Associate Professor Megen Vo So, moving  onto the physiologic sequelae, as well as,   like the workup. You know, we know that eating  disorders can affect every system of the body,   because our body runs on food, and if you don’t  get enough food, everything’s going to go awry.   The things to pay attention to would be vital  sign changes, because our bodies are remarkably   resilient, and often, you know, a little bit of  weight loss is not necessarily accompanied by   vital sign changes. But if you’re seeing vital  sign destabilisation, that is a red flag, it’s   a sign, that they need closer attention, they may  need to admission for medical stabilisation, and   really all these changes are hibernation response.  Their body is trying to shut down unnecessary   energy expenditure, to reduce the stress on the  body, to reduce calories burned, to keep going to   survive. So, what you may see is lowering of the  pulse rate from increased vagal tone. You may see   hypotension, because, again, like vagal tone, as  well as, like, lack of substrate, to be able to   sustain the blood pressure, hypothermia, all of  these things are important to pay attention to. So, kind of, working through the systems, and  I think it’s important to think about cognitive   complications first, because they are often very  pronounced and important to frame for ourselves   about, like, kind of, what is within our young  person’s control and what is not. When people   are malnourished from eating disorders, you  will notice changes in memory, particularly   short-term memory, changes in attention, reward  pathway changes, as well as deficits in problem   solving. So, what this can often look like is  looping, like, feeling like you’re having the same   conversation with them moment after moment, and  truly you may be, because they may not remember. They may not be able to attend to the stimuli  the same way someone who is not malnourished can,   and then send it through the cerebral cortex to  the amygdala, so that it – and the hippocampus,   so that it gets encoded. It actually does  not. And so that’s why it’s also important to,   when you’re talking to somebody who’s  malnourished from an eating disorder,   to keep things as factual as you can,  because the brain actually cannot process,   if we’re talking in these very, kind of, elaborate  scenarios, with lots of metaphors and empathy,   because it can’t hold onto that. And what  you what is to, kind – for them to, kind of,   hear the message as clearly as possible, like,  “Your body is shutting down, you need to eat.” They also have decreased cognitive flexibility.  If we were to image them, what we would see is   decreased cortical thickness, and increased  ventricular size. Some of this improves with   nutrition, some of it doesn’t. So, the functional  aspects of the brain actually do improve, memory,   attention, problem solving, flexibility, all of  that does improve. The cortical size does seem to   improve, but ventricular size may not, and we’re  not really sure what that means, if anything. In terms of vital sign abnormalities that  you may see, I’ve listed here what, you know,   are the generally accepted admission criteria for  the Society of Adolescent Health and Medicine,   which is an international society of adolescent  medicine experts, that have, kind of, agreed on   these as being the admission criteria for  adolescents with malnutrition from eating   disorders. And this would be reasons to bring  them into the hospital for medical stabilisation,   because they’re at risk of an adverse event,  or refeeding syndrome, which we’ll talk about. So, signs that somebody may need admission would  include bradycardia, with a rest hars rate – with   a resting heartrate of 50 while awake, or  45 at night. What you’re worried about is   ventricular arrythmias here, you’re worried  about them going into ventricular pacing,   especially if they’re at risk for electrolyte  abnormalities from refeeding syndrome. You   don’t want them to get there, so  that’s why you’re bringing them   in when their heartrate is in the 40s,  hopefully not lower, sometimes lower. Hypotension, the risk there would be syncope,  introduced from syncope, so, a blood pressure   of less than 90 over 45. Hypothermia, a  temperature of less than 35.6 Celsius,   or 96° Fahrenheit. Orthostasis, the new Society  for Adolescent Health and Medicine guidelines   suggest a pulse increase of more than 40,  actually, for adolescents, or 30 for adults,   it hasn’t been widely accepted yet, and so,  you know, the American Academy of Pediatrics,   and many inpatient hospitals will be a little bit  more flexible with ors – orthostatic criteria for   admission if somebody really needs it. You  know, if they are rapidly losing weight,   that they don’t have appropriate treatment,  they’re unable to meet their needs outpatient,   and they have any degree of orthostasis, it’s  worth thinking through with your inpatient   accepting hospital, about whether they  would warrant admission. But we also know   that orthostasis can take a very long time to  resolve, and so not everybody who’s orthostatic   needs admission urgently. But the definition of  orthostasis is a heartrate change of more than 20,   or a systolic blood pressure drop of more than  20, when they go from lying to standing. So,   if you’re seeing any actual changes that meet  these criteria, it’s worth talking through with   your inpatient service, about whether they  feel like that person needs to be admitted. Certainly, electrolyte abnormalities are not a  grey area, because that can be so risky for all   systems, particularly the cardiovascular  system. So, phosphorous of less than 3.0,   a potassium of less than 3.5,  or a magnesium of less than 1.8,   are – warrant inpatient admission. And EKG  abnormalities, very common in the setting of   malnutrition and weight loss. QTc prolongation,  we generally say greater than 450. Bradycardia on   an EKG with a pulse of less than 50, those  would be reasons to think about admitting. Now, refeeding syndrome. So, you know,  admission is for medical stabilisation,   to prevent an adverse medical sequelae, such  as, arrythmia, sudden cardiovascular death,   as well as refeeding syndrome. And refeeding  syndrome was first described in World War II,   with the liberation of prison camps, with people  who were malnourished, who would then be able   to eat freely. And then they would have massive  shifts in fluid and electrolytes, and actually,   the mortality rate was quite high after liberation  and the increase in food availability. And what we   now know is refeeding syndrome is due to  someone going from a malnourished state,   experiences a rapid increase in food intake,  energy intake, particularly carbohydrates,   which leads to an increase in insulin  release, which then drives everything   intracellular. And because your whole body  depleted from electrolytes, particularly   phosphorous, this can be rapidly fatal. These electrolyte disturbances may not show up   the first day somebody is admitted, because they  are still in this malnourished state and have not   yet experienced increased food intake, although  sometimes you can see them – see the electrolyte   abnormalities right on admission. But they may  not develop until a few days into admission,   as their food intake is increased. So, we are  very careful with how we increase their intake,   and very cautious with checking their  electrolytes. Even if they were normal   initially, we’re checking them every day to make  sure that they are not having drops, and then,   aggressive in supplementing the electrolytes,  even if they’re not having any symptoms yet. So, signs and symptoms can include arrythmias,  heart failure. But other symptoms that may be   a little bit more subtle may include dependent  oedema, so paying attention if you’re noticing   oedema where it wasn’t there, or if there is  oedema, really, initially, on presentation.   They can develop rhabdomyolysis, they can also  develop haemolysis. So, if you’re checking CBCs,   and you’re seeing their haemoglobin drop and not  knowing where it’s going, it’s possibly refeeding   syndrome. They can also, with these massive shifts  in fluid and electrolytes, develop seizures.   And the treatment is to actually decrease the  nutrition or avoid increases in nutrition while   the refeeding syndrome is happening and supplement  the electrolytes aggressively. Because what you   want is to stop the insulin release in the moment,  and then, once they’re stabilised, slowly and   carefully increase their nutrition up, while  monitoring the electrolytes and supplementing   so that you can build their stores, so that,  hopefully, they don’t develop refeeding again. So, just, kind of, back to our case. So, we had  the initial presentation of a 12-year-old with a   25lb weight loss, with amenorrhea, as well as  body image disturbance. And then you examine   her and she appears thin and pale, she has a  delay in her cognitive response when answering   questions and a flat affect. And on vital signs,  she’s bradycardic, with a heartrate of 45,   her blood pressure is 90 over 54. And then, you  have her lie for five minutes and then stand for   two and check her pulse and blood pressure  again, and her heartrate has gone up to 70,   and her BP has dropped to 85 over 42,  her temperature is 36.2. I will say,   hypothermia is relatively rare once they’ve  been sitting in your exam room for a while,   but you do see it in extreme cases. So, what do we do? We admit. She’s bradycardic,   she’s at risk for refeeding syndrome. So, what  do you do? You’ve got this person in your office,   they may or may not have these signs and symptoms  of malnutrition, you know, how do we assess and   what do we do for treatment? So, the role of  the first line primary healthcare provider is   really critical in terms identifying people with  eating disorders, and hopefully, hooking them into   treatment early. There is a better response to  treatment when eating disorders are diagnosed   early and treated by multidisciplinary team,  hopefully, with experience with eating disorders. The other thing that I’ve been hammering, but it  is again, important to say, is that the growth   that happens in adolescence can only happen  in adolescence, the cognitive, as well as the   other physiological growth. So, you want to set  them up for success for the next 80 to 90 years   of their life by making sure they have adult  sized organs and appropriate coping mechanisms. The primary healthcare provider plays a critical  role in the recognition and prevention and   treatment of medical complications from eating  disorders. There is a huge risk of ongoing   physical and psychological effects in young people  who are not recognised as having eating disorders   and who do not receive treatment. The other  part of our job, as the frontline providers,   is to think through the differential, like, you  know, is this truly an eating disorder? Ruling out   other medical problems that could be masquerading  as an eating disorder. And there are many things   that can cause weight loss, or lack of weight  gain, inflammation, inflammatory bowel disease,   malignancy, malabsorption, infections, endocrine  disorders, thyroid disorders, diabetes. So, it’s   important to think through and screen for these  potential other medical problems to make sure,   like, okay, is this really an eating disorder, or  is there something that requires other treatment? Thinking through their intake and activity,  there’s some really interesting studies to   show that for people who exercise more than five  hours per week, which for the average adolescent   athlete, like, it’s really easy to hit that, their  hunger signals do not increase in proportion to   exercise over five hours a week. So, that’s  to say that somebody who’s exercising more   than five hours a week probably has to be, like,  extra conscious of eating more, because they just   can’t say, like, “Oh, I’ll be hungry, and I’ll  eat more.” Their bodies just can’t ramp up the   hunger signals that much. So, somebody who’s  very active, who may or may not be copping to   body image distortion. Helping them think though,  okay, for an athlete, and for optimal performance,   this is what you’re eating, this is what you’re  going to need to do, given that I’m seeing these   sequelae of not eating enough. Are there other  psychiatric issues at play? Depression certainly   can mess with your appetite, anxiety, ADHD,  OCD, so treating these comorbid conditions   can also help with medical stabilisation  and help the eating behaviours overall. So, the goals of the initial medical  evaluation would be to identify potential   underlying organic disorders. Thinking through  signs of hypothalamic pituitary suppression,   so menstrual dysregulation in girls, loss of  libido, loss of morning erections, in boys,   because it’s just really important as a marker  for bone health. Are you seeing any signs that   suggest potentially purging? So, enamel erosion,  parotid gland hypertrophy, callouses on the hands,   what’s called the Russell’s sign, where  they might have thickening or darkening   of the skin over the knuckles from inducing  vomiting with their fingers. Are you seeing   any other serious medical complications?  Vital sign instability, signs of GI bleed,   electrolyte abnormalities on labs? And then, you  know, deciding, is this somebody who’s safe to   follow in the outpatient world, or do they need  admission? And if there’s ever any question,   then I would advise calling your nearest  or most trusted eating disorder expert,   to think through. Because the worst thing that  can happen is that you call and they say, “No,   you know, I think you can follow them  next week, or see them in two days,” or   something like that. But what you don’t want  to miss is something that’s potentially fatal. Then, of course, doing your physical exam.  Ideally, and again, without underwear,   really to check all over for any  signs or symptoms of medical sequelae,   as well as – especially with somebody who’s not  known to you, checking where in puberty they are,   to see, like, is it appropriate for you to  expect this person to have morning erections,   or menses, for example? Get a dry weight, in  – again, in underwear only is how we do it,   so that we can have, kind of, the most consistent  emi – and objective measure. We have them void   first. There are eating disorder behaviours that  lead people to drink excessive amounts of fluids   to feel full, but some people also so this to  inflate the weight in the Doctor’s office, and so,   you really want to make sure you’re getting, kind  of, as consistent a measurement as possible. You   want to get a height, because it will help you map  the BMI, checking the vital signs, I described how   we do orthostatics. And then doing a full physical  exam, cardiovascular being incredibly important,   but also, just all over, to see any other  medical sequelae of malnutrition. And consider   an electrocardiogram, particularly the first time  you meet somebody, or if you’re worried they’re   bradycardic, because again, this may tell you more  about whether they need to be admitted or not. What I suggest in terms of the initial  laboratory evaluation is both to see   if they are having physiologic  sequelae of the eating disorder,   as well as to rule out other causes of weight  loss or malnutrition. So, we get a urinalysis,   including a pH and specific gravity. This is –  I don’t do a clean catch, a dirty catch is fine,   and this is really to see what is their hydration  status. If somebody is very, very orthostatic,   but their – have an undetectably high urine  spec-grav, like, there may be an elevant – there   may be an element of dehydration there. If the  urine pH is high, that can also tell you whether   they’re at risk for having purged, because if  you’re purging, your kidneys are going to try to   pump out base to really regulate your acid-base  status, and some of that will be spilled in the   urine. The other thing you can see in specific  gravity is if it’s, like, abnormally dilu – like,   undetectably dilute, then you may think, okay,  this weight may be falsely inflated by fluid. We do a complete blood count. You can see  pancytopenia in malnutrition, because your   body just doesn’t have enough substrate to  make the cell lines. So, not only can you see,   just like, run of the mill anaemia, but you  can also see leukopenia and thrombocytopenia,   as well. The vast majority of cases, anaemia is  due to iron deficiency. If you were to check,   like, their ferritins, their ferritins are often,  like, six, very, very low. I also get inflammatory   markers, to rule out inflammatory causes of  malnutrition, so an ESR or a CRP. Of course,   electrolytes, potassium phosphorous, magnesium.  Just paying attention, if your lab – if you order,   for example, a comprehensive metabolic  panel, at our lab, it doesn’t include   a phosphorus or magnesium, so just making  sure that whatever you order includes those. Checking liver and renal function, actually,  chronic kidney disease is the most common cause   of failure to thrive in older children,  so, like, older school aged children,   and sometimes it’s missed, so it is important  to check. But also, checking the AST and ALT,   because you can see increases in malnutrition,  as the body tries to break down its own tissues   for energy. Usually you won’t see the  AST/ALT being much higher than 100,   sometimes up into the two or 300s in refeeding,  but usually not much higher than that. I have,   in very extreme cases of refeeding syndrome,  seen it up into the 6,000s, and of course,   like, if you’re seeing it that high, you’re  probably not going to let that go. You’re   going to do additional workup for hepatitis or  obstruction or something else, just not writing   it off. You’ll see a bump with refeeding, and then  slowly come down, as they’re better nourished. I also recommend getting hormonal studies. Thyroid  function tests, including a T3, which can be very   revealing in terms of a – being a better marker of  long-term nutritional status. It is very rare that   somebody’s malnutrition is solely due to primary  thyroid disease, but people are always wondering,   so I do think it’s also important to check, to  set people’s minds at ease. You’ll often see a   sick-euthyroid type picture, where they might  have, like, a little bit of an elevated TSH   with a normal T4, and by a little bit, I mean,  like, less than seven. If you’re wondering,   you can get autoantibodies, but  the T3 is often very revealing,   it will usually be low, like less than 100, if  the malnutrition is due to inadequate intake. In young people who have amenorrhea, checking HPO  axis, so getting a pregnancy test, also checking   their oestradiol, LH, FSH, and prolactin, to  make sure that hyperprolactinemia isn’t playing   a role here. If the oestradiol is less than 30,  you can’t expect them to menstruate. So, there   are some good studies out there to show that  you really need an oestradiol level of 30 at   least to have consin – consistent menstruation.  And again, why we care about this, this is a   surrogate marker for bone health. We can’t  really measure bone health in an easy way,   so menstruation is a marker that you have adequate  hormonal access to have adequate bone health. And   then in males, we recommend checking a  testosterone level for the same reasons,   as well as an LH and FSH. We check the vitamin D  level in everybody, plays a role in bone health,   of course, but also seems to play a role with  mood and inflammatory system activity, infection   prevention, like many, many other systems. So,  having adequate vitamin D seems to help globally. You know, so what do we do? So, you know,  the important thing to keep in mind is that   eating disorders are very treatable, but you want  multidisciplinary, comprehensive treatments. You,   as the provider, want to help the family establish  an experienced team, with a medical provider to   monitor the weight and the vital signs, ideally  a Therapist who has eating disorder experience,   and if possible, a Dietician, who can offer advice  in terms of details when it comes to eating. Now, a Therapist who has eating  disorder experience, you know,   the nature of the treatment is to empower  the family to do what they already know,   which is to feed their child appropriately.  And the medical provider can provide guidance,   in terms of, like, what’s happening with the  weight and the vitals, to say whether this   is adequate or not. So, if you can’t access  a Dietician, you know, don’t let that hold   you up. Move forward with what you can. And  then follow-up and support until recovery. And in terms of outpatient management,  what this looks like would be a goal of   one to 2lbs of weight gain per week. It’s  as simple as if they’re not gaining weight,   then they’re not eating enough. They’re  either expending too much energy,   or they’re not taking in as much as they think  they are. So, adjusting it, so that they are   able to gain that one to 2lbs a week, and like we  talked about earlier, is that there is a better   prognosis when you’re able to gain a pound  a week on average for the first four weeks. Treatment goal weight is determined by their  premorbid growth curve, so you want to get them   back to their curve, because it’s really  their genetic potential and where they’re   going to function the best. If you don’t have a  growth curve available, then aiming for the 50th   percentile is what we would advise, because that’s  average. But then going based on their vital signs   and their hormonal markers, their period for  example, if they are not getting a period back,   wherever they are, they likely need to  gain more. And weight is just a number,   right? It’s okay if you’re higher on the growth  curve, it’s okay if you’re lower and you’re   functioning okay. We just use it as an estimate  for, like, where do we think you need to be. And then, gradually while this is happening,  increasing their activity. They’re not going to   be sedentary the entire time you’re treating them,  because you want them to get practice at eating   what they need to eat, to be able to function  as would be, like, normal for them, in their   context. But for every increase in activity,  you will advise them to increase their intake. And then, I really recommend that parents  initially be in charge of the nutrition,   because eating disorders are what we call  egosyntonic. The young person cannot control   themselves. It can’t fight the eating disorder  on its own, it needs external help. And so,   the goal of therapy is to externalise the  eating disorder, so, we recognise it is not   something within the young person’s control  and empower the patient and family to do what   they know they need to do, which is feed the  young person, so that they can grow. And then,   eventually, hand the control back over to  the young person, in an age appropriate way. I’m going to wrap up there with just letting you  know what happened with the case. So, SH ended   up doing wonderfully. She was admitted a number  of times for medical stabilisation, and then,   she engaged in eating disorder treatment, a forum  called adolescent focused therapy, where she was   really in charge of the nutrition herself. Which  I know is different than what I’ve, kind of, said   needs to happen, but that was because her mother  was quite mentally ill and really wasn’t able to   do it herself. She had wraparound services, where  she had Therapists go out to her home and support   her and really help her from a global perspective,  which was really quite wonderful. And she ended   up being weight restored within a year, was able  to return to school and activity, and did great. So, there is hope, and people do get better,  but it’s important to recognise the signs   and symptoms when you’re worried and refer  when appropriate. So, thank you very much.