Anorexia nervosa I think we’re most familiar with,  and the criteria in DSM-5 are fairly simple. One,   you have to have a restriction of food intake  that leads to a low body weight. There is no   longer a cut-off for how much you have to  weigh, or what percent ideal bodyweight,   or what BMI you have to have, to be low weight.  What this means is that you have to be low,   compared to where you were expected to be,  if you were not restricting your intake. There are suggestions in the DSM-5 of, like,  how you could think about this objectively,   but they really are mostly for adults. So, for  adolescents, we should be thinking about people   in terms of their percentile. And if you’re  falling from your percentile, then, you know,   that would meet criteria for low bodyweight,  compared to where you are supposed to be. And this has to be driven by body image  distortion and an intense fear of gaining weight   or being fat. We know that the eating disorders  change people’s perception of their own body,   so they really aren’t able to be objective  and logical about what their body looks like,   or their experience of it. And  so, they will often say, like,   “I must weigh 200lbs, you know, if I ate  that cracker, I would gain 15lbs,” you know,   it’s just not based in logic, and  that is where the pathology lies. I alluded a little bit to the ways that boys and  girls may talk about this differently, and in –   it’s not always the case, right, like, it – it’s  just recognising that there may be some diversity   in the language that we use, but paying attention  to it. So, boys will often say that they have   a focus on lean muscle, not wanting to gain fat,  would be okay with gaining muscle, and restricting   what they’re eating in an extra way, in an effort  to only gain muscle. Excessive exercise, again,   like, really focused on leanness, performance,  athleticism. I have had more than one young person   be so driven by this athletic performance, by this  desire for muscularity, that they would sneak out   in the middle of the night to go running, like,  multiple young people. So, it can look like that,   where there’s just, like, pathologic drive,  that’s less like, “I don’t like my body, I’m   afraid of being fat,” and more, like, this extreme  focus on muscularity, leanness, performance. Previously, like DSM-4, previous iterations of the  DSM, required people to have certain BMI cut-offs,   certain weight cut-offs, amenorrhea,  or refusal of weight maintenance,   which really implies that there’s some,  like, [additional – 0323] component to this,   and these are no longer part of the  diagnostic criteria. So, if you have   somebody who has body image distortion, concerns  about weight gain or being fat, and weight loss,   such that they are deviating from their previous  curve, that I would argue would be something that   you would really be thinking about, like, hey,  is this meeting criteria for anorexia nervosa? This really has to be persistent  over the last three months,   and there are two different sub types,  because it isn’t always just restricting,   although that’s what we commonly think about,  like, they’re just restricting, restricting,   restricting. But it can be very difficult to  restrict your intake for that long over time,   so some people also have periods of binge eating  and purging, but it’s just not frequent enough   that they’re not losing weight. People who binge  can take in thousands of calories in one sitting,   and so people who really have persistent,  frequent binge eatin – binge eating and purging   often don’t lose a lot of weight. But people with  anorexia can have periods of binging and purging,   but if they’re losing weight or if they’re  a low weight, that’s why they would not meet   full criteria for bulimia nervosa, and we’ll  talk about binging and purging in a moment. Some clues by history would be, like, restriction,  obviously, really focused on healthy or righteous   eating, a refusal to eat things that are unclean  or unhealthy. Rituals around food consumption,   you can often notice some really, like, extremely  disordered eating behaviours, like micro-cutting,   micro-biting. Interfering with the taste of food,  because the eating disorder will distort the way   they experience the food, and almost punish the  young person for eating something such that,   like, it can’t taste good, it must be a  punishment. So, you might see them put,   like, excessive amounts of salt or  pepper, or hot sauce, or, you know,   things like that on the food, so that it  distorts the taste so it’s not pleasurable. Eating in secret, you know, changes in their  appearance, of course, prolonged or frequent or   excessive exercise, as I alluded to. Inability to  sit, you know, they’re just constantly standing,   they’re constantly moving, they just can’t be  restful ‘cause the body’s just trying to churn   through energy, to burn calories. Sometimes you’ll  see them be really interested in food preparation   for others, super interested in cooking and  baking, but they don’t eat what they make, or   they might taste it and throw it away, that is a  huge red flag as well. So, it’s almost channelling   sublimating their feelings about food to provide  for others but they can’t enjoy it themselves. And I always like to put this in, that school  performance is generally excellent. School is   remarkably preserved, because the brain has  enough energy to really do things that don’t   require a lot of flexibility or deviation  from what they’re supposed to be doing. So,   school is one of those things, right,  you do what the teacher tells you,   you bring in your assignments when you’re  supposed to, it’s actually pretty easy to   do. And so usually families will say,  “Oh, but their performance at school,   their grades are excellent,” and it’s like, yeah,  they usually are. But it’s everything else that’s   falling apart, social isolation, withdrawing  from friends, withdrawing from activities,   ‘cause all the eating disorder wants  is to be alone with the young person,   and influence them so that they lose weight.  Anything that gets in the way of that is cut. So, moving onto bulimia nervosa. So, I alluded  to you can’t be low weight to meet criteria for   bulimia nervosa. If you are low weight, then you  may meet criteria for anorexia nervosa, binge,   purge sub type. Well, it’s a little potato,  potato, right? I think this is important from   a communication standpoint, to communicate  with other providers, and among a team,   okay, you’re, like, succinctly, what are  the behaviours we’re worried about here?   As well as from a research perspective,  of, like, hey, phenotypically, you know,   we may think about these differently, do they have  differently, do they have differences in terms of,   you know, their lab results or their prognosis  or their vital signs, that kind of thing? But,   you know, e – people don’t behave in nice, neat  categories, so it’s also okay if, you know,   we kind of put a pru – provisional diagnosis  and things shake out over time and you adjust. But for bulimia nervosa, you can’t be low  weight, and you have to have, on average,   one episode of binge eating with a con  – compensatory behaviour, per week,   on average for three months. So, you may  go two weeks without binging and purging,   and then you may binge and purge five times in a  week, you know, and, on average, it works out to   about once a week for three months, that  would meet criteria for bulimia nervosa. Binge eating, you know, is defined as, in an  objective amount of time, so, for example,   in a two hour period, somebody’s rapidly consuming  more food than a typical person would eat in   that amount of time, that is accompanied by  intense feelings of guilt, or loss of control.   They don’t want to be doing it, they feel very  uncomfortable, they want to stop, and they cannot. And then, it’s followed by an  inappropriate compensatory behaviour,   we typically think of vomiting, but it  could be excessive exercise, that is,   like, temporarily related to the binge. Could be  diet, it could be diuretic of laxative misuse,   you know, I just had a binge, I’m going to take a  handful of laxatives to try to flush it out of my   system. And this compensatory behaviour really  has to be, kind of, associated with the binge. And the – this is all driven by body image  distortion, [clears throat] and a desire   to influence their body shape or size.  You know, when you think about, like,   a binge, [clears throat] people with anorexia  may say that they binge. And so it’s really   important to quantify, like, hey, what does that  look like? When – last time you binged, like,   what was it? And it’s very telling, right? A true  binge is really more food than somebody would eat   in that time period, but people who would restrict  may say, like, a normal amount of food is a binge   for them. And while, you know, you could consider  it a subjective binge, because it’s distressing to   them, and it’s more than they typically eat. An  objective binge is, like, people usually have a   trigger food, and there’s usually a trigger event,  because binges are, at their root, poor coping. So, I’m feeling very stressed out, I’m  feeling very sad, or lonely, I’m bored,   that kind of thing, triggers a binge, and people  often have a trigger food [clears throat] that   will, kind of, set it off, so carbohydrates  or something highly palatable, very salient,   where I’m going to eat some cereal, and it  triggers me. And so I eat not one bowl of cereal,   but I eat the whole box, and then I eat all  of the stale boxes of cereal in my pantry,   you know, even though I don’t want  to, even though it doesn’t taste good. And then I move onto other foods, all the  ice cream, all the butter, without toast,   just the butter, you know, all the expired  things, because you just can’t control it.   While this is happening, they feel terrible, they  don’t want to be doing it, they feel too full,   they feel really unhappy, but again,  it’s maladaptive coping that’s causing   this to happen. And then the compensatory  mechanism, like we talked about, vomiting,   excessive exercise, you know, 2am I’m  going to get on the treadmill because   I just finished a [dinge – 1154], like,  that kind of thing, very, very abnormal. So, some clues by history, other than what we  just talked about, would be, like, you know,   poor coping binging triggered by stress,  anxiety, some negative emotion, eating in   secret. They don’t clean up when they’re binging,  so families will usually know when it’s happened,   you know, everything will be gone, the kitchen  will be a mess, the wrappers are everywhere.   They might find food wrappers in the person’s  room that aren’t cleaned up, that kind of thing,   can be a really big clue. Using the bathroom after  meals, and, you know, people have to use bathroom,   but if it’s, like, every time, they finish  eating, like clockwork, they run to the bathroom. And certainly if people are hearing any sounds,  like, the water’s running, sometimes the drains   get clogged, that kind of thing, can be a clue.  In extreme cases, sometimes people actually, like,   kind of, vomit in bottles or bags and don’t throw  it away, and parents can find that. And then,   you know, preoccupation with body weight,  shape or size, comments about it, like,   excessive negative comments about themselves,  about their bodies, is a huge red flag. You know, there are people who only have the  binge and don’t have the compensatory purging,   or the compensatory behaviour, and those people we  would diagnosis as having binge eating disorder.   Which is a new diagnosis in DSM-5, but it is the  most common eating disorder in the United States,   and really is something that, from a Primary  Care perspective, warrants paying attention to,   in terms of, like the obesity epidemic. While  most people with obesity do not have binge   eating disorder, about two thirds of people  with binge eating disorder do have obesity. So, it’s just important to think through  when you have somebody in your office,   like, what are the behaviours, and what is  the history here? So, then you can, kind of,   target your interventions. It’s often accompanied  by other comorbid, mental or medical disorders,   right? If two thirds of people with binge  eating disorder are also diagnosed with obesity,   they may also have metabolic syndrome, diabetes,  hypertension, so it’s important to recognise. And so this, like bulimia, you have to have, on  average, one episode of binge eating per week,   for three months, to meet diagnostic criteria. You  know, just an aside about binge eating disorder,   ‘cause, you know, we are talking about all eating  disorders, they – binge eating disorder can be   first diagnosed in childhood or adolescents. So,  it’s important to start paying attention to this,   even early on, even though the majority of people  will have their first binge after the age of 18.   But people who develop binge eating disorder  in childhood m – have a higher risk of having   another eating disorder, or being diagnosed with  another eating disorder, during their lifetime. They often have greater severity  of those eating disorder symptoms,   particularly bulimic symptoms, and  it is often associated with, like,   more attention to their weight and their shape  and size, from an early age. There’s also a   higher risk of trauma, or a higher association  with trauma, I should say. So, this is where,   again, you know, I’m saying this over  and over again, where history is key. I’d like to spend a few minutes talking about  avoidant restrictive food intake disorder,   since it’s a relatively new diagnosis, new to  the DSM-5, though I think for anybody who has   seen children [laughs] over the last 20 years, you  know, we’ve known – not even 20 years. For anyone   who’s cared for children, even before DSM-5, we’ve  known kids like this have existed, we just now   have a shared language for it. So, avoidant  restrictive food intake disorder, or ARFID,   I think about as pathologic picky eating. It is  not driven by body image disturbance, but these   young people have such extreme restriction in the  things that they eat, or their eating behaviours,   again, not driven by body image, that they  can’t meet their needs and they can’t grow. So, there’s three sub categories of  ARFID that are coming to light now,   now with increased recognition. One would be the  kind of pure, pathologic picky eating, or what   we call selective eating. So, families will often  say that these kids just were terrible eaters from   the beginning, they were terrible breast feeders,  they didn’t accept the bottle, they had a terrible   time introducing solid foods, and then really,  like, have – after sol – introduction of solids,   had a really restrictive range of  foods that were acceptable to them. And often, these kids can kind of putter by  in elementary school, you know, they may be   low on the growth curve, but they’re often,  like, kind of, just hanging out right at that,   you know, third percentile, fifth percentile.  They can meet their needs, they’re not huge,   they may not even be, you know, at their  parental potential, their genetic potential,   but they, kind of, roll along the curve.  And then, adolescence hits, puberty,   their increased needs skyrockets, but they  just don’t have enough acceptable food to   meet their needs, and they deviate from the  curve, and that’s really where trouble hits. So, they may not be losing weight,  but they don’t grow appropriately,   and then it really is exacerbated during puberty.  And this is usually where, like, you know, they   don’t necessarily have, like, huge, significant  medical sequela early in life, but as puberty   hits, and their energy needs are not met, this is  where they can often have vital sign instability,   more, like, nutritional deficiencies, the  need for admission really can hit then. The second sub type would be people who are – the  – what we call fear of aversive consequences. So,   they have some kind of insult, where they are  then afraid to eat, and afraid of the negative   consequence of eating. Again, it’s not body image  disturbance, it’s, like, a fear of choking, a fear   of vomiting, a fear of abdominal pain, a fear of  poisoning, that’s one that I have seen before. And so these people often have a growth curve  that looks like anorexia, where they’re, you know,   going along their curve just fine, and then  something happens, they have a GI illness that   leads to vomiting, and then they’re just so afraid  of vomiting afterwards, choom, they lose weight.   It can be associated with anxiety, or obsessive  compulsive disorder, so it’s also important to,   kind of, get some history there on, like, is  this somebody who’s always been an anxious   person? Who’s always ha – been a little bit  ritualised? Because there is an association there. And then third sub type is the low interest,  so these are the young people who just – they   seem to be wired differently. They just  have no interest in eating, you know,   their hunger signals just aren’t  salient enough to them for them to   respond appropriately. They could go all  day without eating and not really notice,   and then the parents come home at the  end of the day, and they’re, like,   “What did you eat today?” And they’re, like, “Oh,  I didn’t eat.” But it doesn’t really bother them. There is an association with ADHD, I have noticed  an association with screen time, you know,   it seems to be, like, the way that screens hold  their attention can really help them override   the hunger signals. And their growth curve  often looks the same as the selective eaters,   where they just, like, kind of, putter along,  kind of, low on the growth curve, and then   puberty hits and they don’t meet their needs,  they just kind of skate long. And that’s where,   again, like, vital sign stability, failure  to thrive, failure of growth is compounded   by the deviation between what they’re supposed  to be doing and what their body is able to do. De – distinguishing these types of ARFID  from just normal, old picky eating is that   it really has to be significant in the  way it’s, kind of, shown. Like, either   they have significant weight loss or a failure to  thrive, failure to achieve their expected weight   gain or growth. It can lead to significant  nutritional deficiencies, such as scurvy,   vitamin D deficiency, other deficiencies. They  can become dependent on Enteral supplements,   or other nutritional supplements that are not  food, like, Ensure or Boost to meet their needs,   which is not typical and abnormal [laughs]  for a child who would be growing normally,   so that can be part of the diagnostic picture.  Or just significant interference with their   psychosocial functioning, the kids who can’t eat  at school, who can’t eat around other people,   who can’t attend social events, because there may  not be anything for them to eat. I’ve certainly   had families who’ve said, like, “We haven’t  travelled since the child was born, because   they just wouldn’t eat, and so there’s nothing  we can do.” That’s really abnormal, and that   would distinguish it from normal, picky eating,  where you have, like, a, you know, a toddler   who only wants to eat dino nuggets, like, may –  that may be age appropriate, this is different. Some other things just to keep in mind, so  it can’t be – ARFID can’t be in the context   of a lack of food or an unavailability of  food, or culturally sanctioned practices,   right? So, many different cultures have,  like, fasts, as part of their normal,   cultural behaviour or religious behaviour,  like, the ARFID can’t really be because of   that. You really can’t attribute it to another  medical condition. I will say, though, that,   like, you know, there are associations and  comorbidities we frequently see, like, anxiety,   OCD, pervasive developmental disorders, or autism  spectrum disorders. Like, ARFID can occur in the   context of those disorders, and having one of  those doesn’t preclude you from having ARFID. But, for example, like, if someone has oesophageal  – eosinophilic oesophagitis, and they can’t eat   because they have eosinophilic oesophagitis,  [laughs] like, I would argue that you can’t   necessarily diagnose them with ARFID, unless  you have a very pervasive picture beyond their   current diagnosis, their current other medical  diagnosis I should say. You know, it – ARFID   can persist into adulthood, it’s very important  to treat it early, so that hopefully it doesn’t   interfere with their psychosocial functioning in  adulthood, when parents may not be as involved. And they may also go on to develop  another eating disorder. Sometimes   people just don’t have the words to  say what they’re going through, or,   you know, they have one eating disorder and,  over time, they may develop another. So,   having one eating disorder doesn’t preclude from  having another presentation at another time. You know, some things to think about, to  distinguish ARFID from normal behaviour,   or other, you know, sort of, behaviours. So,  like, avoidance of foods based on sensory   characteristics, so they won’t do sauces, they  won’t do squishy food, or they won’t do crunchy   food, ‘cause they’re worried about choking. Like,  avoidance in an extreme way, really only eating   very small portions. I take care of a lot of  young people, both on the inpatient and the   outpatient side at our hospital, and there’s  often a phenomenon where, like, no matter what   they’re presented with, they only eat 20% of  it, or only eat, like, a certain percent of it,   because that’s just, like, what they can accept,  no matter how big or small it is. So, you know,   only eating a small portion consistently is red  flag. Really just, like, having no appetite,   having, like, really no interest in food,  is something else that can be associated. Or   being afraid of eating, or afraid of an aversive  consequence to eating, that is also a red flag. You know, when we think about the way that these  people present, I’ve kind of alluded to it,   and for anyone who takes care of people  like this, this is probably what you’ve   seen as well. Compared to people with  anorexia nervosa or bulimia nervosa,   young people who are diagnosed with ARFID are  often younger, so usually it’s early adolescence,   so 12.9 years versus 15 to 16 and a half  years for anorexia and bulimia. They have   been shown to have a longer duration of  illness, because it’s usually a lifetime   problem. They are more likely to be male  than other types of eating disorders. And   their percent median bodyweight in this study  was in between anorexia and bulimia nervosa,   so median bodyweight being the weight that would  correspond with the 50th percentile of BMI. We no longer use ideal bodyweight, or  estimated bodyweight, we really talk   about things in terms of, like, where are you  in relation to the 50th percentile for BMI?   Or if you’re adjusting that, right, ‘cause  they were never a 50th percentile person,   even before all this happened, then you  might use the term treatment goal weight,   to really describe what we’re  – what are we getting at here?