervosa.

Third, our focus is on much more than weight gain -- we provide a comprehensive continuum of care, including Outpatient, Partial Hospitalization and Inpatient Programs focused on relapse prevention and long term recovery. Our goal is to help our patients return to a full life and healthy function and to reach their potential. Patients requiring hospital-based care are admitted to the Inpatient Program and once stable, transition to the Partial Hospitalization Program. While in hospital-based treatment, the multidisciplinary psychiatrist-led team meets daily with each patient to assess progress and individually tailor treatment plans.

How does the program help its patients?

In the Inpatient Program, the initial approach is to help patients change their behavior, block urges to engage in familiar unhealthy habits and eat a wide range of foods of differing calorie densities in healthy combinations and amounts. Once patients progress to the Partial Hospitalization Program, the focus shifts to practicing social eating skills in real-world settings—eating in the cafeteria, in restaurants, with family, preparing meals, grocery shopping —and mastering relapse prevention tools that will help maintain recovery once patients return home. The Partial Program has affiliated, supervised housing and can accommodate patients from out of state.

In treating anorexia nervosa, weight restoration to a normal, healthy weight and eating a wide range of foods are both important to recovery. Due to limited insurance coverage and the high cost of inpatient treatment, severely underweight patients may not be able to reach this goal if they are gaining weight too slowly or do not receive help in broadening their food repertoire. There is no evidence that partial weight restoration improves long-term prognosis in anorexia and we have shown that when carefully monitored, a faster rate of weight restoration is not associated with elevated medical risk of refeeding syndrome.

What are some factors that increase risk for eating disorders?

We know that genetic vulnerability to eating disorders is significant, especially in the case of anorexia nervosa, and that having a first-degree relative with the disorder increases risk tenfold.

Ninety percent of cases of anorexia and bulimia occur in females. It is likely that estrogen somehow facilitates onset of the disorder in vulnerable individuals, as it is rare to see these disorders before early puberty, when estrogen levels start to rise.

Dieting appears to increase risk for eating disorders, as can stressors or anything that causes the first 5 to 10 pounds of weight loss. For example, it is not unusual for anorexia to develop following a bad bout of gastroenteritis or mononucleosis in a teenage girl.

Are there any exact causes of eating disorders? 

We don’t know what the exact causes of eating disorders are, but we believe a combination of genetic vulnerability and environmental stressors interact to trigger their onset. Once an eating disorder develops, however, other factors may come into play that maintain disordered eating much like in substance dependence, where the original reasons for taking the substance become overshadowed by physical dependence and habit as the disorder advances.

Have there been any recent findings in research that have led to advancements or changes in treatment in the program in the last few years?

The most important advance in the treatment of anorexia nervosa has been the recognition that family therapy is the best intervention for adolescent anorexia nervosa. In particular, this approach focuses on helping parents re-feed their child, rather than searching for root causes or explanations for his or her behavior. For bulimia, cognitive behavioral therapy remains the best approach. For severely ill patients who do not respond to outpatient interventions, inpatient admission to a behavioral specialty unit, such as the one at Johns Hopkins, can be lifesaving. Anorexia nervosa in particular has the highest lethality of any psychiatric condition, yet full recovery is always possible.

How will someone know if he or she needs treatment for an eating disorder?

Once an eating disorder is impairing physical or psychological health or social function, it is time to seek professional help. Typical physical signs are loss of periods, cold intolerance, feeling faint or gastrointestinal complaints. Psychological signs can include depressed mood, anxiety, poor concentration, and a consuming preoccupation with food and weight/shape. Social consequences include avoiding social meals and activities that involve food, due to anxiety about either overeating or undereating, along with others commenting on one’s eating behavior.

As an issue that carries psychological consequences, what are some of the most important things for patients to keep in mind as they go through the treatment process?

Ambivalence toward treatment is typical of both anorexia nervosa and bulimia, especially treatment that focuses on normalizing eating behavior, yet behavior change is necessary for recovery. This is a disorder that, in a sense, you act yourself into, and you cannot talk yourself out of it. Talk therapy alone may help you understand your eating disorder, but only changing your behavior and practicing healthy eating will correct the thoughts and feelings that sustain disordered eating over time.

What is considered a full recovery for eating disorder patients?

A full recovery constitutes eating a wide range of foods at regular meals and in social settings, and not being continuously preoccupied with thoughts of food and weight. If underweight, this also means reaching a healthy weight, as starvation maintains anorectic thinking patterns and behaviors.



*Refeeding and weight restoration outcomes in anorexia nervosa: Challenging current guidelines. Redgrave GW, Coughlin JW, Schreyer CC, Martin LM, Leonpacher AK, Seide M, Verdi AM, Pletch A, Guarda AS. Int J Eat Disord. 2015 Jan 27. doi: 10.1002/eat.22390. [Epub ahead of print] PMID: 25625572 [PubMed - as supplied by publisher]


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{ 4 comments… read them below or add one }


M March 4, 2015 at 11:32 pm

What do you think about the fact that the hospital's wellness program focuses so much on weight loss instead of actual health. With BMI and waist circumferance screenings and weight watchers and innergy programs. Also less caloric beverages around campus?


Angela Guarda MD March 5, 2015 at 12:53 pm

Obesity and related medical illness are a major epidemic at present. Educational public health interventions to help individuals make life style changes in diet and exercise associated with long term weight maintenance or gradual weight loss are important. Healthy weight loss is associated with improved health indicators in obesity. Overall, I welcome the changes and educational campaign we are seeing around campus -- including the posters about sugary beverages and limits on caloric soda sales. There is strong data to support the link between consumption of large portions of sugary beverages and obesity.


C March 4, 2015 at 2:38 pm

One of my colleagues is anorexic as she both restricts and purges on a daily basis. She's extremely thin and hides the extent of her thinness by wearing loose clothing. If she eats something during a holiday or other party at work, she will purge it within 30 minutes in the ladies room. I have chosen not to intervene as this is her choice to do this. I imagine it is very similar to addiction in that the person has to want to change. I don't think she views it as a problem. I see it as very unhealthy. What is an observer supposed to do?


Angela Guarda MD March 4, 2015 at 3:52 pm

You are right in likening eating disorders to addiction as they are both motivated behavioral disorders. Although choice is involved it may not be a totally free choice. In anorexia nervosa, patients feel compelled to continue doing today what they did yesterday. As with addiction, most patients eventually seek treatment under pressure from those around them and motivation for recovery tends to improve as they progress in treatment. Taking your colleague aside, supportively but frankly describing the behaviors you have observed, expressing concern and recommending she seek treatment at a local eating disorders program will help her get one step closer to seeking care.


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