Associate Professor Megan Vo Hi, I’m Dr Megen  Vo. I’m a Clinical Associate Professor in the   division of Adolescent Medicine at Stanford  University, and today, we’re going to talk   about eating disorders in adolescents,  with a focus on diagnosis and management. I have no disclosures. And some learning objectives, I’d like  us to be able to recognise signs and   symptoms of eating disorders,  really be able to describe the   different diagnostic categories  of eating disorders, and describe   appropriate medical workup and outpatient  management, and recognise when to refer. I like to frame this in terms of a case,  which is really, honestly, a typical case   – a typical presentation of a young person who  might come to you with an eating disorder. So,   SH is a 12-year-old Asian-American female who  presents for her annual well-child check. She   has overall been well, however, during the visit,  her mom reports that for the past six months,   she’s been refusing to eat foods that mom prepares  at home, such as rice, and is now a vegetarian and   says she only likes American food. She’s  also increasingly interested in watching   Korean dramas online, and has made comments  that she would like to look like a K-popstar.   Mom also notes that she’s lost about 25lbs, and  has not had a menstrual period in several months. So, what now? We’ll come back to this. To frame, as we all know, nutrition in adolescence  is re – a really unique period of time, it’s a   time of great change, and their needs are really  high. They’re gaining 20% of their adult height,   they gain 50% of their skeletal mass,  in terms of bone mineral density,   their BMI is naturally increasing  as they go through the muscle spurt,   as well as the growth spurt overall, in  terms of length and bone mineral density,   and they have their maximal protein and calorie  requirements outside of the first year of life in   infancy. But poor eating habits are super common,  and it’s really a combination of social factors,   environmental factors, as well as, you  know, this risk of disordered eating. When we think about daily needs, for  the average adolescent just to grow,   who’s not doing anything other than just  living their life and going to school,   males will need up to 3,000 calories a day,  and females will need up to 2,800 calories   a day. I don’t advise calorie counting for  adolescents, but if you ever think through,   kind of, a typical adolescent intake, they  actually have to work pretty hard to meet   these caloric intake needs if they’re not eating  three meals and one to two snacks a day. So,   it’s really important that they also have  some oversight in terms of their eating. When we think about what their MaPRA nutrient  needs are, about 50% of what they need to grow   should come from carbohydrate sources, about  30% from fat, and protein about 20%. So,   adolescents, like everybody, are obsessed  with protein, and it turns out they don’t   need to have additional protein sources,  other than, like, a well balanced diet,   in terms of their daily intake, having a variety  of foods. But they will meet their protein needs,   really, from fruit and vegetable sources  alone, if they’re eating a variety of them,   so they don’t need to be going  overboard with protein supplements. If you add any kind of athletic activity on top of  that, and athlete’s defined as partaking in about   two hours of exercise per day, but, again,  depending on what they’re doing, if they’re   exercising intensively for a shorter amount of  time, they will also need more caloric intake.   They may need up to 1,700 extra calories a day, to  make up for their losses from energy expenditure,   as well as their increased basal metabolic rate,  from hypertrophying their lean muscle lean. There’s some really great studies on improved  athletic performance, reduced risk of injury,   and faster recovery, if young people who are  active are able to eat a post-workout snack within   two hours of activity. And if that post-workout  snack is about two-thirds carbohydrates and then   the rest pretty evenly divided between fat and  protein. Some great studies showing something as   simple as a 2% chocolate milk and a banana can  meet these needs, if somebody is exercising. And then, at the end of adolescence, when  they’ve, kind of, made it through the different   sexual maturity rating stages, and they’re at a  five, lean body mass will decrease for females,   and that is normal, and increase for  males. And then body fat composition   in females will increase, to be able to support  potential pregnancy and regular menstruation. I’m pulling up the Center for Ze – Disease –  I’m pulling up the Center for Disease Control   growth charts, that we use in the US, to just  demonstrate that it’s normal for people to   gain weight, over time, in adolescence,  even after the growth spurt. Because,   even after the growth spurt is done, young  people are going to go through the muscle,   and unfortunately for young women, the  fat spurt, which is normal, to achieve   an adult body habitus. So, even once the growth  spurt is done, people should be gaining weight. We like to use the Plate Model to describe what  people should be eating, because we really don’t   like to have people calorie counting and becoming  obsessive with the details of what they’re eating.   If somebody is eating every two to three hours,  if they’re eating three meals and one to snacks   a day, and it looks roughly like this, then we  know, you know, they’re going to meet their needs,   unless there’s something else gong on that  they have to be paying more attention. The caveat with this is if somebody needs to  gain weight, I usually advise them to shift   it more towards half plate of whole  grains, and then a quarter protein,   and a quarter fruits and vegetables. Because,  like we illustrated before, to grow, people do   need to take in about 50% carbohydrates, and  the same with weight gain, that carbohydrates   are going to be your friend if you need to grow. When we think through just briefly, as providers,   what the normal pattern of eating development  is, is that, it’s really normal to have a limited   palate in early childhood. But that really should  blossom at later school age, early teen years,   and then increase variety and flexibility into  adulthood. And that is because of the biologic   changes in terms of sensation of taste and  smell, and then the changes in the reward   pathway for food. But sometimes this development  can go awry, and that’s really where we become   worried that people are not meeting their  needs and maybe developing an eating disorder. So, when you're seeing somebody in your office,  and you have to do a billion things for them,   but you also need to screen them for nutritional  issues, deficiencies, eating disorders, you know,   what should you rely on? And I really advise  that paying attention to the data is going   to tell the story. Look at their weight,  look at their height, look at their BMI,   and look at it across time. People who are  meeting their needs, who don’t have an issue,   can really be left alone, and they will grow.  They’ll grow, and they’ll stick to one curve,   and you don’t really have to do much with  it. But if somebody is crossing percentiles,   up or down, or if they’re stagnating, which  will lead to crossing percentiles over time,   they’re not growing, then that’s where asking  more questions, getting more history, is key. So, some questions to think about, and these  could potentially we used as a screening tool,   you know, they could be written, having somebody,  like, fill them out before they even get to you,   so you’ve got the answers, that can be really  helpful. The questions I like would include,   do you have any concerns about your body weight,  shape or size? Have you ever done anything to   try to change your body weight, shape or size?  Have you ever tried cutting out foods that you   previously ate? Have you ever dieted? Have  you ever skipped meals or fasted? And then,   like, kind of, more nitty-gritty, like, have you  ever tried to vomit to lose weight? Do you know,   has your weight changed in the last year? And tell me what you’ve had to eat in the  last 24 hours. Everybody will always say,   “Oh, yesterday was Sunday, and I didn’t eat  well,” you know, like, there’s always something,   but it will give you an idea of, like, what does  a – just a typical day look like for this person?   Are they missing meals? Are there entire food  groups that they’re missing? Are they sleeping   all day, and so they can’t eat? That kind of  thing. But I think if you don’t have any time,   that’s your money question, take me through  the last 24 hours, what have you had to eat? So, some red flags that I alluded to, but I  just want to bring to your attention. Crossing   percentiles in the growth chart, people  should be growing. New restrictive diets,   particularly if they’re different from what the  family would normally eat. So, like in our case,   right, which is something that I frequently  see, I’m located in the Bay area in California,   so we have a huge multicultural population. So,  it’s actually really common for people to say,   like, “Oh, they won’t eat our normal cultural  food,” and so, like, diving more into that,   like, what does that actually look like? So,  new restrictive diets, particularly if it’s   different than the typ – family typically eats.  So, new vegetarianism, new veganism, Whole30,   keto, you know, anything that the rest of the  family isn’t eating warrants thinking about,   like, what is the driver here? And what you’re  worried about is, is body image the driver here? Changes in eating behaviour, skipping meals,  eating in secret, lunches coming back uneaten,   par – Teachers or other adults raising questions  about, you know, the person’s eating behaviour,   that is a red flag. And the biggest one would  be missed menses for those who menstruate.   Because it requires so much energy to keep  the menstrual system online that significant   changes in intake can really shut that down,  which is incredibly important for bone health. The SCOFF is another screener that’s validated,  that can be used if you’re wanting to screen for   eating disorder behaviour. And a yes on any  two of these questions would warrant further   history and potentially a referral. So, do  you ever make yourself sick because you feel   uncomfortably full? Do you ever worry you’ve  lost control over how much you’ve eaten? Have   you recently lost more than one stone in the  past three months? Do you believe yourself   to be fat when others say you’re too thin? And  would you say that food dominates your life? So,   a yes on any two of these is a positive  screen for eating disorder behaviour. So, how big is the problem? It’s incredibly  difficult to study across the entire population,   but community-based samples have really  been consistent in showing that about   10% of adolescents will meet criteria for an  eating disorder at some point in their lives.   Community studies also show that up to 30%  of just the general population may have some   disordered eating behaviour or a significant  body image dissatisfaction that doesn’t quite   meet threshold for full diagnosis, but is  impairing and is exis – is impairing and is   significant to the person who’s experiencing  it. So, it’s an incredibly large problem,   and as we’ll talk about, eating disorders  have the highest mortality rate of any   psychiatric disorders, so it is really  important to recognise and to treat early. When we think about the, kind of, traditional  eating disorders that come to mind when I say,   “eating disorder,” anorexia nervosa is about one  to 2% of the population, bulimia nervosa, about   3%, and then other eating disorders, including  avoidant restrictive food intake disorder, binge   eating disorder, a typical anorexia nervosa, those  will make up about the other 5% of the population. When you think about risk factors, really  eating disorders are multifactorial, there   is no one thing that causes an eating disorder.  So, you know, people can have any one of these   things and be fine, and not develop an eating  disorder, but it really is that perfect storm of,   if you have a couple of these risk factors, that  can tip you over the edge. So, we do know that   there is a genetic component to eating disorders.  There’s high concordance among monozygotic twins,   first degree relatives of somebody with an eating  disorder, are at higher risk of developing one   themselves. And mapping studies have really  identified loci around one – on exome 1P,   around the same loci of anxiety disorders, OCD.  So, they’re not the same thing, but we think that,   you know, like all psychiatric disorders,  there probably is a genetic component there. There are environmental factors. So, we do know  that eating disorders have a higher incidence in   Westernised countries, in that, you know, back in  the day when we were able to do these studies of,   you know, pre-Westernised societies that  were then introduced to Westernised media,   in the form of television at that time, that  the incidence of eating disorders actually rose,   after the introduction of Western media. Nowadays,  we do know that social media is a huge risk factor   for the development of body image dissatisfaction  and disordered eating behaviour, anyone who’s ever   been on Instagram or TikTok will tell you  that. So, there are environmental factors. Sports that have a high emphasis on  aesthetics are higher risk, though,   you know, anyone can – even non-athletes  can develop an eating disorder. So,   those sports might be, like, dance, ballet,  swimming, diving, figure skating, gymnastics,   those types of thing we do know may cause higher  risk than others, but again, all sports can be a   risk factor, as well as not sports – as  well as no sports can be a risk factor. There’s a higher incidence among girls, so about  ten to one, it’s described right now. But part of   this may be that the eating disorder diagnostic  criteria previously really were more female   centric. Boys are less likely to be recognised  early, they are less likely to say some of the,   kind of, red flag phrases in the way  that providers are used to hearing,   like, “I’m afraid of being fat.”  They may say things that are more,   like, they’re having an increased worry about,  like, lean muscle mass, athletic performance,   and muscularity, and so I think there’s  a combination of possibly genetic factors   putting females at higher risk, but  also lower recognition among boys. We also know that adolescence is really a  unique time for the development of eating   disorders. There really is something about the  developing brain that puts people uniquely at risk   of developing eating disorders, that once they’re  past adolescence and in Tanner Stage 5, their risk   of developing an eating disorder, all of a sudden,  out of the blue, when they had nothing, is lower. And there’s some interesting studies about  possibly the toxic effect of leptin, unregulated   leptin, so if somebody’s really hungry and they  don’t get fed because they – for whatever reason,   causing oxidative stress in the brain, which  may be a precursor to eating disorder behaviour,   but really uniquely during, like, certain sexual  maturity rating stages. So, there again, it’s   just something about this developing period that  makes you vulnerable. As well as other factors,   like, negative influence from peers or from other  people in their lives, can put people at risk,   so it really is the perfect storm. I’d like to just briefly think about   misconceptions that for any of us who do this  work really know, like, this just isn’t true,   but it may be something you hear from folks who  refer to you, from people out there who may not   have as much experience with eating disorders. So  it’s important to just recognise that these are   not always the case. So, one common misconception  would be that people with eating disorders are   always underweight. You know, we’ve talked about  how binge eating disorder is an eating disorder,   and folks with binge eating disorders typically  are not underweight. You can also have forms of   anorexia, like atypical anorexia, where you start  higher on the growth curve, and you lose weight,   but because you started higher, you  still end up on the growth curve. And so,   if somebody’s just looking at that one data point,  and not looking at the history, they can think,   oh, you're fine, but you are underweight  relative to where you are supposed to be. So,   this really isn’t true, that all eating  disorders, you have to be underweight. Another thing I hear a lot is people with eating  disorders don’t eat at all. “So, she eats,   so she must not have an eating disorder.” It’s  really that they’re not eating enough to meet   their needs, so they typically do eat, but it’s  just not enough. Something that is also a common   misconception is that it’s an issue of control,  that people with eating disorders can somehow   control what they’re doing, and, unfortunately,  it just is not the case. Some really great fMRI   studies, as well as other neuroimaging studies,  showing that the eating disorder changes the   micro and macro structure of the brain, so that  the young person’s brain just does the eating   disorder’s bidding, there’s no way that they can  control it. Which is why it’s so important for   them to have external help in battling it, because  the evidence really shows that people have a   better prognosis if their families are involved in  treatment, if they have a multidisciplinary team. That parents cause eating disorders. Now,  I did allude to genetic predispositions of   eating disorders, but it’s not that parents cause  eating disorders by saying something about food,   or making a comment about how the young person  liv – look – or making a comment about how the   young person looks in a swimsuit, but really,  like, there is no one cause to eating disorders,   and parents are an incredibly important part  of recognition, as well as treatment. And   that eating disorders only affect females  of affluent backgrounds. And, you know,   hopefully my case also illustrates that that isn't  true, that eating disorders can affect anybody,   any gender, of any background, and can look  all different ways, all shapes and sizes. This is just to illustrate the diversity  of eating disorder presentation. After the   change from DSM-IV to DSM-5, the thinking  between – the thinking behind refining the   diagnostic categories of DSM-5 was that fewer  people would hopefully be diagnosed with other,   or non-specified, eating disorders. Which, at the  time, you know, atypical anorexia nervosa, ARFID,   they, you know, were often rolled into these  not otherwise specified categories. And so,   what we’ve found is that, yes, that the  diagnostic statistical manual change in DSM-5,   what we found was the refining of those categories  did help people be categorised more in the, like,   specified categories, like anorexia or bulimia  or ARFID. But also that, for all comers,   that people really were of average weight with  all eating disorder diagnoses. So, again, like,   people don’t have to be underweight to  be diagnosed with an eating disorder. So, just thinking through the different  diagnostic categories of eating disorders,   and thinking through the diversity of the  presentation, these are the diagnoses we’re   going to discuss today. And this was the slide  I was referring to in terms of, like, you know,   refining the categories. So, with the change  from DSM-IV to DSM-5 more people fitting into   anorexia and bulimia, and fewer into these  not otherwise spec – specified categories. Briefly, before we talk about the diagnoses,  for anybody who’s been doing this work over   the last three to four years, we’ve recognised the  effects of trauma on eating disorders. And so, we,   at Stanford, are part of a collaborative that  described what happened with eating disorder   admissions during the pandemic. And we, as well  as 13 other centres across the United States and   Canada, on average, recognised an 18% increase  in admissions to our inpatient hospitals for   medical stabilisation for eating disorders, as  well as a 23% increase in the request for new   assessments. So, this is something that we’ll  continue to learn about in the coming years,   but I think all of us really recognise the mental  health crisis that accompanied the pandemic,   and that really is a secondary  pandemic among our adolescents,   needing more help and more care and attention,  to help them through this very difficult time. So, this is admissions over time,  and you can see the increase,   as well as kind of broken down by  site. And then these are, you know,   requests for outpatient assessment also,  a vast increase over what was expected,   had the pandemic. And then this was a – one of  the sites is an intensive outpatient programme,   they also had a huge increase in requests  for treatment and new assessments.