Dr Megan Vo Hi, I’m Dr Megan Vo. I’m a Clinical  Associate Professor of Paediatrics at Stanford   University and today, we’re going to talk about  eating disorders in adolescence. Some things to   think about while we’re doing this presentation  would be recognising signs and symptoms of eating   disorders and thinking about the different  diagnostic categories of eating disorders. But first, some background, which frames,  you know, the problem, is that nutrition   in adolescence is really unique. It’s  a time of great change and in teens,   their needs are very high. The highest  that they’ve ever been in their lifetimes,   other than the first year of life, going – in  infancy. What happens in adolescence, going from   having a child’s body to an adult type body, is  adolescents gain about 20% of their adult height,   but they gain 50% of their adult skeletal  mass in terms of bone density. As a result,   BMI, which is a measure that Doctors use,  more from a public health perspective,   to describe where someone falls in relation to  other people of the same age, naturally increases   for all adolescents. And they have their maximal  protein and overall caloric requirements of their   lifetime, but as I’m sure any parent of a teenager  knows, poor eating habits are incredibly common. There’s also some gender differences in  nutrition. When we think about the average   birth assigned male adolescent, who’s not even an  athlete, who’s, like, not even doing any sports,   they need up to 3,000 calories a day just to  grow and to live. A female, again not an athlete,   may need up to 2,800 calories a day. Which if  you think about for the average teenager that   may skip breakfast, that may skip lunch, that  may not eat until they get home from school,   it can be really hard to meet your caloric  requirements unless there’s some thought put in. When we think about what teenagers need to  eat in a day and, kind of, the breakdown   of their macronutrients, I know we’re all  totally obsessed with protein, but actually,   most people need more carbohydrates than anything  else. So, about 50% of a teenager’s daily intake   should be carbohydrates and then, the rest pretty  evenly divided between fat and protein. So,   fat is not the enemy here. It’s just that we want  to, kind of, emphasise healthy fats. And again,   everybody’s totally obsessed with protein,  but most people will meet their daily protein   needs just by eating a wide variety of  foods, without needing extra supplements. If we add on any kind of sports or athletic  activity, which we do recommend in general   for all healthy teenagers, then you need  to add additional calories in a day. When   we think about what fuels an athlete best,  even more they need carbohydrates because   that’s the quick energy your muscles will use  when they’re active. And there’s some really   great evidence to show that a post-workout  snack, within about two hours of exercise,   can help improve muscle recovery and then,  performance the next time the young person does   the activity and also reduce the risk of injury.  And so, a post-workout snack is ideally about   two thirds carbohydrates and again, like, pretty  evenly divided the rest between fat and protein. Some really interesting studies about,  like, kind of, what is the optimal makeup   of a post-workout snack have shown that,  actually, a 2% chocolate milk and, like,   a banana is, like, an ideal post-workout  snack. So, people don’t really have to go   crazy when it comes to their intake or  doing anything really special. You just   have to be thoughtful to make sure that to grow,  teenagers are getting a wide variety of nutrients. We often think about things  in terms of the plate model,   rather than counting calories. So, like,  when looking at a normal sized dinner plate,   about half of it would be wholegrains and  then, the rest divided between proteins,   fruits and vegetables and ideally, a  drink that has calcium and vitamin D. Now, when we think about the normal development  of eating behaviours throughout the lifecycle,   when we think about little kids, if any of you  out there have had, or have been around, infants,   toddlers and young children, they’re usually quite  restricted in the things that they accept. And   that’s because their tastebuds are different  than adult tastebuds, so they have, kind of,   different preferences. But over the first two to  three years of life, from infancy to toddlerhood,   their, you know, acceptability of different  varieties and textures does increase. Around   kindergarten, five to six-years-old, this  is, kind of, where the maximal beige food   or white food preference increases, so  where they like potatoes, plain pasta,   chicken nuggets. Don’t you dare offer them a  green vegetable. And that is, again, really,   really normal, but it’s important to keep offering  and keep modelling that these foods are important. And then, preferences will increase and, kind  of, adventurous eating normally does increase   in later school age, the pre-teen years, as the  tastebuds change, as the brain changes and becomes   more interested in novelty, which is a really  normal thing in the pre-teen years. And then,   increases in flexibility will increase throughout  teenage years and into adulthood. But sometimes   this normal development will go awry and this  is where it’s important to recognise, hey,   when is this just, kind of, a normal variant and  when is it something I need to be worried about? So, some red flags to think about when you  think about the young people in your lives   would be young people who are either not growing  or who are losing weight. Because even a normally   developing teenager, who may not be the best at  breakfast, who may occasionally not like their   lunch and that kind of thing, will be able to  eat enough in a day to grow. And depending on   where they are in puberty, the normal growth to  keep up on the growth chart can be, you know, ten   to 15lb in a year, or if you’re – they’re past the  growth spurt, again, this is bone mineral density,   bone mineral density should be increasing.  Muscle density should be increasing. So,   they should be gaining about 5lb per year, on  average, even if they’re not really increasing   in height anymore. So, if they’re not growing,  or if they’re falling on their growth chart,   or if they’re crossing percentiles the  other way, you know, gaining very rapidly,   these are red flags to think about while bringing  them in to be seen, to paying a little bit more   attention to what they’re doing, to seeing  if there’s anything that needs to be changed. Other red flags would include new restrictive  diets, especially if they’re different than what   the family would normally eat, culturally. So,  I – take, for example, like, new vegetarianism,   new veganism, being interested in doing  restrictive diets, things like Whole30, keto,   those kinds of things. Now, there can be a role  for that when taken from a global perspective of,   like, hey, how is this kid doing and what is their  relationship with food? But that is something to,   again, pay attention to and think about where  is the driver here? Is it body image distortion,   which when we think about eating disorders,  that’s really the driver, right? Like,   extreme dissatisfaction with their body  shape, weight or size that is causing them   to have an abnormal relationship with  food, or something else, which again,   you have to balance with their needs and their  growth, which can only happen during adolescence. Other red flags would be things like eating  in secret, skipping meals, particularly, like,   if the lunch is not being eaten. These kinds of  things are worrisome because it is important,   from a biological perspective, to be eating every  couple of hours to keep your hormones in check,   to keep your blood sugar steady, to reduce stress  on the brain, all of those things. And a really   big red flag for people who menstruate would  be losing their menstrual period. The body is   a finely tuned machine and that is, like, kind  of, the first sign if something is going wrong. So, when we think about, you know, who  this affects, I think many years ago,   we used to think of eating disorders as something  that really only affected wealthy females,   right? It was the disease of rich White  people, and we know that is not the case,   both in research and also, like, in our clinical  experience, that eating disorders can come in   any shape and size. It can affect anybody and  that’s why it’s so important to pay attention   to the signs. You can have an eating disorder  and be higher on the growth curve, as well as   being – having an eating disorder and falling  off the growth curve and looking emaciated. Community studies, when we look about, you know,  people just walking around living their lives,   about 10% of people just living their lives out in  the world today will meet criteria for an eating   disorder at some point in their lives, and that’s  the full criteria. Like, they meet all of them,   they’ve got all of the things. And when they’ve  studied people who don’t maybe meet all the   criteria, but have a distorted relationship with  food or have a distorted relationship with their   bodies, up to a third of people during their  lifetimes will have some kind of disordered   eating or really extreme dissatisfaction with  their bodies, such that they’re doing things in an   unhealthy way to change it. So, I think it really  puts into perspective the scope of this problem. Furthermore, eating disorders have the  highest mortality rate of any psychiatric   disorders because they affect the way our  bodies work and they affect our growth. So,   it is really important to recognise the signs when  they’re there. When we think about the, you know,   traditional eating disorder of, like, anorexia and  “I’m afraid of weight gain, I’m afraid to be fat,   I’m too thin,” that really affects about 1% of the  population. Now, it is a huge problem because of   the mortality rate, but actually, about 3% of the  population may meet criteria for bulimia nervosa,   which we’ll talk about, which is more of an  overeating and then compensating pattern. And actually, the mass – vast majority  of people who meet criteria for eating   disorders may not fit very nicely in one of these  categories. And binge eating disorder, actually,   is one of the highest prevalence eating disorders,  where people overeat to compensate for some sort   of stress or some sort of negative feeling  in their lives. So, up to 10% of people will   meet criteria for an eating disorder, but  they’re very, very treatable and they are   really – people are able to live happy,  healthy, normal lives with proper treatment. So, when we think about who’s at risk, you  know, I, kind of, talked about the myth of   eating disorders looking one way and we know  that that is not the case. Eating disorders   aren’t caused by one thing. Not everybody  who gets called fat by their swim coach ends   up having an eating disorder. Now, I certainly  don’t love that, and I wish it never happened,   but we can also feel reassured that humans in  general are quite resilient. So, we know that   there is a genetic predisposition. We know that  they tend to run in families and there’s been   some interesting genetic mapping, where they  have, you know, located certain chromosomes,   locations on chromosomes, that are  associated with eating disorders. So, there is a genetic component. There is an  environmental component, and there’s some really   interesting studies about the effect of social  media and Westernised diets and Westernised   media on all populations in increasing the  prevalence of eating disorders. We do know,   at this point in time, that females are more  likely to be affected than males. But there   is a little bit of a bias there in terms of the  criteria being a little bit more female centric   and boys tend to say slightly different things,  which we will talk a little about, as well. Eating disorders really are unique to adolescents.  It is possible to have an eating disorder into   adulthood, but it is incredibly rare to develop a  brand-new eating disorder outside of adolescence,   and we think that there is a component of the  developing brain being particularly vulnerable   to the development of an eating disorder during  adolescence. You know, I mentioned sports. So,   there has been some interest in determining which  sports put people at higher risk and certainly,   it has been described that sports with a  high aesthetic component, like gymnastics,   figure skating, swimming, diving, can  have higher risk of eating disorders,   but also, non-athletes can develop  eating disorders, athletes of other   sports can develop eating disorders. So,  it is not strictly the sport, as well. There are some common misconceptions which  I’ve alluded to that I think it’s important   to just think about for a moment. That people  with eating disorders are always underweight,   and we, kind of, talked about already how  that may not be the case, depending on the   particular diagnosis. I hear a lot that people  with eating disorders, they can’t eat at all. So,   if anybod – if somebody eats, they  can’t have an eating disorder,   and that’s not true. We have talked about  how the needs, particularly in adolescence,   are really high. So, usually, people with eating  disorders will eat, they just don’t eat enough. Something that is also a common myth is  that people with eating disorders can   control their behaviour, it’s a control  issue, and that really isn’t the case.   We have done some really interesting studies on  mapping of the brain that really show that the   eating disorder is its own thing and, kind of,  hijacks the system to work in its own way. So,   people with eating disorders really can’t control  their behaviour. If they could, they could, like,   snap out of it like that, right? But it doesn’t  work that way. The eating disorder really works   through the person to get what it wants, which  is to influence their body shape or size. Something I also hear a lot is that parents cause  eating disorders and that’s really not the case.   You know, we talked about how they can run in  families, there is this genetic predisposition,   but again, not everybody with the  genes will develop the problem. So,   parents are a really important part in recognition  and treatment of eating disorders. And then,   we talked already about how eating disorders  must only affect females of affluent backgrounds,   and that really isn’t the case. They  can affect anybody, boys, girls,   every socioeconomic status. So, it’s really  important to notice when things are going awry. So, talking a little bit, briefly, about the  different types of eating disorders to frame   in our minds, like, what might this look like  for a young person that you know? The – I think   the one we most commonly think about would be  anorexia nervosa and the diagnostic criteria are   a restriction of food intake, such that the young  person cannot meet their daily needs over time,   which leads to a low body weight.  And there is no cutoff on, like,   how much you have to weigh to be a low  body weight. It means that you have to   have lost weight and be distant from  where you were naturally growing. So,   that can look really dramatic. It can be I was  growing, growing, growing and then, I developed   anorexia nervosa and I fell off the curve. It can  also look a little more subtle, where I’m growing,   I’m doing fine and I start to lose weight, but I’m  caught, right? That somebody brings me to care,   and I’m seen and then, they intervene  and I come back up, right? It’s – so,   it’s weight loss that makes you deviate from where  you would normally be if this had not happened. It has to be accompanied by an intense fear  of gaining weight or being fat. People who   have been around young people with anorexia  nervosa, this can be really dramatic,   hearing the way that they talk about themselves.  That, you know, they must weigh 200lb. “How could   anybody eat this much? I’m disgusting. Nobody  can see me.” And that really is the brain,   the eating disorder working in their  brain. It actually changes the way that   they perceive themselves. They cannot see  themselves objectively. There’s some really   interesting studies on having people with  anorexia nervosa actually draw themselves,   that really shows the perceptual  differences in how they see their bodies. The other thing that goes along with  this, that is a diagnostic criterion,   is body image distortion. So, you know, they can’t  see their selves the way you do or somebody else   does. They can’t see that they’re not fat.  Previous diagnostic criteria included, like,   having to have missed menses, which of course,  then precludes people who don’t menstruate,   people who haven’t had their first period, or  boys. So, that really isn’t a criterion anymore,   and then, there used to be some, like,  really specific weight criteria that, again,   really isn’t the case anymore. So, for anorexia  nervosa, it’s that you have to be underweight,   have lost weight and have this fear of being  fat that is driven by body image distortion. You know, things that might clue you in by  history, the growth curve, the weights. Not that   I’m asking people to weigh themselves, but, you  know, people know, people can see if somebody is   behaving differently around food, isn’t eating as  much as losing weight. And it actually is pretty   easy to lose weight when you’re an adolescent  because your needs are so high. So, if somebody   – you bring them in and somebody is losing  weight, it’s important to pay attention to that. The way eating disorders work is they – all  they want to do is just be alone with the   young person. They – the eating disorder doesn’t  want to be around friends. It really doesn’t want   to do anything other than lose weight. And so,  what often happens is the young person becomes   more withdrawn, may not be as interested  in their activities, in social activities,   in their friends. There may be more secretive  eating behaviour. They often don’t say, “No,   I don’t want to eat that ‘cause it’s going  to make me fat.” I mean, sometimes they do,   but it’s often more coded in, like,  kind of, culturally appropriate,   socially appropriate language, like, “Oh, I’m  not hungry. I already ate.” “No, thank you,   that doesn’t taste very good.” You know,  “I don’t feel like that right now,” those   kinds of things. So, paying attention  to if you’re seeing patterns like that. And then, I alluded a little bit to  the differences between boys and girls,   either birth assigned boys or people who identify  as boys. Studies have shown that they often   use language that is less like focused on not  gaining weight and not being fat, but more on,   like, muscularity, leanness, athletic  performance. So, they may not actually say,   “I’m worried about gaining weight,” but they  may be really focused on, like, “I really only   want to gain muscle. I don’t want to gain fat. I  want to be training really intensely.” And while,   like, some of that can be fine and normal, they  have to be eating enough, right, to support it,   and so, it’s when they don’t that you become to  be worried – that you can start to be worried. Another diagnostic criteria would be bulimia –  or another diagnostic category would be bulimia   nervosa. So, the difference between anorexia  and bulimia is that with – people with bulimia,   they typically do not lose weight. So, being  underweight or having lost weight isn’t a   criterion here and that’s because bulimia nervosa  is characterised by periods of binge eating,   where somebody would eat more than a typical  person would eat in a discreet amount of time,   like two hours. And it’s accompanied by this,  like, extreme feeling of, like, loss of control   and guilt. “I just, like, I can’t stop, and it  feels terrible,” and then afterwards, accompanied   by some, kind of, compensatory mechanism. We  typically think of vomiting as the compensatory   mechanism, but it’s not always the case. People  can compensate with, like, excessive exercise,   use of diuretics or laxatives, and again,  this is all driven by body image distortion. People with bulimia, they do not have to do this  every day to meet diagnostic criteria. On average,   once a week for a period of three months  to meet the full criteria. So, again,   these behaviours have to be fairly persistent.  Like, you know, one day of overdoing it   doesn’t necessarily mean you have bulimia,  but if it’s a consistent pattern over time,   that’s when you become to – that’s when  you start to be worried. And people with   bulimia can have periods of restrictive  eating, as well. So, it doesn’t have to   be mutually exclusive from the other disordered  eating behaviours and in fact, it can be really   hard to maintain one type of disordered  eating behaviour. So, we may see people,   kind of, cycle through these things as the eating  disorder, kind of, tries different techniques. Some clues that this may be happening.  Again, like, secretive eating behaviours,   use of the bathroom after meals can be  worrisome. Now, we all have what’s called   the gastrocolic reflex, where you eat, food  hits your stomach, everything moves down,   and you do have to use the bathroom. But if  it is a persistent thing where somebody is   eating and then, they’re running off  to the bathroom every time they eat,   it can be important to pay attention to that.  Evidence of vomiting or laxative use or diuretic   use, you know, if you’re seeing these things  around the house, if you’re – they’re Amazoning   it and you’re seeing it arrive, these kinds  of things are really important to notice. And then, like, language. For both bulimia  and anorexia, noticing language about, like,   you know, excessive emphasis  on their appearance, right,   that their self-worth is really tied into their  appearance, being thin. “No-one will love me,   no-one will want to be friends with me if I’m not  thin,” which is really sad to hear, as anyone,   a family member, a parent, a provider. And so,  noticing that and seeking help if you’re hearing   things like that, even if you’re not noticing  any of these other things, is really important. The other eating disorder I alluded to that I  want to discuss briefly would be binge eating   disorder. So, this is a relatively new diagnosis,  though again, I think, like many of these things,   people have known that this is around and now  we have a common language to discuss it. And so,   this is episodes of binge eating without the  compensatory mechanism, and so, this actually,   as I alluded to earlier, is actually the  most common eating disorder in the community.   And what this might look like on a growth  chart is somebody who’s growing, growing,   growing along their curve, everything is, kind of,  consistent and then, they start to rapidly ascend   growth percentiles. So, it can be  really important to just, like,   notice this and ask a little bit  more about why is this happening? And to define a binge, it would be eating  more than a typical person would eat in   a discreet amount of time, so of say, two  hours, and it usually is not very subtle,   because it’s accompanied by feelings of guilt  or loss of control and it’s really driven by   poor coping, right? Something stressful  happens, I’m feeling sad, I’m feeling lonely,   some – I’m feeling bored, these are common  triggers, and I eat my trigger food. Often,   people have a trigger food. It’s usually something  that we call, like, highly salient on the palate,   so, like, cereal or carbs or something like  that. Something that you, kind of, get that   immediate rush of pleasure from eating.  But instead of stopping when they’re full,   people who are in a binge will keep  going, even though they don’t want to. So, you know, they may go for the cereal and then,  what will happen is they will eat all the cereal,   even if it’s not what they have a taste for.  Even if it’s expired or a little bit stale,   they’ll eat all of it, and then, they may move  onto another food. So, they move on – maybe move   onto the ice cream or the desserts or something  like that. And meanwhile, while this is happening,   they’re really feeling like I just can’t stop. “I  feel full, I don’t feel good, but I cannot stop.”   But the difference between this and bulimia is  there isn’t a compensatory mechanism afterwards   and that’s why they’re – you can often see changes  in the weight upwards because it’s just the   bingeing. And this doesn’t happen – again, like  bulimia, this does not have to happen every day.   On average, once a week, on average, for three –  a three-month block of time, but it’s important   to get people with binge eating disorder help,  as well, to address the coping. To really think   about, hey, what are my triggers and, you know,  what is a more positive way I can deal with that? The last eating disorder that I would like to talk  about is something called avoidant restrictive   food intake disorder. So, this is another new  one in the Diagnostic and Statistical Manual,   which is the psychiatric manual that we use  to think about, hey, what are the categories   of eating disorders and, you know, who fits,  kind of, where? So that we have – can have a   shared language to talk about things, as well  as a research framework to think about hey,   what are the best treatments and,  you know, how can we help people? And avoidant restrictive food intake  disorder, also known as ARFID,   is something, again, that I think folks have  known has been around for forever. We just now   have this common language to discuss it, and I  think about it as pathologic picky eating. So,   we talked in the beginning about how it’s really  normal for smaller children to have picky eating   because of the way their tastebuds have developed.  And people with ARFID have this to an extreme   degree, really, kind of, outside of that time  period. It can develop during early childhood,   but then would persist, such that they  cannot meet their needs. And it isn’t   driven by body image or a fear of being  fat or a fear of weight gain. It really is   that their range of acceptable foods is  so small that they can’t meet their needs. So, typically, the way that I see this is, like,  they might be smaller on the growth curve, like,   their entire lives. Parents will often describe  that they may not have been great breast feeders.   Introducing solid may – solids – introducing  solid foods may not have been very easy and then,   you know, they got to preschool and  elementary school and their range of   foods that they could eat was pretty limited. And  then, adolescence hits and their needs skyrocket,   but their appetite and their range of acceptable  foods has not increased in proportion and so,   they really just start to deviate  from the curve in this extreme way   because they’re supposed to be growing and  they just have never really learned how to eat. Now, please take heart for any parents of picky  eaters. This is not everybody, but this is why,   you know, this is, kind of, an extreme example  of where pickiness can really be a problem.   And like I said, there is no – there – and like I  said, body image and fear of being fat is not the   driver here. It really is that their ability  to eat, their sensation of hunger signals,   seems to be different than other people  and so, they can’t really rely on that. We think about people with ARFID that  there are probably three different subtypes   that we’re seeing clinically. One would be, as  I described, like, kind of, this extreme picky   eating. They just can’t meet their needs. They  have a very limited range of acceptable foods,   and if they’re not available, then they just don’t  eat. A second would be kids who have a fear – what   we call a fear of aversive consequences. There’s  something about eating that they’re afraid of,   and again, it’s not the body image stuff. It could  be a fear of choking, a fear of vomiting, a fear   of abdominal pain, that is so extreme that it gets  in the way of eating. And so, then, these people   often look more like people with anorexia, where  they might’ve had, kind of, a normal growth curve   and then, something happens. They have an illness  where they have vomiting or they have an episode   of abdominal pain that makes them so afraid  to eat that, then they start to lose weight. And then, the third subcategory is people who  just, kind of, have low interest in eating. They   may not be as picky in terms of their range  of foods as the first type, but they just,   like, don’t seem to have the same types of  hunger signals and so, eating just really   doesn’t seem to be of interest to them. So, they  really could go all day and not eat, especially   if they’re distracted by something, screens,  videogames, something like that. And again,   they just, kind of – as puberty happens, they  just, kind of, deviate from their growth curve.   It’s often accompanied by ADHD, so treating  that can be a really important part of this. So, again, not everybody with picky  eating can be diagnosed with ARFID,   but red flags to think about would be if there’s  significant nutritional deficiencies. Like   if somebody has such extreme ARFID that they  don’t eat any fruits and vegetables and then,   they have vitamin C deficiency or something like  that. Failure – what we call failure to thrive,   so if they’re not growing according to their,  kind of, normal growth curve or we often will   estimate what people’s adult height will  be based on their parental heights and if   they’re not, kind of, meeting those  goals, that can be a red flag sign. If they’re dependent on, like, formulas beyond  infancy to meet their nutritional needs. So,   these are kids who may be dependent on Ensure  or PaediaSure to meet their needs. Now,   there is definitely a role for that if somebody’s  busy and they just can’t eat or drink anything,   occasionally. But if they’re meeting the majority  of their needs through one of these nutritional   formulas, that is a red flag. And if this causes  significant interference in their psychosocial   functioning, you know, they can’t go to birthday  parties, they can’t partake in school events,   they can’t eat in the cafeteria if  their lunch isn’t packed for them,   that kind of thing, this is another  red flag. And it’s hugely important   that young people learn how to eat  in childhood and adolescence, so they   can take that into their later adulthood,  when they are expected to be independent. [Audio cuts out – 3406] know what to do if  you think that you know somebody who has an   eating disorder. If you’re worried that  a young person has an eating disorder,   the first step would be to bring them in to be  seen, to get some objective data on how are they   growing? How does it look compared to their growth  chart? And see if they need any additional workup   or testing to see if there’s something else  that could be causing this, because certainly,   medical problems, besides eating disorders, can  cause weight loss and issues with growth. So,   it’s important to get that checked out,  get those things ruled out. Meanwhile,   if you’re worried if people are, you know, talking  about their body image, if you’re worried there   may be some poor coping in there or something  like that, that you’re also getting them help. We know eating disorders are best treated with a  multidisciplinary team. So, a medical provider to   talk about, “Hey, what” – you know, “what do we  need in terms of growth? What do we need to see   in terms of weight? What are these labs looking  like?” And to check their vital signs, their heart   rates, their blood pressures, their temperatures,  to make sure that there’s nothing adversely   affecting their bodies. As well as a Therapist  experienced with eating disorders to help the   family, as well as the young person, recalibrate,  think about triggers, think about the way forward. The most evidence-based therapy for  eating disorders is something called   family-based treatment, where really,  the Therapist is empowering the young   person and their family to tackle the  eating disorder together, to, you know,   practice their skills and prioritise eating. And  then, in time, once it’s not as acute or emergent,   handing the independence back over to the young  person so that they can eat more independently,   but also, noticing, “Hey, what – where might  there be some triggers? Where might there   be some challenges?” so that they can  weather that in an age-appropriate way. And in our clinic, we always like to offer  Dietician assistance to really think about,   “Okay, what does the family normally eat and  how do we achieve weight stabilisation or   weight gain or what have you with what  you guys would normally eat? What does   that look like?” And that way, if there’s any  questions, you also have that expert advice. So, that’s what we always advise in terms of  treatments, and we also know that people do get   better. It can seem like gloom and doom. It can  seem really difficult because it’s a medicine that   has to be taken multiple times a day when you’re  talking about food, but people do get better. The   longest term studies being 22 years, showing the  majority of people with eating disorders really   do have lasting recovery and it usually happens  much sooner than 22 years past diagnosis. But   that, for me, is really important to keep in mind  that while, you know, the initial period after   recognising the eating disorder can be really  intense and can require a lot of appointments,   a lot of really intensive sessions, people do  get better. And it seems to be a combination of   both therapy, weight gain, making sure they’re  stable, but also time. That once they’re out   of this vulnerable period where the brain is  developing, they become much less vulnerable   to these negative thought patterns, and  they really can be more resilient to them. You know, some things to keep in mind if  you are somebody who is caring for someone   with an eating disorder or may be, that really  early weight gain has the best prognosis. The   studies have shown if somebody is able to gain  a pound a week for the first four weeks, that   their prognosis at the end of a year is better in  terms of physiologic and psychological recovery.   And it is probably less about that actual, like,  there’s something about a pound and more that they   have a system in place that has recognised the  problem and is changing to address the problem. So, I do hope that this is  helpful. Some resources that I like   online include something called FEAST, F-E-A-S-T,   their website. It’s aimed at families and young  people who are affected by eating disorders. And   the National Eating Disorder Association  website also has lots of really helpful   articles, as well as videos and resources that  can be helpful for teens and families. Thank you.