Assessing the eating habits of young patients is tricky, but this presentation from UCSF eating disorder specialists offers an update on diagnostic criteria, tools for detecting a problem, techniques for talking to patients and families, and guidance on referrals.
Yeah. Today's topic is recognizing and treating eating disorders in adolescents and young adults. Mhm. For the first portion of this talk, I will be speaking to you um today um Starting with screening and assessment. So the what, who and when and how to screen for eating disorders. Uh Doctor Downey will pick up with the medical aspects of how to work up a patient, what early intervention may look like and how to support families during treatment. And finally doctor Bucklew will finish off with when and how to refer for evaluation. So in terms of identifying eating disorders, the diagnoses have been evolving and in fact they evolved rapidly. In 2013. With the fifth edition of the diagnostic and statistical manual here, we have listed the names of the diagnoses that you might be familiar with. But we thought what we would do is run through and just identify what's different about these perhaps since you trained and learned about these originally. So starting with anorexia, nervosa, comparing the old version of the GSM number four to the version in 2013 Version five, you can see here, you might be surprised to find that there's no weight cut off for anorexia nervosa diagnosis. So the GSM by five does still set the expectation that patients who made the diagnosis for anorexia nervosa have low weight. But this 85% threshold, which was always confusing, has been removed. Bulimia nervosa has been changed slightly too. You can see here that the frequency of binge purge behave behavior to meet the diagnosis has been decreased to once a week over three months binge eating disorder, you may not have realized was not previously an official diagnosis, it was considered a research diagnosis. It is now officially a diagnosis, which is important obviously for billing and reimbursement and access to care for these patients Who have been estimated to make up 35% of populations seeking clinical care for weight management. Atypical anorexia nervosa is a new diagnosis, and we'll spend a little bit of time talking about that today, but very briefly, atypical anorexia nervosa describes patients who have eating disorder, psychopathology that is consistent with anorexia, but they present with normal weight, so they are not underweight. And then the final diagnosis that will be mentioning today is are fitted or avoidant and restrictive food intake disorder. Um, this is extreme picky eating, but really picky eating that interferes with nutritional status or with psychosocial functioning. Uh, this is really, I would say out of the list, the least well understood diagnosis. Even to us, we do this every day. It still feels new. Studies are trying to piece out potentially different subtypes of this picky eating. Um, and they've come up with um, this diagram shown here. Uh, Some kids have prominent fear of aversive consequences, such as choking. Some kids have a lack of interest. So these are the kids who potentially are, we've had patients who are involved in gaming and they just forget to eat all day. Uh And other patients have really strong sensory defensiveness. So certain foods, especially often fruits and vegetables, but the truth is that um that diagram doesn't really hold up clinically. Uh There is often an overlap of all of these different um characteristics when it comes to extreme picky eating or our food. So I will be spending the focus of my talk today on evaluating weight and growth um and highlighting what are some problematic growth patterns. And then Dr Downey will pick up problematic behaviors. So when should you be concerned, we wanted to start with this point, you are not in charge or nor do you need to feel that you have to make a diagnosis. In fact, we often take time to make a diagnosis even when patients are referred to our team. So really um so while we went through those lists of what the diagnosis look like, um it's not necessarily sorry to be sure. It's just necessary to know when something looks concerning. So what are the weight patterns that are concerning before we talk about the behaviors? Mhm. First let's just recall that normal growth takes on many shapes. Uh If you are a primary care provider in the community, we know that you're doing an excellent job tracking growth because as part of our program we actually request um historical growth records because it's very helpful for us to evaluate growth to evaluate malnutrition and to evaluate treatment goal weights. Uh And we are always impressed by the quality of the data that we get from you in the community. So we know that um primary care providers are tracking this really well over time. I wanted to remind you that the 50th percentile we refer to that as the median um B. M. I. And just as a reminder oftentimes malnutrition is calculated by the percent of median BME. So in other words, how far is a young person from the average from the median? Um but as you know, as long as an adolescent or child is tracking within their own preset channel, we do consider that to be normal growth even if a kid is on the higher side, like shown here at the 85th%ile or they're growing on the lower side and that is considered healthy for their body habit. This um in reality when you're collecting clinical data, especially on slouching adolescence, um you know that these roads can look a little bit bumpy but still we would say this is normal because it generally follows a channel. So when would you be concerned? You would be concerned when a young person is falling off their curve. So here are two examples, one where a young person was growing at the median and fell off the curve here, where the person was growing on the smaller side. But in both cases, falling off the curve is a pattern that may indicate or is consistent with the patients. We see who are eventually diagnosed with anorexia nervosa. Now recall that I mentioned that a typical anorexia nervosa is um anorexia nervosa psychopathology at normal weight. And here you can see a pattern that may indicate that this is a patient who was growing well at the 85th percentile fell off their curve and when they come to us, they still look quote unquote normal by national data standards, by CDC curb standards. Um, but they may meet criteria for severe malnutrition and I'll show you how to evaluate that. Another concern that is more easily missed is a flattened to be my curve. And here you can see three examples with our young person who was on the smaller side, the average kid and the kid who was growing on the higher side. But in all cases, if you have a flat Bme curve, especially when patients are gaining linear height, it indicates that they're losing weight and this can be a red flag. So how much weight loss is a concern? Well, in our most recent position paper for the Society for adolescent health and Medicine, you can see here that in addition to calculating how far the patient is below the median BMI to indicate whether they have mild, moderate or severe malnutrition. We're also now really paying attention to what percentage of their body weight have they lost. So thinking back to the curve, we just saw where the young person was falling off the curve, starting at the 85%ile while there's still above the median. So they would be at 100% or 105% of the median. If they've lost 20% of their original body mass, they can be considered to have severe malnutrition. Uh And I wanted to explore that concept a little bit. It's really um somewhat new but gaining traction in the literature. Um, and the term is called wait suppression. So let's just walk through or illustrate wait suppression with two um two patients Jill and jane. These are two girls 16 years old at five ft five who have lost significant weight through restriction and excessive exercise. Now, Jill, as you can see here, started at £125 which would be considered normal around the median for a five ft five young woman and she comes to at £85 with a Bmi of 14.2 representing a 40% weight loss. I mean, sorry, £40 weight loss. Now there's no question. That would be a young person you'd be very worried about. But what about jane, jane? Started out overweight. She was £260. She comes to you at 100 and 28. So she is still normal technically in weight by national standards. BME is 21.3 but jane has lost £132. So the question is, are these two girls equally malnourished? Well, if you think about it in terms of weight suppression and you can calculate it using this formula here, it's not very complicated. It's really the highest historical weight minus the presentation weight, divided by the highest historical weight. You can see here that Jill lost 32% of her weight, Jane has lost 51% of their her weight. And so by the criteria, the New Sam criteria that I just showed, both of these young women have lost more than 20% of their initial initial body weight. And both would be considered to have severe malnutrition, even though Jane is technically or quote unquote normal compared to national standards. Now, why do we care about weight suppression? Well, like I said, this is gaining traction in literature. And in fact, a study that dr Bucklew and I just conducted really showed that for patients who are coming to our hospital program, the degree of weight suppression predicts their illness severity. So the young people who come to us who have a larger magnitude or duration of weight loss had what appeared to be a higher risk for the re feeding syndrome when they were admitted to the hospital, those who had lost weight faster had more severe bradycardia, which Dr Downey will pick up on in a minute. And finally, longer duration of illness was associated with biochemical markers of body composition and hypogonadism. So we're very, very concerned about kids who have had a large weight loss or a rapid weight loss even if they're not underweight. Uh and I just want to point out that guidelines now from the Academy of nutrition and Dietetics, as well as the parental and central nutrition society have um Recognise this concept of rapidity of weight loss. And you can see here that even if a patient has only lost 5% of their body weight, if the weight loss has been rapid over one month, that could be considered severe. And just on the note of rapid weight gain, I did want to show um this curve which is rapid weight gain, which often is a pattern that is indicative of binge eating disorder. Certainly not always, but this is sometimes what we see in our kids who are binging. So to wrap up this portion on growth, I want to just remind everybody that normal growth does not necessarily rule out an eating disorder. While on the one hand, it doesn't diagnose and eating disorder. It also doesn't rule out that there is an underlying problem. So keep in mind that young people who have bulimia nervosa so often have a normal growth pattern and then for our patients with our fit or the extreme picky eating. Oftentimes they're taking supplements of their subsisting on a very small repertoire of foods, but they're managing to keep their weight normal. So I will uh stop there and turn things over to Dr Downey. Mhm. Thanks so much. Dr Garber. Hi everybody really nice to be with you in this virtual space today. The portion of my talk is really designed to give you concrete actionable information for implementation in your clinics. I know that often these families that can be difficult to talk to you. It can be difficult to know what to say. And so having a little bit of a template I think can be really helpful and hopefully not make you late for your next 8910 appointments that afternoon. All right, so we're going to move on to the Scaf Scott is a really solid screening tool that you should feel free to use again when you're me having trouble finding the language what to ask, how to ask it. I think this is a really nice tool just for reference. It was created in 1999 in the UK and so the scaf acronym actually doesn't hold up that well kind of hilariously. But here is a run through of these questions. Do you make yourself sick because you feel uncomfortably full? Another way to ask that is about self induced vomiting. Do you worry that you've lost control over how much you eat? That's the sea. Have you recently lost one stone? That's the o in scoff. Which that's kind of meaningless to us right on the side of the ocean at least. But essentially saying have you lost weight? And dr Garber gave a beautiful overview of what that looks like in the clinic, Do you believe yourself to be fat when others say you are thin, that's the first f And lastly would you say that food dominates your life? Another way to ask that is, how much of the day are you really worrying about your next meal or what you're going to have next? It's pretty sensitive to pick up some eating disorder behaviours. Again, not completely diagnostic, but a really nice, quick and dirty screening tool that you should feel empowered to use. Um I would also say again, don't feel like you have to stick to the exact wording of this screener, right? I think doing it in your kind of authentic voice, in your own personality, you're much more likely to get an authentic response in return, so feel free to just kind of use this as a tool, but not something you need to stick with very rigidly next slide. So, another important point. Just keep your eye on the experimenters, right? These are young people who maybe don't screen positive on the scoffers aren't giving you really overt signs. Um But folks who are dieting, for example, what we know is that dieting is actually a really risky health behavior and adolescents, we know that dieting increases risk for the development of an eating disorder and it actually co varies with a bunch of other risky health behaviours like tobacco use, alcohol use. Um And sex behaviors interestingly dividing also predicts being overweight into adulthood. And so the more literature we see on this, the more we're finding that dieting a predisposes to eating disorders and be increases your chances of gaining weight long term. And so it's just not that helpful of a thing to be recommending to our young people. Next light. One large prospective cohort study that looked at this was Project Eat. They had a cohort of just over 4700 young people and where I would draw your attention, you can see under the girls column, there's ow for overweight and obese column, right? And those folks by in large, in large percentages, they're trying to lose weight, They're doing it in with a lot of healthy behaviors right there, exercising, decreasing sugary drinks, that kind of thing. But also in huge numbers, are engaging in unhealthy behaviors right there, fasting, their skipping meals and even more notably engaging in what we would call extreme dieting behaviours, right? Turning to unregulated pills, self induced vomiting laxatives diuretics. Um, and for the vulnerable young person engaging in those behaviors, might kind of set that that ball in motion of developing a full blown eating disorder. Yeah. So what are some other red flags just again, kind of have your spidey senses up for these young people who are struggling? Right again, they may not overtly screen positive, but here's some other things to be aware of. Certainly primary or secondary. Um honoria, there are a bunch of reasons for that and they should be worked up. But keeping disordered eating on your differential is important. Dizziness or sync api particularly if it's unexplained, can be a symptom of an eating disorder and one that warrants further attention. New gi complaints is a big one. We find that our patients who struggled with disordered eating have an exquisitely sensitive kind of bring gut connection. And so just again, this could be caused by a multitude of things, but important to keep disordered eating on your differential abnormal eating or excessive exercise, abnormal eating can look a bunch of different ways. For some folks, we see, um, this picture of kind of orthorexia, right. This insistence in almost obsession with healthy eating for another person that might look like they have taken over cooking for the household, right? And maybe that's great. Oh, that's a new hobby. But then you realize maybe they're taking control over food production in the home because they also want to have complete control over what's going in their food, right? Or they're wanting to know explicitly how many calories are in everything that can be a red flag. And lastly, and I know that everyone is screaming for this already, but certainly changes in mood, social withdraw, refusing to eat with the family. Those are red flags. Again, that could be indicative of eating disordered behavior. Early intervention is key. I don't think we can stress this enough. And if you're a primary care provider absolutely. This can be a life saving intervention to really know that this disorder eating is going on and to make that early referral. We know that timely intervention is important because a shorter duration of illness is actually associated with improved outcomes, quicker outcomes and better long term remission. So the sooner we can intervene for these young people the better. So what does a medical evaluation look like in the P. C. P. S. Office? So of course of course we want to get a height and weight. But particularly if you can get the patient in a gown to do that, it's really helpful. We often say that eating disorders like to passionately protect themselves. So sometimes an eating disorder might make a young person way they're closer pockets down with heavier items to falsely elevate their weight. So getting a weight in the gown to give a really accurate representation of what's going on can be really helpful. Of course, what you're already doing a thorough physical exam. Just as a reminder, there are some really characteristic physical exam findings we look for. Remember that things like Linux go growth of kind of fine here over the body, really cold extremities in the case of self induced vomiting, we're looking for those calluses on the knuckles, a really good dental exam, right, looking for the acid rubbing off an animal. All of those things can be really excellent clues to what's going on. I'm also parodied hypertrophy. Um there's a huge list but certainly those are some of the bigger ones. Of course we want to look carefully at vital signs. But just as a reminder, Ortho static vital signs are really important for this population. And as I'll get to later, can be an indication for inpatient admission are for our personal use. We really like Ortho statics to be done with five minutes of lying down and then taking the pulse and blood pressure and then followed by two minutes of standing before you again repeat those vital signs so that can feel lengthy in the case of a short visit. But important to do them properly to get an accurate measurement. I'm getting an E. K. G. Is particularly important if you're already noticing bradycardia on the vital signs. If you can get an E. K. G. To just give you further data of course that's great to look for bradycardia. Any kind of arrhythmias and prolonging of the Q. T. Interval. And then lastly if you can do it in the clinic great. We would ask that you get some screening lab work which will be on the next slide. So some of this is obvious but maybe some of it not. It's certainly not a prerequisite that you've done all of this if you're going to refer to eating disorder treatment. But it's certainly helpful to have this information in advance. The first thing looking at electrolytes of course. Bmp calcium, meg foss um Common things being common. We're looking for hyponatremia hypothesis. Pity me. A hippo khalidiya. Those tend to be pretty common hypoglycemia. Something I think that's under recognized in the eating just sort of world and can actually be a source of acute mortality for these patients. Really important that we're looking at electrolytes. A pregnancy test goes without saying for our young people um A. S. T. And L. T. We're not uncommonly see a trans am in ITIS or hepatitis of malnutrition. And so again that's just a little bit more data to see how nutritionally compromised the body is at intake thyroid studies, right? We want to be able to reverse anything that's easily reversible. So hyperthyroidism, we see weight loss, hypothyroidism. We often see a depressive kind of illness that might be leading to decreased nutritional intake. So that's an easy thing to do and to rule out a cbc, right? We're looking for anemia. It could be leukemia, could be thrombosis, Kapini a but it's not uncommon that we see bone marrow suppression due to malnutrition. Um And it's important that we know that ahead of time, if there is any family history of IBD celiac disease, certainly feel free to go ahead and get the celiac panel crp or s are, we would not want to miss an inflammatory bowel disease and call it an eating disorder. So feel empowered to order those a year. Analysis really goes along with what I was talking about before with the eating disorder, often wanting to protect itself. Some of our young people will drink a lot of water before they come into the clinic. Again in thinking about elevating that weight. And so we're going to look at things like the spectrograph and the ph to determine things like are we fluid loading or to give some evidence of purging and then lastly urine drug screen, of course, substance use can masquerade it can suppress appetite. Um and so we want to be able to rule out a substance use disorder if that was in fact the case. So what are inpatient admission criteria? This makes things easy, right? Because if someone meets this criteria and they're in your clinic full stop, you know that you're going to send them for inpatient admission. So the first thing we're going to look at is how dr Garber was talking about earlier, someone who's less than 75% of that median BMI or they're expected BME. So you may not have time to calculate in the heat of the moment. But if you take that historical BME curve you find what's 75% of that BME curve. If you're under that, that's probably going to be an indication for admission. Or at least a reason to give us uh to call us and we can discuss the case together. Vital Stein instability. We're looking for a heart rate that's above 50 beats per minute when they're in your office. Anything less than that likely an indication for admission, Hypertension. Same thing. We want them to be above 90/50. As far as Ortho Statics, we're looking for a decrease in systolic blood pressure of 20 from that line position to standing. Or a decrease in diastolic blood pressure of over 10. Um as far as pulse changes, we are a little bit more liberal about this. In the kind of academic position papers, you will see an increase in 20 beats per minute. I think our census would be the whole hospital. Um if we follow that recommendation. So we're looking at a pulse change of greater than 35 beats per minute between lying down and again standing. And then if the temperature is less than 36°C also um an indication for admission. Other reasons you might think about hospitalizing someone with eating disorder, behaviours, frank dehydration, particularly on physical exam. We know that young people can't be dehydrated for a long period of time without serious medical sick. Well that's a reason to come in any kind of electrolyte abnormalities that come up. When you get labs. A reason to give us a call and discuss admission of course prolonged Q. T. See any kind of arrhythmia. You see absolutely a reason to be impatient with us arrested growth and development, acute food refusal. Or just a frank failure of outpatient management. If you've been following someone and trying to connect them with therapy um And met management maybe and you're just not seeing progress or things continue to get worse. Consider hospitalization, uncontrolled binging and purging even in the setting of medical relative medical stability. Um Sometimes these folks really benefit from hospitalization to kind of break that binge purge cycle. We also know that with purging medical stability now doesn't mean medical stability tomorrow. Right. Um And so we're really careful with those folks. Any kind of other acute medical complication from the eating disorder of which there is a laundry list but kind of common things being common. We do sometimes see esophageal tears. Um Sync api of course, particularly recurrent syncope, e even seizures from hypoglycemia or other electrolyte imbalances a reason to go inpatient and then co morbid psychiatric issues. Certainly we see in high volumes in this population, I'd say the one that often requires hospitalization. Of course suicidality is highly co morbid um with these eating disorders. Also, very severe obsessive compulsive tendencies can be very difficult to manage in the outpatient setting and sometimes require hospitalization. So I want to go through a quick case example to kind of tie some of this information together. An assistant way because we're not together in person, I will just kind of go through this case by myself. So this is the case of Lucia's, she's a 16 year old female, she's coming in just for a routine, well child check historically, she's tracked along the 90th percentile for weight and B. M. I. Since her freshman year of high school, she started playing volleyball, running track, which he really encouraged her to get involved in those activities. Her parents and coaches really provided praise. She started eating healthier while she was playing sports. She also started exercising not just during sports practices but also outside of that. On the weekends, you notice from her previous visit, she's actually been tracking a little bit lower along the 75th percentile really since beginning sports in high school, but more recently she's dropped to like 50 45th percentile of BME in the past six months since initiation of this really strict paleo diet that she read about online, you talk to her alone, you know that she would actually like to continue losing a little bit of weight. So what are kind of next steps here? So this is a kid, overwrite your your spidey senses are up, you might want to go ahead and administer that scoff screen or at least ask some of those more detailed questions about her behaviors. I think this is a nice time to point out. It's really important that you have some time with the patients alone and also the parents alone for these encounters. Remember eating disorders can be what's called really ego santa nick, right? They feed or protect the patient in some way the eating disorder behaviours might alleviate really negative emotions on the inside. They might provide a strong sense of control for the young person. Um, for some folks, even losing weight kind of almost gives them high, really activates their sense of reward. Um, and so again, folks are going to oftentimes protect their eating disorders. So getting the parent's perspective alone can be really helpful. And on the flip side young people might volunteer for more information without their parents in their room. So I would have already separated parents, talked to Lucia on her own, talk to parents alone and you do get some more information. Parents raise significant concerns. She's refusing to eat dinner with the family, She's only preparing her own lunch for school, won't let mom do it anymore and she's exercising two to almost three hours each day. So at that point I would go ahead and say, you know what? There's someone who's struggling. I'm gonna go ahead and draw labs here in the clinic and grab an E. K. G. Two. I would also do a quick screen um for impressive depressed depressive or anxiety symptoms and a screen for kind of imminent suicidal ideation to see where she's at. So luckily she's normal vital signs in your clinic. You do go ahead and pursue Ortho static vital signs. Those are also normal and they don't seem to be any symptoms or behaviors requiring immediate hospitalization. Right? So check one. Don't have to get her admitted today. Um You get the labs backs let's say the next day the E. K. G. Is also normal. So you call the family to really discuss your concerns right? Based on her degree of weight loss and behaviors. You do suspect an eating disorder. And you note that eating disorders have serious medical complications. So you're really concerned for her safety and her future. Well being, you also go ahead and refer her for eating disorder specific treatment. Just a quick note here to say, remember patients with eating disorders just very wildly from a genetic standpoint. So while for this patient, her vital signs are completely stone cold normal, and you're glad about that, you also don't want to invalidate how sick she is based on her degree of weight loss. Right? And so it's okay to say that for another kid with this degree of weight loss, they might really be seeing an organ damage at this point, and you just can't predict. So you just don't want to invalidate the experience. You want to say things like these behaviors in and of themselves are worthy of treatment and compassion take care. So, in addition to your referral, how else are you going to empower this family towards recovery? So, we're going to talk about delivering care in an Fbt framework Fbt or family based treatment is really the gold standard approach for treating young people with eating disorders and it's a framework that involves the whole family. It really empowers caregivers and so parents or foster parents, whoever, whoever has that role in the family, we want them to truly take control of re nourishing their child. And yes, over time, months of care, autonomy for re feeding is gradually transition back to the young person. But the emphasis is on parents or caregivers really taking control of that. And the idea, right, is that when someone is so sick, we say they're eating disorder is really entwined with their own consciousness. We can't trust the young person just yet. We can't trust the eating disorder to make good informed decisions um, about re nourishing themselves. And so we transfer that autonomy over to caregivers at the beginning of this treatment. So, you certainly do not need to be an expert in fbt. But if you understand kind of the language and the spirit behind the treatment, you can really help to accelerate the treatment process. Okay. Yeah. So just some quick and dirty dozen donuts of what that could look like in practice. So we want to really raise the level of concern to increase engagement with the treatment. It is okay to say that things like anorexia, nervosa really actually quite a high risk of death, both from suicide and medical complications. It's okay to talk about the profound medical consequences for some families to really get them engaged. Will say if your child had a cancer maybe going full court press on treatment, right? And really having an eating disorder, it's not that different. Do stay away from explicit calorie counts and wait discussions. Just another thing for their eating disorder to really glom onto, right? We want to keep it general food is your best medicine. I know that eating this volume of food is going to be hard and it's the only way to get back to your life. Do empower parents to take control, we're going to be doing that. But if you can do that to you guys have really long standing relationships with these families, that can be really helpful. Um you can say things like you fed your daughter to this point, you have made a strong healthy kid and you know how to do it again. Just simple, empowering phrases like that. Just some quick don't we don't want to get into negotiations with the eating disorder, so it's ok to validate that things are hard. Like, I'm sorry the eating disorder is making it so hard for you to follow your meal plan, but your health is non negotiable and I need you to stick to the plan. So, right, it's like firm tough love, but we don't want to give into the eating disorder. We also don't want to empathize too much with treatment difficulty because the reality is this therapy is really stinking hard. Um it's essentially an exposure every time they show up, right, It's distressing for patients. And so it's totally ok to validate it again, that this is hard, that the treatment is hard. Um but you know, when they come in and say, oh gosh, I really don't like my therapist or my therapist is making me do really hard things. It's okay to just encourage and say, I know it's hard and you've got this, we've got to get you back to your life. Lastly when they come in, say, the patient is doing better, they're moving towards recovery. We just don't want to emphasize things like weight gain, shape concerns, right? We want to highlight those things that really make someone who they are right. We want to highlight improvements and mood attention and sleep, all of those things that are really they're worth the hard work of eating disorder treatment. Um So thank you with that, I'll turn it over to dr popular. Thank you. Uh Doctor Downey and Dr Garber, I'm going to talk a little bit then about um you know, for example, if Lucia um you decided to refer her um thinking about when and how to do that. So as Dr Downey um went through Lucia's vitals were normal uh and did not require hospitalization. So, you know, I put up this side both to explain what we have at U. C. S. F. But also to kind of reiterate that most patients with anorexia and with eating disorders are treated as outpatients. Um And thinking about our patient management includes a multidisciplinary team, Oftentimes uh including a therapist uh as well as a medical provider who is continuing to follow medical progress. Uh and then also a dietitian or nutritionist who in the F. B. T. Model is frequently most often working with parents. Um but may also as the young person moves towards more autonomy, may also work with the dietician. So we offer all of that on an outpatient um level of care, and then we do offer hospitalization for the patients who are medically unstable. Um And um uh we also have an outpatient higher level of care. Um So for many patients who maybe have done fbt or kind of worked on an outpatient level of care or have been hospitalized and may need um higher level of care than just outpatient, maybe they're hospitalized multiple times. Um So our patient higher levels of in Clare can include partial hospitalization programs or intensive outpatient programs which offers kind of multidisciplinary treatment from you know, multiple hours a day. Um And we typically run multi family therapy program um But that is currently on hold due to the covid pandemic. Um Also for our outpatient treatment programs, we continue to offer our outreach program in Pleasanton. Um And then Dr Downey will be um staffing the r marin program again uh at the end of this month. Next line. Yeah. So um what do we do? And the inpatient hospitalization? So again our inpatient treatment model is really meant for medical stabilization and nutritional rehabilitation. So our patients um Receive three meals and three snacks which are monitored by one of our trained safety attendance. Um we decide all the nutrition and the way I explain this to patients and families is that just as if you were going to receive a medicine in the hospital that we would decide both the dosage and the timing. We are doing the same thing with your medicine, which is the nutrition. We do have the ability to initiate um nasal gastric feeds as needed. Um And then we do regular land monitoring, have patients on cardio respiratory monitors as needed. Um We do replete electrolytes as necessary depending on re feeding. Um patients are typically on bed rest to conserve energy when they're hospitalized and then gradually return to activity even in the hospital. Um And we do offer an interdisciplinary team that includes our psychologists who are on the in patient service who complete a comprehensive behavioral health assessment, a social worker who may help families identify resources um for discharge as well as well. The patients in the hospital, we have a nurse coordinator uh and then are registered dietitian who works who is dedicated to our team. We are fbt informed given that that's uh most commonly our patients are adolescents, all that we do also admit young adults. Um And so we do try and start the process of empowering parents while patients are in the hospital. Oftentimes it can feel like a very un empowering time since we are making all of the decisions. But um we have family present for meals um with the young person um and really try and um empower parents to take the next steps next time on the outpatient side. We also offer an interdisciplinary treatment approach. We try and offer an initial comprehensive assessment that includes a meeting with a psychologist, physician um as well as um one of our registered dietitians uh and then offer ongoing management including medical management and monitoring as well as the nutrition counseling and therapy most often that may include family based treatment to start but may also offer other modalities as needed. Excellent. Mhm. Um So um during covid things have changed rapidly. Um We actually went from doing no telehealth on friday to 100% telehealth on monday. Um We continue to offer services by telehealth, but I would say there's been some advantages in terms of um collaboration with primary care providers. Um So having patients CS via telehealth but continuing to see their primary care providers for um wait uh and vital signs um We've also been able to have a broader scope of treatment where we've been able to offer more treatment across the state. Um are impatient. Census is at a record high, so um eating disorders as you may have seen in kind of the lay press and the newspaper have sort of thrived from the pandemic and much of that may be related to some of the social isolation. Um And um we also virtually have done inpatient multidisciplinary rounding so our patients continue to see our inter disciplinary team on the impatient service, although much of that is virtual now, but we still kind of have a multidisciplinary team working in the care for all of these patients. Um Our um and if you do you have a patient that has a positive screen and that you're worried about that you would like to speak with one of our physician team members calling the 1877 You see child number, it's helpful um And we're happy to speak with you about a patient who you may think needs hospitalization or um you have other questions about. Um And usually if you complete the referral form um include the relative um you know clinical relevant clinical information as well as growth charts. Our referral coordinator will reach out to the patients, but patients can also call um our patient coordinator. Yeah. Yeah mm.