Associate Professor Ellen Fitzsimmons-Craft  Hi, thanks so much for having me. I’m Ellen   Fitzsimmons-Craft, and I’m an Associate Professor  of Psychiatry at Washington University School of   Medicine, and I’m really pleased to be here today  to talk with you about eating disorders. In terms   of an outline of what we’ll be going over today,  first, we’ll be talking about the diagnostic   criteria for eating disorders and their features,  warning signs, what eating disorders look like,   the biopsychosocial model, and also, a  bit about screening for eating disorders. So, first, I just wanted to start off highlighting  a recent report that came out in the last couple   of years, on the social and economic cost  of eating disorders. This was specific to   the United States but preven – provides some  great data to provide some context for the   importance of this problem. So, first, just in  terms of the prevalence of eating disorders,   we know that about up to nine or almost 10% of  individuals will experience an eating disorder in   their lifetime, which in the US, amounts to almost  30 million Americans that will have an eating   disorder at some point. Eating disorders are also  extremely severe, and can have high mortality,   and research has shown that there are up to –  over 10,000 deaths per year as a direct result of   an eating disorder, equating to one death every 52  minutes. We also know that eating disorders affect   everyone, despite some of the stereotypes,  and we’ll talk more about that in a bit. Eating disorders are also highly costly to  society. As you can see here, this report,   which was put out as a collaboration between  a group at Harvard and the Deloitte Economic   Access Team, found that the yearly economic  cost of eating disorders was almost 65 billion,   with an additional loss of wellbeing per  year equating to about 327 billion. This   includes very high cost to the hospital systems  in terms of both high costs for Emergency Room   visits and inpatient hospitalisations,  as well as, you know, loss of wellbeing,   that’s kind of borne by individuals and family,  government, employers, society. So, clearly,   these are really severe common problems  that we need to find some solutions for. But first step, of course, is to better  understand, and so, let’s talk a little   bit about eating disorder diagnoses. So, we’ll  go over each of these now, in terms of the DSM-5   criteria for each and some of their features.  So, first, let’s talk about anorexia nervosa,   or AN. So, according to DSM-5, the first criterion  for this disorder is restriction of energy intake,   relative to requirements, that leads to a  significantly low body weight. And here,   significantly low weight is defined as a weight  that’s less than minimally normal, or for   children, less than minimally expected. It’s also  accompanied by an intense fear of gaining weight   or becoming fat, a disturbance in self-perceived  weight or shape. We’re often finding that weight   and shape are among the most important things  for a person’s self-evaluation. And it comes in   one of two sub-types, the restricting sub-type,  or the binge eating and purging sub-type. So,   in the restricting sub-type, there would  not be any binge eating or purging present. In terms of features of AN, we see a lifetime  prevalence of about 1%. Historically, we’ve seen   a prevalence of about 90% female to 10% male,  and it’s also been shown to be more prevalent   in occupations and sports where having a lower  body weight may be seen as advantageous in some   way. So, for example, wrestling, dancing,  running, gymnastics. In terms of onset,   this usually onsets in the teen years, although  typically, we see two peaks. One being around   the age of 13, when many individuals, and girls  in particular, are entering puberty and their   bodies may be changing. And then another  around the age of 18, when individuals may   be experiencing life transitions, such as going  off to university or starting in the workforce. In terms of course, this can be variable.  Less than half of individuals with anorexia   nervosa have been shown to fully recover and  about 20% do experience a chronic course. But   younger age of onset is associated with  better outcome, as is early intervention,   really highlighting the need to address these  problems as soon as they’re identified. And   in terms of mortality rate, this can be  up to five to 10%, which is one of the   highest mortality rates of any psychiatric  illness, second only to opioid use disorder. Regarding physical consequences, this  can include things like osteoporosis,   brittle hair and bones, having yellowish skin,  lanugo that can develop, so that’s that kind   of downy hair on the face and limbs. We  can also see impaired renal function,   bradycardia and heart attacks and  cardiac failure. So, as you’ll recognise,   many of these physical consequences are  really side effects of starvation. So,   these are, again, you know, very serious  mental illnesses that shouldn’t be ignored. So, moving onto the DSM-5 criteria for bulimia  nervosa, or BN, the first criterion is this   involves recurrent episodes of binge eating, which  can be described in terms of two key features.   First, eating an amount of food that’s definitely  larger than what most individuals would eat,   in a similar time or circumstances.  So, you know, more than – for example,   many people may have a little more than they  usually do at a holiday meal, but this is,   kind of, eating an amount that would be much  larger than what most individuals would eat,   you know, maybe for a more regular meal or any  time of day. Accompanied by a sense of loss of   control overeating during the episode. So, that  loss of control is often described as feeling like   a ball that’s rolling down a hill, or feeling  like you just can’t stop once you get started. Those recurrent episodes of binge eating  are accompanied by recurrent inappropriate,   compensatory behaviours that individuals engage  in, in order, or in the hopes of preventing the   weight gain that they believe can be associated  with those episodes of binge eating. So, these   would be behaviours like self-induced vomiting, or  using laxative or diuretics, engaging in fasting,   so, you know, going a whole day or more without  eating, or excessive or compensatory exercise. In order to meet DSM-5 criteria, these  behaviours are engaged in for, on average,   about one time a week for three months. And  we also see in BN that that self-evaluation   is unduly influenced by body weight and shape,  so again, we see that body weight and shape are   among the most important things in terms  of how individuals judge themselves as a   person. And finally, this disturbance doesn’t  occur during episodes of anorexia nervosa. So,   if an individual has lost substantial  amounts of weight and is underweight,   as we discussed in AN, even if they were  engaging in some binge eating and purging,   that would not be defined as bulimia nervosa.  That would be that AN, binge purge sub-type. Regarding the features of bulimia nervosa,  this has a bit higher lifetime prevalence,   about one to 2%, and we still, historically, have  seen about 90% females to 10% males. Onset tends   to be a little bit later than anorexia nervosa,  so usually from about age 15 to the early 20s,   and the course can be chronic or  intermittent. We do see a crossover   to other eating disorder diagnoses occur in a  minority of cases, for example, to, you know,   binge eating disorder, other specified feeding or  eating disorder, which we’ll talk about in a bit. Mortality for this disorder is lower than that of  anorexia nervosa, but risk of suicide and suicide   attempts is higher. And regarding the physical  consequences of bulimia nervosa, a lot of these   can be contributed to the recurrent engagement and  binge eating and self-induced vomiting behaviour,   in particular. This can include things  like swollen glands in the neck and jaw,   rotting teeth, which actually leads Dentists to be  ones that often identify cases of bulimia nervosa.   We can see liver and kidney damage, electrolyte  imbalance and also, rupture of the oesophagus. So, moving onto the next main  eating disorder diagnosis in DSM-5,   which is binge eating disorder, or BED. So,  this is recurrent episodes of binge eating,   just like we talked about in bulimia nervosa,  that are characterised by a large size,   as well as that experience of loss  of control that we discussed. And   the binge eating episodes are associated with  three or more of the following features. So,   one, eating much more rapidly than usual, two,  eating until feeling uncomfortably full, three,   eating large amounts of food when not feeling  hungry, four, eating alone because of feeling   embarrassed by how much one is eating, and five,  feeling disgusted with oneself, depressed or very   guilty afterwards. This is associated – this  pattern is associated with very high distress,   and on average, the binge eating is occurring one  time a week for three months, to meet diagnostic   criteria. And this is not BN or AN, so those  diagnoses really trump this one in the DSM-5. Regarding features of BED, the  lifetime prevalence is higher,   about three to 5%. We see a three to  two ratio of adult females to males,   and in adolescence, that ratio is three  to one, girls to boys, so this one is more   common in men than other eating disorders  we’ve discussed so far. In terms of onset,   this typically occurs during late adolescence or  early adulthood, so up to the mid-20s, but it’s   more likely than the other eating disorders  to develop later in life. In terms of course,   the natural course of binge eating disorder is  often longstanding. We can see an average duration   of 14 to 16 years, and it can take quite a while,  unfortunately, for individuals to be identified   with BED and to receive services, sometimes.  And we do see a high rate of crossover to BN,   and vice versa. Importantly, BED also does affect  individuals across the weight spectrum, but it is   two to four times more common among individuals  who are experiencing overweight or obesity. So, OSFED is other specified feeding or eating  disorders. So, these are a few different   categories in DSM-5, that don’t quite meet those  diagnostic criteria that we just discussed for AN,   BN and BED, and then a couple of other important  eating disorders are noted, as well. So,   under the OSFED category, an individual could  be presenting with atypical anorexia nervosa,   so we see all the same features of anorexia  nervosa, except that the individual’s weight is   not technically in the underweight range. So, this  may be somebody who’s still lost quite a bit of   weight and we’re seeing, you know, that very high  emphasis on weight and shape, but their weight may   still be above, you know, sort of, the minimal  threshold of what’s been determined normal. We can also have diagnoses of BN and BED that are  of low frequency, and/or limited duration. So,   maybe they don’t quite meet that frequency of  one time per week, or they haven't yet – those   behaviours haven't yet been in existence for three  months, so we can use an OSFED diagnosis in those   case. Purging disorder is a repeated engagement  in purging, without the accompanying binge eating   behaviours. And then finally, night eating dis –  syndrome is recurrent episodes of eating at night,   typically after one has gone asleep and then  wakes back up. So, that’s an OSFED presentation,   as well. And then, finally, we have  unspecified eating or feeding disorder,   which is a bit of a catch-all diagnosis, and is  characterised by presentations in which symptoms   characteristic of an eating disorder do cause  clinically significant distress or impairment,   but don’t meet the full criteria for any of the  other diagnostic categories that we’ve discussed. One more eating disorder of note is  avoidant restrictive food intake disorder,   or ARFED – ARFID. And this is an eating  or feeding disturbance that’s often   manifested by a persistent failure to meet  appropriate nutritional and/or energy needs,   and is associated with one or more of the  following. And so, first, I should say,   this might be an eating or feeding disturbance  like having a total lack of interest in eating   our food, or maybe avoiding certain types of foods  based on the sensory characteristics of the food,   maybe not, you know, liking how they feel. Or even  concern about the aversive consequences of eating,   maybe an irrational fear of vomiting,  for example. And this eating or feeding   disturbance might result in significant  weight loss. So, this is, you know,   failure to achieve that expected weight  gain or faltering growth in children,   so maybe kids who are falling off their growth  curve, a significant nutritional deficiency,   you know, dependence on supplements, and/or  marked interference with psychosocial functioning. So, importantly, this disturbance is not  better explained by a lack of available food,   or by any sort of culturally sanctioned practice.  And it’s also important to note that this is   not accompanied by any major weight and shape  concerns. So, this eating and feeding disturbance,   you know, would not be seen as being a result  of having, you know, a high level of body   dissatisfaction, or a high level of concerns about  weight and shape. You know, it’s really, kind of,   manifesting on its own, and wouldn’t better  be diagnosed as anorexia or bulimia nervosa. So, as you heard me talk about, you know, when  we discussed some of the gender breakdowns in   our eating disorder diagnoses, you know,  I talked about men and women. Because,   historically, we’ve had the most research  on eating disorders in those populations,   and particularly, most of our research has been  in girls and women, and even more research,   you know, has really focused on white cisgender  girls and women. But we do know that transgender   and gender diverse individuals do face significant  stressors, including things like discrimination,   barriers to healthcare access, peer victimisation,  and family rejection and maltreatment. And these   stressors, independent of, or in concert with,  gender dysphoria, or not feeling like one’s,   you know, gender assigned sex matches with their  gender, may elevate risk for eating disorders. There has been more recent data that have – has  found that variation in reported prevalence of   eating disorders in transgender and gender  diverse populations ranges from two to 18%,   with rates of disordered eating even greater.  And other research has also shown that these   individuals may experience greater severity  of eating pathology. So, for example, research   has shown elevated rates of self-induced vomiting  and diet pill and laxative use in transgender and   gender diverse young adults, compared to their  cisgender peers. And it’s also been shown that   these individuals have higher suicidal ideation  and attempt rates than individuals with EDs who   aren’t transgender or gender diverse. So, really,  an important population that’s actually quite at   high risk for eating disorders and that we  need to do more research on moving forward. And, overall too, just to further highlight  the magnitude of the problem, as we discussed,   you know, anorexia nervosa has a prevalence of  around one to – 1%, bulimia nervosa one to two,   you know, binge eating disorder, somewhere in  the three to five range. And then we have that   whole other specified and unspecified eating  disorder categories, which amounts of pretty   high prevalence of eating disorders as – over  the lifetime, as we discussed in the beginning,   up to a 10% lifetime prevalence,  so these are not uncommon problems. They’re also problems that have very high mental  health comorbidities. So, one very large study   found that over 50% of individuals with anorexia  nervosa had another Axis I diagnoses – diagnosis,   with anxiety disorders and mood disorders very  prevalent, as well as substance use disorders.   In bulimia nervosa, comorbidity was even  higher, up to 95%, with again, anxiety and   mood disorders very common, and substance  use disorders also common. And then in BED,   we see another Axis I diagnosis in 70% or more  of cases. These disorders can also be comorbid   with personality disorder diagnoses, including  in anorexia nervosa, it can be quite common   to see those Cluster C diagnoses, those anxious  avoidant personality disorders, and in Cluster B,   the more dramatic, erratic presentations. So, moving on, let’s talk a little bit   about warning signs for eating disorders.  So, in terms of warning signs or symptoms,   or what to look out for in individuals who  may be experiencing these concerns, first,   there may be very high preoccupation with food,  eating and/or calories. So, individuals can engage   in a lot of cooking or baking, or obsession with  recipes, but really refusing to eat, you know,   maybe most of that food that they’re cooking or  baking or cutting out the recipes for. There can   be a really high obsession with watching cooking  shows or cal – counting calories obsessively,   cutting out food groups. There can also be very  high reluctance to eat with others. You know,   maybe someone who’s saying, “I’ve already  eaten,” or they bring their own food to   meal outings in a way that isn't typical of  what their peers of family members are doing. We can also see food rituals, so  cutting food into really small pieces,   and pushing that – those little pieces around  the plate, maybe to make people, kind of,   think that they’re eating, but, sort of, you know,  kind of, distract people about that, and also,   an excessive use of condiments. There can also  be secretive behaviour related to eating. So,   this might be especially prevalent in those  binge type presentations, where maybe there’s,   you know, food missing from the home, or  wrappers are, kind of, found in the car or in   the individual’s bedroom. And then maybe a  pattern of starting to notice that somebody   is really regularly using the bathroom shortly  after eating, which would likely be to vomit. There’s also those high weight and shape  concerns. So, this can include really frequent   self-weighing, or really frequent use of the scale  at home, maybe wearing baggy clothes to hide their   shape. Individuals can also spend a lot of time  scrutinising their shape or their body in the   mirror, or engage in a high level of body checking  behaviour, you know, pinching skin on the stomach   or on the thighs, or things like that, just to,  you know, do their own assessment of how they   measure up. And then, finally, we may see some of  those physical signs that we talked about before. So, as we’ve discussed, you know, these are  really important problems to try to detect as   early as possible, and in the US, the National  Center of Excellence for Eating Disorders has   put out a really nice checklist to recognise the  symptoms of an eating disorder. This is freely   available at the link noted on this slide. And  this checklist will help you to understand those   signs of an eating disorder, so you can help to  get people the help that they need. This could   be a good checklist to use in Primary Care,  or even just for any provider or individual   who might be concerned about somebody. And  so, this is a good one to keep on hand. So, let’s talk for a moment about what do eating  disorders look like? Eating disorders have often   been stereotyped as affecting skinny, white,  affluent girls, standing for the SWAG stereotype,   as it’s sometimes been referred to. And I  think you’ll hear that a lot in our culture,   that, you know, “Oh, I” – or “they couldn’t  possibly be somebody that experiences an eating   disorder,” because there’s this really  widespread belief that, you know, again,   only a certain type of person, again, often  times these skinny, white, affluent girls,   could experience eating disorders. But we  do know that eating pathology is a spectrum,   there’s not only one kind of eating  disorder, like we’ve discussed here. You know, we have eating disorders of all  kind of types, and eating disorders also   have been shown to affect individuals of  all genders, you know, as we discussed,   these disorders are actually appearing to be  highly prevalent in transdren – gender and   gender diverse individuals. They also occur  across, you know, racial and ethnic groups,   and some disorders have actually been  shown to be even more prevalent in   certain individuals of racial and ethnic  minority backgrounds. They also present   in individuals living in higher weight bodies,  as we discussed, sexual and gender minorities,   and individuals with low socioeconomic status,  and even those living with food insecurity. And, you know, it can be important to, kind  of, think about weight and eating disorder   presentation, because, again, there’s often this  idea that eating disorders only occur at that   very low weight, or, you know, more that anorexia  nervosa type presentation. But weight and eating   disorders can have a lot of different ways it  may present. So, we can see weight fluctuation,   we can also see weight suppression, where there’s  a significant difference between an individual’s   highest weight since reaching adulthood, and their  current weight, outside of pregnancy, of course.  And then we can also see in adolescence a  lack of weight gain or height growth. So,   this might be presented as an individual, you  know, really falling off of their growth curve,   you know, those charts that are often used  by their Paediatricians, as seen to the   right on this slide. And I think it’s just  overall important to take away the message   that eating disorder symptoms and behaviours  can occur in individuals of any body size,   so we really should be attuned to those problems  in everyone. So, despite that SWAG stereotype, the   eating disorder reality is that it can be anyone,  and you can’t just tell who might have an eating   disorder by looking at them. Again, these can  occur in individuals of all types of backgrounds. As noted too, food insecurity has actually  been receiving some additional attention   in the field in recent years. And food  insecurity is defined as unpredictable   or unstable access to food, which can lead  to a, kind of, feast or famine response,   where individuals may eat more during periods  of abundance, or maybe after, you know, some of   their benefits or their food stamps come in, and  then eat less during perse – periods of scarcity,   or where there may not be enough money for  food. And this can really resemble that binge   restriction cycle, which could sometimes  trigger the onset of an eating disorder,   and maybe eventual engagement in some of  these behaviours for other types of reasons. Individuals with food insecurity may also use  compensatory behaviours to deal with shame   that they may be experiencing. We can also see  engagement in extreme restriction, to feed other   family members. You know, maybe, you know, trying  to save food for children in the family, hiding   food or eating in secret, aversion to certain  food groups. And importantly, food insecurity   does disproportionately affect individuals from  racial and ethnic minority backgrounds, low   income households, rural populations. So, these  individuals may be more likely to experience,   you know, not enough access to food, or unstable  access to food, which again, has actually been   shown to be associated with disordered eating  and an increased likelihood of BED and BN. Research has also shown that children  growing up in food insecure households   are more likely to engage in binge  eating, night eating, secretive eating,   and so, this is a really important  issue to pay attention to. Again,   not assuming that just because somebody isn't  from a wealthy background, you know, they can   experience an eating disorder, and actually,  food insecurity may put them at risk for one. So, you know, in response to all these myths  that are out there about eating disorders, the   National Center of Excellence for Eating Disorders  in the US has put out some really great materials   about the “Nine Truths about Eating Disorders,”  that really dispel some of the myths that are   out there. So, truth number one being that “Many  people with eating disorders look healthy, yet can   be extremely ill.” Number two, “Families aren’t  to blame,” which sometimes they historically,   have been, but instead can be patients and  providers best allies in treatments. Number three,   “An eating disorder diagnosis is a health crisis,”  so it’s not a choice, it’s not about vanity,   but this is “a health crisis that really  disrupts personal and family functioning.” Number four, “Eating disorders aren’t choices, but  are seriously biologically influenced illnesses.”   Number five, as we’ve been discussing,  “They affect people of all,” you know,   “walks of life, all genders, ages, races,”  etc. Number six, they “carry an increased   risk for both suicide and medical complications,”  which we’ve discussed here today. Number seven,   “Genes and environment play an important role in  the development of eating disorders,” so it’s not   one or the other, it is their combination.  Number eight, reiterating what I just said,   “Genes alone don’t predict who will develop  eating disorders,” and number nine, “Full   recovery from an eating disorder is possible, but  early detection and intervention are important.” And if you're interested in learning more about  these Nine Truths, I’d really encourage you   to check out this publication, first authored by  Katherine Schaumberg, and from Cyndi Bulik’s team,   published in 2017 in the European Eating  Disorders Review. That’s on “The Science   Behind the Academy for Eating Disorders,” and  the NCEED’s “Nine Truths about Eating Disorders.” Also, I just wanted to spend a moment, you know,  kind of, reiterating what I just mentioned about   it’s just genes alone or environment alone. It’s  – we really think about the – how eating disorders   develop as being derived from a biopsychosocial  model, or meaning that all of these influences,   kind of, combine to create the perfect storm for  an eating disorder. With regard to the biology,   you know, somebody may have genetics that put  them at greater risk for an eating disorder,   or maybe is going through puberty or  menopause, or maybe has some change in   certain brain chemicals. All those can, kind of,  set the biological stage for an eating disorder,   and then might be coupled with some psychological  risk factors, that an individual could be   experiencing that could further elevate that risk  for an eating disorder. So, for example, maybe   somebody who’s generally prone to experiencing  anxiety or depression, maybe someone who’s prone   to having high perfectionistic tendencies, or  maybe doesn’t have the very best coping skills. So, we have that biology and that psychological  that are, kind of, coming together,   and then maybe further triggered by things in the  individual’s environment, to actually, you know,   kind of, pull the trigger for an eating disorder.  This could include, you know, cultural factors,   like in much of Western society, the influence  on achieving, you know, certain body ideals that   may be very thin or very muscular, or whatever.  Also, pressure from family or peers or the media,   or experiencing critical comments from family  or peers, and also, those media and social   media messages. So, all these things, kind of,  come together, to result in the development an   eating disorder. And it’s almost never just  one of these things that would lead to that. So, finally, I just wanted to end, you know, given  the importance of these problems and the severity   of problems, you know, talk for a moment about how  we can screen for eating disorders. And screening   and identification is a really crucial first step  in accessing care for eating disorders. About 80%   of people, or more, never receive any kind of  treatment for their eating disorder. So, it’s   really important that we work to better identify  these problems. And this is especially critical,   you know, really this identification piece, given  that less than half of individuals with eating   disorders recognise they have a problem. But that  self-recognition is associated with help seeking. In one study, they found that close to half of  participants who recognised they had a problem   with their treatment had ever sought treatment,  versus only one in five who did not recognise a   problem had sought help. So, we really need to  work to inner – increase identification, both,   you know, kind of, providers identifying  individuals with these issues, you know,   family members, close friends, as well  as increase that self-recognition. But there are a lot of current problems  in screening and identification. Those   stereotypes get in the way of  eating disorder identification,   both by providers, and, you know, even without  yourself, you know, maybe not feeling – like,   I’m not the type of person who could experience  an eating disorder. There’s also a gender – a   general under recognition of binge type eating  disorders. Again, eating disorders are often   thought of as that anorexia nervosa piece,  and providers often miss eating disorders,   and this problem is just further exacerbated  among those who don’t fit the stereotypes.   And research has, indeed, shown that individuals  from racial and ethnic minority backgrounds with   eating disorders are significantly less likely  than their white counterparts to be diagnosed   with an eating disorder, or to even be asked  by a Doctor about eating disorder symptoms. So, early detection is key, but patients rarely  present directly for eating disorders care. They   may be secretive or ashamed, or again, they may  not even realise that their problem yet, you know,   is that serious that it should warrant treatment.  So, we’d really push for routine screening with   Primary Care providers or Mental Health providers,  and leveraging those existing relationships to,   you know, screen in a sensitive manner, and then  facilitate connection to referral resources. And,   again, just because we can’t reiterate  it enough, early diagnosis and treatment   is associated with better prognosis, so the  earlier we can catch these problems, the better. So, who should be screened? Well, you know, I  think many of us in the field would argue that   given the prevalence of eating disorders,  up to 10% of individuals in their lifetime,   all adolescents and adults should be screened  as part of new patient visits and/or annual   physicals. But if we want to think about  groups that are particularly high risk,   those might include adolescents and young  adults, you know, those about 12 to 25,   when we see a vast majority of eating disorders  onset. Patients in key transition periods,   so this could include things like, you know,  puberty, menopause, but also life transitions,   individuals going away to college, or maybe  experiencing a divorce. Patients with certain   medical conditions that have been sociated to  – been associated with increased prevalence   of eating disorders, like GI complaints and  diabetes, athletes, patients with a family   history, patients seeking treatment for weight  loss. Military and veterans are actually at   increased risk for eating disorders, and  patients with a trauma history, as well. So, now I just want to spend just a couple  of minutes just talking about three available   screening tools that you may find of use.  The first is the SCOFF, which can be used   in adolescents and adults, and is comprised of  five items, and the letters really, you know,   stand for some of the key words in the questions.  So, one, “Do you make yourself sick because you   feel uncomfortably full?” Two, “Do you worry  you’ve lost control over how much you eat?” Three,   “Have you recently lost over 15lbs or  one stone in a three-month period?” Four,   “Do you believe yourself to be fat, when others  say you're too thin?” And five, “Would you say   that food dominates your life?” So, one point  if given for a yes for each question, and if an   individual endorses two or more of those, research  has shown that further assessment is indicated. And the National Center of Excellence for  Eating Disorders in the US has put out   this really nice tool, that’s available at  eatingdisorderscreener.org. This is called   the Screening Brief Intervention and Referral to  Treatment for Eating Disorders, or the SBIRT-ED   tool, that was originally really designed for  Primary Care providers, and helps providers to   actually administer that SCOFF in their practice,  and gives practical tips for how to talk to a   patient about their result, and actually even some  language for the electronical medical record that   can be copy and pasted. So, you might find  this to be a really helpful tool for you. Another alternative screen to the SCOFF is  the Eating Disorder Screen for Primary Care,   or the ESP, which can be used in adolescents and  adults. And so, this is just a different five item   screener, that has some research support behind  it, as well, and like the SCOFF, two or more yes   responses indicate that further assessment is  indicated. And then, finally, there’s the Binge   Eating Disorder Screener-7, or the BED-7, which  has been validated for use in adults. And so,   if you're particularly concerned about BED,  this might be a tool that you would want to use. And so, that is all I have for you today. Thank  you so much for listening, and for being here   today to learn a little bit about eating  disorders. I really appreciate your time.