In recent years eating disorder occurrence has dramatically increased in teens and young adults. In this interview with Dr. Douglas S. Kalman PhD, RD, FACN, FISSN and Dr. Susan J. Hewlings, PhD, RD, we discuss the crucial importance of supporting eating disorder treatment through proper nutrition and, if necessary, adequate supplementation to fill in nutritional gaps. Plus, we examine the targeting of the supplement industry in proposed and already enacted state bans on dietary supplement sales to people under the age of 18 and the supposed connection of teen supplement use and the occurrence of eating disorders.
Bio: Dr. Susan J. Hewlings, PhD, RD, serves as the Senior Vice President of Scientific Affairs at Radicle Science and is a Co-Founder of Substantiation Sciences. With a lifetime dedication to health and fitness, Dr. Hewlings brings over two decades of extensive experience in research, teaching, and medical writing in nutrition, sports nutrition, and scientific consulting for both the dietary supplement and medical industries. Her academic achievements include a PhD in Nutrition, an MS in Exercise Physiology, and a BS in Nutrition from Florida State University. She is a registered dietitian and completed a research fellowship in protein metabolism at the University of Texas Medical Branch, as well as earning a graduate certificate in cannabis science from the University of Vermont Medical School.
With over a decade of providing scientific and nutritional expertise for various industries including dietary supplements, food, beverage, and companion animal nutrition, Dr. Hewlings has been instrumental in bridging the gap between science and product development, marketing, and sales for numerous leading brands in the supplement industry. She has held faculty positions at Stetson University, University of Central Florida College of Medicine, and Central Michigan University. Dr. Hewlings has numerous publications in peer-reviewed journals, trade journals and a variety of media.
Outside her professional endeavors, Dr. Hewlings is the founder and director of a non-profit 501c3 animal rescue, The ARF Shack Inc. Susan lives in the Florida Keys and is a distance runner by heart, but also enjoys aerial arts, weightlifting, yoga and paddleboarding with her dogs.
Bio: Douglas S. Kalman currently serves as a Clinical Associate Professor in the Nutrition Department within the Dr. Kiran C. Patel College of Osteopathic Medicine at Nova Southeastern University in Fort Lauderdale Florida. Dr. Kalman has taught undergraduate and graduate courses at NSU and at other institutions (FAU, FIU, NYU, CW Post,NYCC). Historically, Dr. Kalman was a co-founder of the International Society of Sports Nutrition (ISSN).
Most recently, Dr. Kalman served as the Senior Vice President of Scientific and Regulatory Affairs for the trade association, The Natural Products Association (NPA). Earlier in his career, Dr. Kalman was the VP of Scientific Affairs for Nutrasource, a nutrition-centric Contract Research & Service Organization. He has worked six Olympic games and with a multitude of teams and individuals on the collegiate and professional sport levels. Dr. Kalman has been involved in over 400 clinical trials and projects within the food/beverage/dietary supplement and pharmaceutical industries. He has published over 100 peer-reviewed manuscripts, more than 100 abstracts/poster sessions, and has authored or co-authored five academic textbooks. Outside of his love for the field of nutrition and health, Dr. Kalman enjoys time with his family, exercising, and in being of service to others.
- Can you tell us a little bit about yourself and your professional background?
Dr. Kalman: Thank you, I am a Registered Dietitian by training and by choice. My higher-level education has focused on clinical nutrition, research and applied nutrition. Currently, I am a Clinical Associate Professor at Nova Southeastern University in the Dr. Kiran C. Patel College of Osteopathic Medicine. I am also a partner in a consultancy, Substantiation Sciences. Over the years I have worked in clinical nutrition, research, public health, education, advocacy and other related areas. I have been blessed to work with professional and Olympic athletes as well as collegiate athletes for more than 20 years. As a co-founder of The International Society of Sports Nutrition, it has been my pleasure to help support continuing education and growth for the field of applied human sports nutrition.
Dr. Hewlings: I have a PhD in Nutrition and conducted an eating disorder prevention program as my dissertation topic. I had a practice for 9 years where I specialized in treating individuals with eating disorders. I have received specialty training in eating disorders counseling and completed an internship at The Renfrew Center in Philadelphia. I have taught courses in Eating Disorders and have written and spoke about the issue for over 20 years.
- What role do you think nutrition – diet and supplementation – can have in the treatment of eating disorders?
Dr. Kalman: Diet is what you eat, we have to think of the definition of diet when discussing it. I prefer to utilize the phrase “dietary style” versus pigeonholing the word. For many the word “diet” is a trigger, this we must undo. Eating disorders are defined as mental health disorders and that the food or diet is the symptom of the problem. Anorexics typically avoid foods, those with bulimia may eat foods, but then either regurgitate it by mouth, or by over-exercising (exercise-bulimia), and yet others suffer from binge eating disorder. With eating disorders, if having to be “in general”, one worries about adequate caloric intake, sufficient nutrient intake, and adequate hydration. Often those with eating disorders are having nutritional issues that can be addressed by working with a Registered Dietitian as part of the healthcare team for the individual with an eating disorder. Dietary supplements are standard care in eating disorder treatment. If they are standard care, how can they also be causal of an eating disorder as promulgated by Harvard’s STRIPED organization. Please see the presentation and references cited here for how Eating Disorders are classified by Medicine, healthcare, and the Insurance Industries.
Dietary supplements offer assistance in a person with an eating disorder to achieve enhanced or better nutrient intake, which overall helps support better health, including metal well-being. To declare that taking a dietary supplement will lead to an eating disorder is a non-logical emotional leap with no basis in fact, and in fact does more harm to society than it does any good.
Dr. Hewlings: Nutrition plays a key role in the treatment of eating disorders. Dietary supplements, including protein and other “muscle building” supplements, are a key part of the treatment. This is reflected in the clinical treatment guidelines put forth by many major health professional organizations such as the Academy of Nutrition and Dietetics (see my paper). As an example, in treatment it is not uncommon to use protein and other supplements to compensate for nutritional needs that the patient is unable to meet on a daily basis. Often, they sign a contract of treatment and agree that if they don’t meet nutritional needs they will consume these supplements to meet them. It is very challenging to reason with a “starving” or malnourished mind, so nutrition is an important part of the treatment to support proper cognitive function, reasoning, and thought processes.
- What common nutrient deficiencies are often seen in those with eating disorders?
Dr. Kalman: Besides overall calories for their energy needs, there is insufficient or deficient intake known of protein, essential fatty acids, Vitamin A, B-vitamins (i.e., thiamin, folate, B6, B12), vitamins C, D, and E. It is known that at least 28.3% of those with eating disorders have nutrient deficiencies, with up to 33.2% having at least 2 deficiencies.
Dr. Hewlings: It depends on the eating disorder and the extent of the restriction, and or compensatory behaviors. In addition, it is important to note that eating disorders are commonly associated with multiple co-morbidities that may also contribute to deficiencies, so every case is different. However, protein-calorie malnutrition, electrolytes, magnesium, vitamin D, etc., in fact, electrolyte imbalances are commonly associated with death in those with eating disorders.
- What is the role of amino acids for someone with an eating disorder?
Dr. Kalman: Amino acids are the precursors for making “proteins” and for many functions in the body. Amino acids – via dietary protein intake – are also the natural precursors to our neurotransmitters; when a person has insufficient protein intake (and insufficient essential amino acid intake) the ability to optimally synthesize all of the neurotransmitters is impacted, and not in a positive way – this, too, affects mood states. Protein and amino acids are very important for eating or ingesting when dealing with an eating disorder in order to give the body the building blocks for the immune system, for muscle health, and for healthy neurotransmitter synthesis.
Dr. Hewlings: Essential amino acids (EAAS) could play a very critical role, especially because they offer a benefit to muscle growth and maintenance with very few calories. This can be an important nutrient type that recovering patients would be more willing to agree to.
- Why do you think the supplement industry is being targeted in proposed and already enacted state bans on dietary supplement sales to people under the age of 18?
Dr. Kalman: I think that the supplement industry is being targeted by Harvard’s STRIPED organization and various States of the Union because nobody ever fights back against campaigns that are rooted in and crafted to be about “protecting the children”. Harvard’s STRIPED and various states have made this an issue of “dietary supplements are a dangerous thing and taking them can lead to negative side effects like eating disorders, so we must not allow those 18 or below to have access to a dietary supplement”. Makes no sense and is a logical fallacy.
Dr. Hewlings: I am not 100% sure, except that my guess is that the funding is emotional based. Someone who tragically lost a loved one to an eating disorder or those who are seeking to offset their own tragedy have been misdirected.
- Have you seen evidence that teen supplement use is closely connected to occurrences of eating disorders?
Dr. Kalman: There are two survey studies that I am aware of that broadly asked if the person has ever consumed a dietary supplement AND if they have ever had an eating disorder. Asking those two questions is not how one determines that one causes the other. Survey research is fraught with all sorts of weaknesses, making this leap is one such huge error.
Dr. Hewlings: There is none. I have looked extensively at the studies that groups like STRIPED says support the connection. There is NO evidence of causation. Please see my paper.
- If so, how narrowly can we define which specific ingredients would be of concern, to avoid restricting sales of broad categories of otherwise safe products?
Dr. Kalman: I see no reason for any dietary supplement or dietary ingredient that is legally and lawfully on market to be restricted from use by someone 18 or younger. I would ask, should we ban access to buy or get high calorie, high sugar foods that are devoid of nutritional quality? Legal and compliant dietary supplements and ingredients that are on the market already must meet Federal standards for safety for human consumption. We do not question such about foods, so why think it legitimate to feign a concern for what those 18 and younger may buy? I think we should applaud those 18 and younger who engage in exercise, who work for health, and for those who include dietary supplements as part of their lifestyle. Heck, supplementation in this country starts at birth! Typically, within 48 hours of being born in a hospital – it is standard to provide the baby with vitamins D and K (supplemental), so in reality supplements are part of our lifecycle health and are not totally recognized as such.
Dr. Hewlings: No ingredient, or one thing for that matter, causes eating disorders. They are multidimensional and complex mental health disorders. To even suggest that they are caused by any one thing is remiss and prevents those who suffer from receiving the multidimensional resources they need to recover. The funding for treatment and for research to identify best treatment and etiology is very limited. The fact that this group from Harvard is choosing to allocate such limited resources to absolute nonsense is unsettling and irresponsible. If I thought for a second there was even a slight connection, I would be supporting these efforts and using my expertise and resources to speak to every state legislator I could to get these bills passed. I am committed to helping those with eating disorders see that they can move past it. I am committed to helping understand what contributes to their development. As part of that, I am committed to speaking out against these false and misguided efforts to ban these products. Not because I care about the economical impact it will have, because I do not believe they will have an impact on the supplement industry. BUT it is the misinformation that gets associated with the message and the misallocation of misguided resources.
- Where can someone struggling with an eating disorder find more information regarding nutrition, and who they can reach out to for assistance?
Dr. Kalman: For anyone who thinks that may have an eating disorder, besides contacting your own Primary Care Physician and asking for help, one can contact any of the following groups for assistance or a referral:
- National Alliance for Eating Disorders
- The Renfrew Center
- National Eating Disorders Association
- Monte Nido – Residential Treatment
- Others also exist. Healthcare practitioners can go here for continuing education: National Center of Excellence for Eating Disorders
- Where can people learn more about your work?
Dr. Kalman: Two easy places to learn more about me and my works are LinkedIn and ResearchGate.
To learn more about Consultancy, see www.substantiationsciences.com.
Dr. Hewlings: My LinkedIn
