Eating disorders (EDs) are part of the current emergency in children’s mental health, with pandemic-related factors that include social isolation, disrupted routines and excessive screen time. In this guide, Sara M. Buckelew, MD, MPH, debunks myths about which populations get EDs; offers keys to assessing patients and tips on talking to families; and describes inpatient treatment. Learn why pediatricians – who typically seek to reassure parents – may need to raise the alarm instead.
thank you. Um Yes and please um interrupt if there are questions. I put some slides together, but I'm happy to answer questions as they come up for. Um and happy to be here with you today. Um So gonna talk some about um eating disorders um during the pandemic. Um and a little bit about um both assessing disordered eating and eating disorders as well as the hospital. Um and just like to always start with some key principles in relation to disordered eating. Um thinking about that that obviously eating disorders are serious disorders worth potential for life threatening complications. Um some studies talk about mortality for anorexia being as high as 10% lifetime and putting it the same as childhood leukemia. Um so um also recognizing that eating disorders occur in all genders, ethnicity, socioeconomic groups and patients of all people of all sizes and weights. Um and that unfortunately denial of symptoms and ambivalence for change is often part of the disorder. I think also recognizing that um physicians and the medical establishment is often seen and often is a source of weight bias and stigma. Um And thinking about that parents messages about food and weight matter. Um So when I talk about eating disorders today, most uh of what I'm talking about often tends to be restrictive eating disorders. Um which really there are three main ones that we see, So anorexia nervosa, which is, you know, um key features include severe restriction and patients are underweight um uh with significant body image disturbance and fear of fatness. Um atypical anorexia nervosa which is kind of um been more and more present in the media. There was just actually a large um new york Times magazine cover article on atypical anorexia. Which is essentially the same as anorexia nervosa all the same feature psychologically except that patients are um at a normal to higher weight. Um That is considered typical or normal. Um bulimia nervosa will talk about a little bit. Um But uh and binge eating disorder I'm not really going to talk about at all. Um And then avoidant restrictive food intake disorder um Which I think is also becoming more and more recognized which was new to the D. S. M. Five. Um which is unlike anorexia is very heterogeneous diagnosis meaning patients present in many different ways. Um But those are the patients who have severe restriction of um foods for reason other than body image. So there can be no body image disturbance. So sometimes that can present as um you know fear of vomiting that's causing um restriction. It can present as like um severe picky eating or um you know we see it um Not uncommonly among patients with autism who may have particular issues with certain textures. Um Or even colors. I had a patient you know last week tell me I never eat white food. Um So kind of there's some reason other than than body image. Um So you are all well well aware of this um just with the national emergency in Children's mental health that was declared um about a year ago or a little bit over a year ago and certainly that has played out um over the years um in terms of uh this focus on mental health amongst adolescents um and um as you can see from all these headlines, um eating disorders are part of that um uh that crisis um for sure and we have more and more kind of research to show that that is true that there has been um an explosion in um uh presentations of disordered eating. And this is from a study um that was done at michigan which shows kind of the The number of admissions per month for medical complications. It's kind of a similar to ours, medical complications for anorexia. You can see from 2017 through through the start of the pandemic was you know pretty stable and then um as the months increased following the start of the pandemic. Just this surge. And if you looked at our data which I have done on a UCSF pretty similarly seeing the same kind of change in slope. So um I have no doubt that you all are also experiencing that as part of your practice and what you see um This is another study but you can see this is from boston similar just um change in slope again of inpatient admissions and patients who are admitted for medical complications. Again a unit similar to ours. Um and you know these increases are not just in the US but have been seen and described globally. Um So so it is happening across the world with studies showing um increases in europe Australia asia um and also published in Israel. So if we think about some of the reasons for the ride and disordered eating during the pandemic, um it's kind of a perfect storm um when we think about adolescents. Um so um both with increased risk and we'll talk a little bit about media exposure um disruption to daily routine and social isolation also contributing to increased risk as well as the lower protective capacity and access to care. Um all worsening symptoms. Um Oops, so if we talk a little bit about the media exposure, um this is actually a study that has nothing to do with the pandemic. It actually was done um you know, over 10 years ago, it was also all in relation to um the earthquake and tsunami in Japan. Um and it showed kind of the impact of distressing news content on disordered eating. So certainly during the covid pandemic um you know, with adolescents on their phone um and doing kind of the increase in doom scrolling um just exposure to tv and internet coverage of the Japan disaster was associated in and of itself with disordered eating, including dieting and uh moral control. So there's some research to show that peri traumatic reactions and sleep disturbances are associated with disordered eating and certainly that could could play a part. We also know that screen time during the pandemic um uh increased uh you know, tremendously um with, you know, one study showing a mean total daily screen use of 7.7 hours per day, which was double um prior to the pandemic. Um and so, you know, screen time during the pandemic, we know increased. And we also you know that much of the media exposure that teens are are bearing witness to including social media um has a focus on body image and can make body image worse uh for our teens. And this is just from some of the internal documents that came from facebook and in relation to instagram. Um and the negative impact um that instagram was shown to have um internally from their own research on teen girl body image specifically. Um and I also just want to point out some of the weight media messages um particularly around covid, you know, early in the pandemic. There was um you know, concerned that being overweight was was going to worsen your um your disease should you get covid. Um There was also kind of a lot of messages about um weight gain um and the inevitability of weight gain related to the change in life that happened at the start of the pandemic. Um and those messages were kind of Um consistently in the lay media in terms, you know, there was the re renaming of the COVID-15 in terms of talking about weight gain associated with um with changes in lifestyle um that were related to covid. Um and there became this um both inevitability of weight gain as well as overstated messages encourage encouraging dietary restriction, encouraging people to avoid weight gain at all costs. Um and then if we think about, you know, obviously the disruption to daily routine and structure, loss of extracurricular activities, um loss of meal socialization with friends and classmates. And this is just a um a quote. I was doing lots before before, but even more now, partly because I actually like it partly to fill the time and partly from an unhealthy driven mentality, Rest days feel unnecessary because I'm resting every day. So just change in um kind of how teens perceive their daily routine and some of that leading to um to more compulsive potentially behaviors. Um and this is a quote also from a study that my eating disorder feels more valuable to me than ever. It's the only constant in what feels like a completely upside down and scary world and it's my only locus of control. So for patients who were really feeling like the covid pandemic was um was something that was out of their control completely. Their eating disorder may have felt more controllable um in a negative way. Um and then social isolation. Um uh you know, these quotes again, just sort of highlight some of the feelings that um teens expressed um uh in talking about social isolation and changes in their eating patterns. Um both, you know, some who had worked on trying to be able to eat with people and then not um and then some who just really missed kind of that that practice um and then just a little bit about kind of the other piece in terms of lower protective capacity and access to care. Um and thinking about food insecurity. Um so um there has been um you know more research about um that in adolescent populations who are followed into adulthood that food insecurity is associated with extreme weight control behaviors and may um contribute all also to binge eating. Um And so um something else um that kind of during the the pandemic was was an issue if you think also about um patients who are struggling with eating disorders, often having very particular um food habits or or you know where they may only eat like if you think about that a patient with our fit, who only eats one kind of yogurt and and then you know, during the height of covid when they're you know, with food shortages, that one type of yogurt wasn't available and kind of how that may have contributed to that patients um medical stability and stability in terms of their eating disorder. Um And then you know, the big thing um uh then I I I'm sure you have all felt and certainly we have all felt is just the lack of available treatment. Um And so um you know eating disorders um typically require specialized care at least for for therapy support um kind of um finding a therapist who is not a specialist may really um not help um in terms of um supporting recovery. Um And um you know with the mental health crisis um and certain the demand for mental health services during that crisis, the lack of available specialists and available services um really lead to treatment bottlenecks and inability to access appropriate care no matter how hard everybody was trying. Um And you know with that um patterns changed right? This is a study that looked at the increase in um emergency room visits for eating disorders. And you can see from that that red line compared to the blue line sort of at the start of the pandemic. Um The red line was what was actually observed and the blue line was more what was expected um People were looking for for treatment and services wherever they could get it. So you know including emergency room visits um uh And um and specialists you know I think um uh we've we you know got an influx of referrals from other specialists to you know may have been referred patients that um uh that providers weren't sure where to send. So you know if they have a memory a seeing um uh O. B. G. Y. N. Or a sports colleague or if they you know have weight loss seeing A. G. I. Position all of those things make sense. Um But it it just also you know, spread out the burden um as well um You know, I want to um to just also highlight um that there is an urgent need to prioritize more affordable and accessible eating disorder treatment. You know, um the historical myth of eating disorders only happening in skinny white affluent girls or the swag myth. Um And really us having increasing evidence of what was probably there um about eating disorders being on the rise amongst men, amongst older adults, amongst gender and sexual minority individuals. Um And underrepresented ethnic groups and um definitely um in patients um from all um all walks of life. One of the things that we have evidence on is that higher SCS does predict higher rates of treatment seeking amongst those who are ill. And I think that also is um in relation to kind of potentially this bottleneck. Um and um uh really needs to be addressed um at a much larger level. I think also an understanding that there are differences in presentation amongst different groups um and differences in treatment which which haven't been studied as rigorously as they should be. Um So, you know, thinking again about the treatment bottleneck um uh causing long wait times causing the burden to fall on referring in primary care providers providers being referred to other specialists and patients being increasingly and more severely ill and in a disease where we know how important early intervention is, particularly for anorexia. Um We know that um the longer symptoms go on. Um the um pour the outcomes. Um I think also thinking about um you know if you have concern where there is smoke there usually aspire. So being attuned to your concerns, parents concerns about these these um potential diagnoses. So um I have a patient example um that I can go through um Uh so a parent brings their 15 year old in who decided they wanted to eat healthier and exercise more and parents notice that they've lost significant weight. Um And um in part I bring this this slide up. Uh This is a study that also showed the kind of the impact of covid 19 on adolescents with eating disorders that presentation. Um And it showed that for those this is a small study size, but if you look at for those who presented um kind of covid triggered eating disorder, which was those 2020 patients really, I think um that they presented with lower B. M. I More medically unstable and more likely to require inpatient admission. So um that was a lot of what we were seeing kind of um in 2021. And even even some now um if you think about the patient that presented um this is the scoff. Um So the scoff is a validated screener for um uh for disordered eating or eating disorders. Um It's from uh the UK. Um And when the first question is literally asking about purging, so do you make yourself sick because you feel uncomfortably full? Um do you where you've lost control? Have you recently lost £15 or more in a three-month period? Um do you believe yourself to be fat when others say you're too thin and when you say food dominates your life? Um and yes to two or more supports um increased concern for an eating disorder. Um And you know, I think it's also, you know, a diagnosis is not necessary if you're concerned, be concerned. And I think as pediatricians often times um we do a lot of reassurance. Um we reassure families. Um and and with eating disorders it's kind of, it can be helpful to kind of. Oftentimes you have to tip that because um Oftentimes we need to raise more urgency than a family may have. So it may be that kind of um parents or caregivers have normalized the disordered eating behavior or um or they may have some um even personal history as the parent or caregiver. And so they may minimize and and the eating disorder itself will encourage that minimization. Right? So um so the patient, the adolescent or child may also kind of um help that minimization. So um oftentimes our job as pediatricians is actually to raise more urgency and more alarm. Um Rather than than reassure um uh Which just can be a little bit different than how we are used to working. So um you know if you're seeing concerning weight patterns or you're seeing concerning behaviors it is appropriate to be concerned. And if you have a patient that you're concerned about you know um doing your medical evaluation um obtaining height and weight in a gown preferably um um And we typically do a your analysis before we have a patient weight. And the reason that we do that um is to help us um kind of interpret both the vital signs and the weight um In that if a patient is very dry um that can be helpful to know kind of um uh interpret their heart rate and their Ortho static signs. Um As opposed to if the patient's um very water loaded or you know has a very dilute urine. Which may be helpful in knowing um if they are um drinking a lot of water to make their way to appear higher than than they wanted to um have had patients who have water loaded so much that they presented with hyponatremia seizures. Um So it's it is helpful to get that information um Especially if you're setting weight goals for patients who might use use drinking water to get their weight up for Williams um Again plotting growth and evaluating growth curves um looking at vital signs um performing a physical exam and obtaining an E. K. G. And lab work um Again with lab work especially it is often normal. Um Even if a patient is quite ill so um you know trying not to also minimize concern that um uh if the labs are normal that everything is okay if you're still concerned you can still be concerned uh because labs can be often um misleadingly normal. Um This this graph is from the society of adolescent health and medicine. Um And it's really kind of highlighting the definitions of malnutrition and and um you can see that malnutrition can be defined by B. M. I. Z. Score but it also can be defined by percent of body mass loss. Um And so that can also be important in terms of thinking about um some of those patients with more of an a typical anorexia presentation and that they may have lost a very high percentage of their body mass at a very short time period. Even if they're being M. I. Z. Score is um not in these levels they still may meet criteria for for malnutrition. Um These are the lab tests that we typically um uh think about ordering or do order um kind of the standards um that you might expect. Um And then other ones to consider um including celiac including um urine drug screens. Um We also um you know thinking about hormone levels depending on menstrual status. Um These are the same criteria which were more recently updated particularly the Ortho stasis. Um My idol signs were updated. Um And the Ortho static heart rate change was made a little bit higher um guidelines. Um For adolescents I believe it went to a heart rate change of greater than 40. Um Whereas for adults it is still at um 35. Um and um and then sort of the biggest reason that we may admit um is bradycardia. Um hypertension is another common reason for admission. And actually if you look under that other section on the far right. Um uh The B. M. I. Percentile is another reason that we may admit um Just based on percentage of expected body weight Um in the hospital the inpatient treatment really. Food is the medicine. Um we explain it to families and patients that um just like any medicine that you were to get in the hospital. We pick all the medicine so um we select all of the food that patients are getting. Um they get three meals and three snacks. Most patients start at about 2000 kilocalories per day. Um And we advance the nutrition daily. Um All patients must get their nutrition. So if they're not able to eat it by mouth they can have a liquid supplement. We use boost plus um in the hospital and they're replaced calorie for calorie for what they do not eat. Um And if they're not able to drink the supplement then they do get an N. G. Tube um and get it that way. Um And the way that we advanced nutrition is really meant to minimize the risk of re feeding syndrome. Um And um and on average right now our hospitalizations are about eight days. Um So um you know some patients are shorter. Some patients are longer. Some patients are a lot longer but on average it's about eight days. Um if we have this patient who doesn't need admission um criteria. So um but you're still concerned and the parent kind of says we need help and we have no idea where to start. Like what what do you what do you do with that patient in your office? Um So family based treatment is the most evidence based treatment. Psychological treatment for um anorexia nervosa. Um It has some studies also supporting its use in bulimia nervosa and some in um are fitted. Um It is also evidence based very tippy anorexia. Um Really the core tenants of family based treatment are empowering parents. So um what I often tell families is um this is not touchy feely therapy um The patient themselves likely will not like the therapist. Um uh It is not kind of television therapy of lying on the couch and talking about how you're feeling. It is really parent coaching in many ways about how to manage those um exact situations of the kids sitting at the table refusing to eat and um so it's meant to empower parents um to really not allow the eating disorder to be in charge. Um It also really focuses on separating the child from the eating disorder so that parents are able to see what is the eating disorder and and even remember some about what is their, what is their child and that these two entities um are not the same. Um and they're not they're not punishing their child, they're trying to get rid of the eating disorder even though it can it can seem uh more punishing. Um And I think, you know, as as um uh pediatricians um who may be following patients who are in F. B. T. Um you know, thinking about again how to um continue to um empower parents, um validating again that this is incredibly hard trying to reinforce everyone that no one is to blame. Um There can be often a lot of guilt, a lot of um blaming on every side. So trying to reinforce that message. Um I already talked about trying to raise, raise the level of concern to enhance engagement just to kind of piggyback on that, you know, family based treatment um often refers to the first session, the therapist often referred to the first session even as the the funeral session because it's really again meant to kind of raise urgency and parents about this being a life threatening illness and really the need for parents to kind of take control over it um provides some basic nutrition guidance to parents um even empowering them that you know most often they've successfully fed their kid up until this point and so trying to to reinvigorate them um to knowing they can do it um um uh For the patient I think it can be helpful to talk about common physical complaints that happen with re feeding. So you know letting them know to expect um that they're gonna feel full that they're gonna feel bloated, that they're gonna feel uncomfortable. Um You know that some things that can help or you know um abdominal massage or playing a game for distraction or thinking about some symmetric cone or trying to um uh to really um do some anticipatory guidance about some of the physical issues that um that may happen um And then also created A backup plan with everyone about what to do if if the teen or patient acutely refuses to eat. So when would they call you? When might they present to an emergency department? Um do they know to call their therapist? Kind of what would their plan B um if they're just um really refusing, you know, is it that they call you after 24 hours of not having eaten or kind of what are their safety steps? Um And that's kind of all of the slides that I have um I think that um you know the pandemic is is still ever changing and with us um And you know, we have seen a little bit of stabilization in terms of the numbers of patients that we're seeing. Um At least it doesn't seem to be increasing quite as it was. Um We've done a lot. Um and I think a lot more is known about how to manage patients with eating disorders via telehealth. Um That wasn't true before the pandemic. Um So those are kind of my my quick slides and um I'm gonna stop stop sharing and see if people have questions.