So Dr. Megan Riddle, I am so glad to have her speaking today. She's a board certified physician in both adult psychiatry and consult liaison psychiatry. She's the Medical Director at the Eating Recovery Center & Pathlight Mood and Anxiety Center here in Seattle. 

She is currently a Courtesy Clinical Instructor with the University of Washington Department of Psychiatry and Behavioral Sciences and enjoys teaching. Her particular interests are inclusivity in eating disorder research and supporting historically marginalized individuals in accessing evidence-based eating disorder treatments. So we're delighted to have her, and I'll turn it over to you, Dr. Riddle. 

Well, I am very excited to be here. So thank you so much for having me. This is a topic that I am incredibly passionate about. And so really excited to be able to share some knowledge with all of you. So first of all, I think it's really important to say that I'm speaking from a place of privilege when I give this talk. 

It's really important to consider eating disorder treatment in the context of our own intersectional identities and those of our patients. Eating disorder research and treatment has historically not done a great job of this. We've really tended to center white, able-bodied, neurotypical female narratives, and I just want to name that it's important to ensure that diverse voices are included at the table when we are having these conversations. 

We have several objectives today. I was chatting with folks before this presentation started that there is a lot to talk about. So I will go pretty quickly. I believe you will all get these slides, and I'm happy to answer questions at the end. 

So some of the objective today, we're going to just talk about who's at risk for eating disorders? And how and who should we be screening? We'll also talk about interventions for eating disorders, and when we should be thinking about referring out for specialized treatment. 

And then we'll also be incorporating how do we do this in the virtual space? What are some of the advantages and disadvantages, the unique challenges that come with providing virtual eating disorder care? So first of all, why talk about eating disorders? 

Eating disorders have a high morbidity and mortality. All eating disorders carry with them increased risk of death, both as a result of suicide as well as from medical complications. You will actually see in the literature that anorexia nervosa has one of the highest fatality rates of all mental illnesses. It's really beat out only by opioid use disorder. So we're talking about really serious mental health issues. 

Also important to talk about eating disorders because they're relatively common. I think sometimes we think that they're rare, but many, many people struggle with eating disorders or disordered eating that significantly impacts their life. 

So at any given time, some 30 million people in the US are struggling with eating disorders. So you're going to see these folks in your clinic setting regardless of where you're practicing. In fact, if we look at adolescents, eating disorders are actually the third most common chronic condition in this age group. 

It's also important to keep this on your radar because these patients are at high risk for a variety of complications. And so we need to be thinking holistically about these individuals and making sure they're getting the care that they need. 

Also really passionate about talking about eating disorders because these patients tend to fall through the cracks. We all hold certain assumptions about who has eating disorders based on a variety of sociodemographic and physical factors. 

So we may all picture the prima ballerina look when we think about who should have an eating disorder, but really, eating disorders span across all genders, ages, socioeconomic statuses, body types and sizes, races and ethnicities. Is really anyone can have an eating disorder. 

I'm also passionate about this because the earlier we identify someone who's struggling with an eating disorder and get them into treatment, the better their outcomes tend to be. We could absolutely see improvement in someone who has had an eating disorder for 30 years. There is absolutely hope for these individuals, and it is better if we're catching them when they've had the eating disorder for three months, a year, two years. So earlier identification, really helpful. 

We also need to talk about eating disorders because we unintentionally do harm with these folks, and with other individuals based on antifat bias that is sort of an entrenched part of our society and frequently part of our education as well. 

So medical and mental health education tends to perpetuate our cultural beliefs around food, weight, shape, health, worth. All of those things get all tied together. And the idea that thinness is really closely tied to wellness is this deeply held truth in the medical field and in society at large that is actually far less evidence-based than we are led to believe. And we end up causing harm to patients based on assumptions or statements we make about their body weight. 

All right. Pivot a little bit and talk about the development of eating disorders. So we understand getting an eating disorder, who is at risk in a biopsychosocial framework, like we do other mental illnesses? So we're going to talk a little about cultural factors, a bit about genetics, and then a bit about individual factors. 

So with regards to cultural factors, we all grow up in this-- by and large, we all do-- at least in this thin is beautiful and fit culture. It can be very hard to counteract that greater social narrative. It creates a lot of pressure. And as a result, a significant portion of individuals, including very young individuals, end up dieting at a very young age. 

And although not all eating disorders start with a diet, many do. There are also significant genetic components. So eating disorders are significantly heritable. When we look at underlying neurological factors, we see changes in the serotonin, dopamine, and opioid systems in individuals with eating disorders. So we have some real underlying biological factors as well. 

And then finally, in terms of various individual factors. So trauma is a significant predisposing factor for the development of eating disorders. Also, certain personality types or features put someone at greater risk. So perfectionism, rigidity, impulsivity, high tendency for avoidance, all of those things can create greater risk for developing an eating disorder. 

And then finally, like psychiatric comorbidities can increase individuals risks of developing disordered eating. So a significant percentage of folks with eating disorders have comorbid mood and anxiety disorders, some of which may be preceding or precipitating factors in the development of their eating disorder. 

So it's important to understand what are the eating disorder diagnoses out there? So I like to start and highlight this is directly out of the DSM-5. And so it defines eating disorders broadly as persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning. 

And I highlight that last component, because we probably all had the friend who's like, gone on the Whole30 diet or has done the like juice cleanse for a month, and it's all they talk about. Their brain is kind of taken over by food. But they get to the end of the month or whatever, and then they go back to their normal living. 

It didn't really-- they were maybe more annoying for that month because that's all they talked about, but it did-- they went to work, they went out to dinner, they did their life things. That wouldn't constitute an eating disorder. So there really is the significant impairment to their ability to function in their life and their physical health. 

The two eating disorder diagnoses you're probably the most familiar with, because they've been around the longest, anorexia nervosa and bulimia nervosa. So for anorexia, we get a restriction of energy intake, leading to significantly low body weight. 

And this is coupled with an intense fear of weight gain or behaviors that interfere with weight gain. So the food is set in front of them, and they just can't eat it. And all of this is coupled with excess concerns around weight and shape, or thinking about their body all the time. 

In bulimia, you have recurrent binge episodes. And that's associated with eating an excess amount of food in a discrete period of time and feeling out of control when they do it. These binge episodes are then coupled with some form of compensatory behavior to try to offset or prevent the weight gain. 

We typically think of purging by vomiting, but purging can also be using laxatives, diuretics, diet pills. There could be other forms of purging behaviors, is also important to think about. There are specific time and frequency requirements for bulimia. So they need to be doing the binge eating and purging at least weekly for at least three months to fully qualify. And we'll talk about what you call it when they haven't quite met that criteria. 

And then, like anorexia, it has the same excess concerns about shape and weight. So they're pretty perseverative around body image. Two diagnoses that were new to the DSM-5 are binge eating disorder and avoidant restrictive food intake disorder. 

So in binge eating disorder, like in bulimia, we have these recurrent binge episodes, eating an excess amount of food, feeling out of control. But unlike bulimia, it is not coupled with some form of compensatory behavior. 

And this has the same frequency and duration requirements. So at least weekly for at least three months to count. I will say usually by the time folks with binge eating bulimia show up to care, frequently it's been going on longer than three months. 

But again, we'll talk about what we call it when it's less than that. And then, unlike bulimia, it does not have the excess fears of weight and shape concerns as part of the diagnostic criteria. They may absolutely have that, but it's not required to make the diagnosis. 

And then avoidant restrictive food intake disorder, or ARFID for short, is an eating disturbance, typically a restriction that prevents a patient from meeting their nutritional needs and leads to at least one of the following. So weight loss, nutritional deficiency, dependence on supplements or tube feeds, or interference with psychosocial functioning. 

And this is not happening in the setting of anorexia or bulimia. So if they have anorexia or bulimia, those supersede this diagnosis. Now, you might be reading those criteria and you'd be thinking, sounds a lot like anorexia. Like, they're not eating enough, and you're putting them on a tube. Like, what's the difference? 

So the thing that distinguishes these two is the motivation behind the restriction or the food limitations. So for anorexia, those are based on weight and shape concerns, whereas for ARFID, they tend to be concerns about the food themselves. 

So either-- the food itself. So either like the texture of the food or the taste or the way the food feels in their body. For example, feeling like they experience a lot of GI distress out of proportion to any diagnosed GI illness. Also patients with a fear of choking on their food can fall into this ARFID category. 

It is highly comorbid with folks who are on the spectrum and also significant increased rates of OCD in individuals with ARFID, which you can maybe see why that might be the case. OK. The last two diagnoses I want to talk to you about are the grab bag diagnoses. So other specified feeding and eating disorder or OSFED. 

So this is where those patients fall that don't quite meet the other diagnostic criteria. So for OSFED, they've got symptoms of an eating disorder, it's clinically significant, but they haven't quite met other criteria. So this is someone who's been binge eating for two months, not three. Or someone who's bingeing and purging, but less than once a week. 

The diagnosis that I really like to highlight in this category, because it tends to get missed, is atypical anorexia. This is a very unfortunate name because it is actually the more common form of anorexia. So atypical AN involves an individual who meets all of the criteria for anorexia, but they have not yet dropped into what we would consider a low weight state. And they may never. 

They may be someone who is living in a larger body, has a higher body weight. They've lost 50 pounds. They are suffering in all the ways that individuals with anorexia suffer, but they are not recognized because they are not in a tiny body. 

This is where antifat bias can wheedle its way in, and these patients tend to get to care very late. Because sometimes they've actually been put on the diet by a well-meaning medical provider that is under-informed about the risks. And then unspecified eating disorder is just like an unspecified mood or anxiety disorder. Your spidey senses think there's something there, but you don't have all the information. 

So when we want to make an eating disorder diagnosis, who should we be screening? I really want to highlight that individuals with eating disorders rarely come in saying, I have an eating disorder. Sometimes they do. Sometimes that's your level of insight, and that's fantastic. But frequently, if you are seeing them for a mental health reason, it is often a different mental health reason than an eating disorder because it can present a lot of different ways. 

The exception to this tends to be when a worried family member drags them into your care, and it's the family member who's like, I think they have an eating disorder. And the individual themselves does not tend to share that. And we'll talk about why. 

So who should we be screening? So the American Academy of Pediatrics actually advocates for routine screening of all preteen and adolescent patients because rates are so high in this population. And if we get it early, we have much better outcomes. So if you are seeing kids, please be thinking about doing regular screening. 

For the adults, the American Psychiatric Association, their most recent eating disorder care guidelines, which there's a link to later in this talk, actually recommend screening for eating disorders as a routine part of all mental health screening, which I think is fabulous. 

I would say it's generally not happening, but I would really encourage you to at least be screening individuals in high risk groups. Who's at high risk? Young adults. This tends to be something that onsets in teens and early adulthood, although it can impact people much later in life as well. Also, be really thinking about it in the LGBTQ community, particularly individuals who are genderqueer. They are particularly high rates of risk for eating disorders. 

Also, because this is a relapsing remitting illness, typically if you are seeing someone who has had a recent major life stressor, that tends to be helpful to do a screening for because they may have an eating disorder as a teenager, they may have gone into remission, they may have been doing quite well, and then have a major life event, and it pops back up again. 

We mentioned eating disorders are highly heritable. So if you know there's a family history screen, those folks. Anyone with rapid changes in weight should set off some alarm bells. And then athletes, particularly those in sports with an emphasis on shape and weight. 

Well, how do we screen? There's a variety of screening tools out there. I don't love any of them, but I will share them with you. SCOFF is probably my least favorite. It is the oldest one. Then there's screen for disordered eating and eating disorder screen for primary care. 

I like these both better because they were created after we had binge eating disorder in the DSM. So they do do a little bit of binge eating screening. None of them screen well for ARFID, so there's also a Nine Item ARFID Screen to be aware of. 

This is the eating disorder screen for primary care questions. So are you satisfied with your eating patterns? Do you ever eat in secret? Does your weight affect the way you feel about yourself? Have members of your family suffered with an eating disorder? And then do you currently have or have you had an eating disorder in the past? 

As you can see, you're going to screen in people who potentially don't have eating disorders, but it is a good initial screener. And the evidence would say, if you have time for only one question, the question you ask is simply the last question. Do you have an eating disorder? Or have you had one before? That is the highest yield question in this set. So if you're asking nothing other than that, that is the question to ask. 

There are a variety of more in-depth assessment tools as well that can be really helpful if you are, say, tracking symptoms over time. Or if you don't feel fully comfortable doing a full diagnostic interview yourself, these can give you some additional information? 

Where I work, we use the eating disorder examination questionnaire, the EDEQ, to track progress over time for our patients. But there, as I mentioned, are a variety of other screeners out there to just be aware of. So how do we start the conversation? 

I think sometimes patients aren't screened because we don't know what to do. And so we kind of don't want to know if we really don't know what to do next or even how to have the conversations. Well, let's talk about some of that. 

So one of the first things I like to do is to start by normalizing it. And I'll say something, often when people are under a lot of stress, they'll eat more or less than they would otherwise. Does this happen to you? I would imagine it's happened to all of us, right? 

Like, we've been super anxious before an exam, and so breakfast hasn't happened. Or on the flip side, like, we've had a really stressful day, so maybe we reach for a pint of ice cream. Like, this is a normal human behavior, and tends to be a nice segue to help open the door to that conversation in a non-judgmental way. 

So when you're making the diagnosis, I think about asking questions in three main domains. Things we need to know about. So we need to know about eating behaviors, we need to know about purging behaviors, and we need to know about the relationship with their body. Body shape and weight. 

And then in a motivational interviewing vein, I like to ask questions about life impact. So I'm going to put a variety of questions up here. You will get these slides. But I'll ask them to walk me through what they're eating in a typical day. Are there rituals around food? Are they having a lot of judgment after they eat? 

Purging behaviors, I really want to know what they're doing, how often, how long have they been doing it, because that has implications for medical complications. And then in terms of body weight and shape, asking if they're trying to change their body. I like to ask how much time they spend thinking about it. Like, is their brain focused on their body all day long? That's a sign that maybe this is a problem. 

And then life impact, I always like to ask, how is this impacting you? I do ask how is it helpful? Because frequently the eating disorder is serving some sort of purpose. And if you can understand that, it goes a long way to developing rapport and helping figure out how to address this. And then is it causing you any problems? Again, thinking about motivational interviewing. 

I just want to acknowledge that this could be a really difficult conversation to have. It is very important to convey empathy and curiosity while avoiding judgment. We all have our own relationship with food, weight, shape, our own bodies that can sometimes complicate this. 

So it's really helpful to have good self-awareness about how this impacts you as well when you're walking into these conversations so you can leave your stuff at the door. In terms of just some basic do's and don'ts, name your concern. If you are worried about someone, please don't-- please tell them. Don't avoid that. 

Also important to acknowledge the distress that treatment may bring. I really want you to avoid reducing this to you just need to eat more or just stop bingeing, or just don't purge. That is very reductionist, please don't. It will cause harm and rupture rapport. 

Also, just avoid making weight and shape comments. I wish the entire universe would just avoid making weight and shape comments about bodies that are not their own. And then just being really aware that things saying like, oh, you look good, you look so much healthier just get interpreted by these individuals as like, oh, my gosh, you've gained so much weight. So again, trying to stay away from those weight and shape comments. 

And then finally, please don't forget this is a mental illness, not a choice. Nobody wakes up one day and is like, you know what sounds great today? I'll develop an eating disorder. Sometimes they can feel very volitional. So like I just really highlight this. Yeah. 

OK. Where do we treat? Eating disorders are really treated across a whole spectrum of care. Outpatient, intensive outpatient, partial hospital, residential, inpatient units. And we need to be determining if someone is appropriate, particularly when we're working in the virtual care setting. 

So the real things that I want you to consider the most are, are they medically stable? What do their comorbid psychiatric issues look like? And how willing, able are they to engage in that sort of space? So typically, the individuals who are most appropriate for virtual care are folks who are appropriate for outpatient level of eating disorder treatment. 

But sometimes the virtual care or outpatient care can be a bridge to a higher level of care. So it might be the place that we start and see how it goes. It is also a bit of a bell curve because also in outpatient are the people completely unwilling to address their eating disorders, which I don't really talk about a lot in this talk, but I'm happy to talk about as well. 

OK. Virtual care for eating disorders. I just want to acknowledge that there's some unique challenges and opportunities here. So opportunities in the virtual space, you reduce barriers. Things like geography, financial barriers. Frequently, eating disorder treatment centers or in a city far away. And there can be real barriers to getting there. 

Also, some of the work that you do is actually better done at home. So you can do exposures right in the home space. That is awesome. You can also include their support people, their family, their friends, their pets, like whoever might be support can be right on that screen there with you. And just overall, I think can really help increase inclusivity for individuals. 

Challenges include safety. I mentioned these individuals are increased risk for suicide. Accountability can be an issue. When you are on a screen, you are only seeing this much of the patient, and you don't necessarily know what's happening over here and if all of the food on the plate is just getting dumped in the trash can next to them or fed to their dog. 

Also, it's sometimes hard to interrupt behaviors in the space in which they are ingrained. So if this person has been binge eating every single night in their home for the last five years, it's hard to interrupt that behavior. It is like, it is an intensely ingrained and reinforced habit. 

Also sometimes measuring progress or measuring behaviors, it requires a lot of accountability from the individual, which is sometimes hard because I say people with eating disorders can be the most honest folks, but eating disorders themselves are really sneaky. So even our most honest individuals may not be telling us everything because it is hard. It is hard to tell on their eating disorder. 

And then monitoring medical stability presents its own challenges in this. OK. Just being mindful of time. Just questions I want you thinking about when you're thinking about treating someone in a virtual space. Are they safe? Are they able to change their behaviors? Are they willing to change their behaviors? 

What's our access to specialist care look like? We'll talk about that shortly. And then once someone is engaging a treatment, are they getting better? If they are not getting better a month or two in, think about making a change. 

Because these folks-- someone who's just partially recovered from an eating disorder is living in purgatory. It is a miserable place to be, to be working really hard and not actually getting better. So try not to let them stay there too long if at all possible. 

Eating disorder treatment is absolutely a team sport. That's one of the things I love about this work. So really having a therapist, a social worker, a mental health care worker, a primary care provider, whether that's a physician or NP, a psych provider, and then a registered dietician, all there to support the patient. 

It is ideal if one of these individuals has eating disorder experience or can seek consultation. My email address will be at the end of this talk. You are welcome to reach out to me if you have eating disorder questions about someone. 

If no one on this care team has interest in eating disorders, it's probably not ideal. Probably need to swap out someone who has at least an interest in learning more, even if they don't have expertise themselves. But you're all here. So I expect you to have an interest in learning more. 

As I've alluded to, lots of serious medical complications. Please do not make assumptions about their medical stability based on their weight. That can be very deceiving. Here's medical resources just for you to be aware of. I know that's not necessarily your role, but I think it's important to know what's out there. 

So Phil Miller has a book that's sort of the bible of medical eating disorder treatment, which is the first one there over on the left. And then this Academy for Eating Disorders Guide to Medical Care is actually a free resource that is pretty short and pretty digestible. 

So if you know someone has a primary care provider or they're going in to seeing, you could definitely highlight this information for them. Because many primary care providers also do not have eating disorder experience. I want to highlight that these individuals frequently don't just have an eating disorder going on. Often there are other things, whether those are psychiatric disorders, other medical concerns. 

Sometimes these other comorbidities can be predisposing factors to their eating disorder. Sometimes they can be sequelae, a consequence of their eating disorder, or sometimes it can simply be impacted by the eating disorder. 

So really important that they have careful medical and psychiatric care to help understand what level of care they need, and helpful to consider including specialists like gastroenterologists, endocrinologists, those sorts of things if someone is more medically complicated. 

This is a slide just for awareness. It is out of the APA's practice guidelines that's freely available, and it just talks about when does someone need to go to the hospital. It's primarily medical, but I think it's helpful for you to just be aware that this resource is out there. 

OK. Moving quickly. But I want to make sure there's time for questions at the end. So we're going to now start to talk about eating disorder treatment. I think about eating disorder treatment as having four main components. 

We have to address the basic nutrition. Are they getting in food, and are they getting in food on a regular basis? Then we have to talk about eating disorder behaviors. What are they doing with that food? Is it getting in their mouth? Like, what's happening there? 

And we're going to talk about psychotherapy and the role for psychotherapy, and then we'll talk briefly about pharmacology. The short version is meds are not super helpful, but I'm a psychiatrist. So I'm obligated to tell you about them. 

All right. Nutrition. Nutrition is a non-negotiable part of eating disorder treatment. I highlight this because symptoms will not get better without regular intake of sufficient nutrition. This is also true for binge eating. People are always like, what about binge eating disorder? Is different? No. No. People with binge eating also need to be eating regularly enough food for their body throughout the day. Very important. 

Patients always, I've yet to meet a patient who doesn't feel this way, it seems. They always want to change their thoughts and feelings about food before they change their behavior about food. And my job would be really easy if that were an option, it's not an option. They actually have to get enough nutrition to then be able to work on the thoughts and feelings. And that is really hard, and that is the crux of why eating disorder treatment is so hard. 

Collaboration with an eating disorder savvy dietician is extraordinarily helpful. I will go so far as to say some dieticians who do not have eating disorder treatment training can be harmful to these folks, particularly if this is like an atypical anorexia case, and they also have diabetes, and then they put them on a restrictive weight loss diet. 

So it's really important to, again, have that team member be eating knowledgeable or at least eating disorder curious. Dieticians do things like set target weights. Like, if someone needs to weight restore, where do they need to weight restore back to? 

They will work on setting meal plans and caloric amounts if someone is significantly undernourished. Not uncommon that they actually need 4,000 calories a day to weight restore, which feel like a lot of food, particularly for someone who's been restricting. 

Typically, so I work primarily at residential and partial hospital programs. We're usually looking for 2 to 4 pounds a week of weight restoration if someone is weight suppressed. In the outpatient setting, usually more like half a pound to a pound a week. 

If someone is undernourished and weight suppressed, usually we are not wanting them to engage in much movement other than what they need to do for their daily life. Some ways in which we can impact this through our virtual intervention. 

So first of all, consider the timing of your sessions to challenge eating disorder behaviors. So if someone is struggling with restriction, planning to have a session at lunchtime and have them actually eat food while you're there on the screen with them providing support can be incredibly impactful. 

Similarly, if someone is engaging in a lot of purging behaviors, scheduling for right after the meal so you can sit with them and help them with distress tolerance as they have this urge to purge, that can also be really useful. 

If you're not doing it over necessarily a meal time per se, just checking in about, hey, what's food looked like today? Have you had anything to eat? And then actually having them pause and go get something if they haven't eaten yet today. 

And even if they say I'm going to eat after my session, I think encouraging them to go and get it now. A classic eating disorder move is to say they'll eat later. The delaying tactic is very real. You could also work with the individual to track their eating disorder behaviors and their meal completion. There are some apps that can help with that. 

Also collaborating with family members and social supports to bolster accountability. Like hey, can you-- I know you don't live with anyone, but hey, can we set up so your best friend could virtually join you at lunchtime, or something like that? 

Or maybe you could go to your parents' house for a meal. Or maybe there's a work buddy that could be an accountability buddy for you. And then creating a plan at this point about how weight is getting tracked, particularly for individuals who are weight suppressed. 

This page just has some meal coaching tips on it. We tend to want to keep prompts positive, short, and direct. Providing lots of validation for their distress. Telling them when they're doing a great job. Also prompting a coaching around very small things like, hey, I see you're taking small bites, can we take some larger bites. 

Reminding them it's important to give their body fuel for their needs. And then prompting them to keep going can be some components of that meal coaching. All right. Eating disorder behaviors. Folks can engage in a whole wide variety of behaviors with their foods. 

And a lot of the work at this stage is really, if we think about it in terms of exposure work, if you have done like OCD exposure work in the past, you have all of the knowledge to do this. In terms of a skill set way, it is very parallel. 

So much of the work is exposure therapy. Patients really benefit from validation and support while they're doing those hard things. As we've mentioned, treatment plans can include family support, structured meals, exposures to places. Patients with eating disorders will sometimes avoid like restaurants or grocery stores or eating with family. So working on reintegrating those things. 

Also goals around expanding the quantity and variety of foods. One of the best predictors of someone being able to sustain recovery is that they have a lot of variety in their food intake. They typically don't start there, but we'd love for them to get there. And then if someone is in a nutritional and medical place to do so, plans around exercise and joyful movement that isn't rigid and punitive and compensatory. 

In terms of virtual interventions, as we alluded to, being able to do exposures in the home can be incredibly helpful. Think about doing exposure work in a variety of different-- on a variety of different things with telehealth. So you can think about eating a challenging food together. 

Like, maybe they-- I had a patient who hadn't had a donut in 30 years. And so eating a donut with her was one of our therapeutic things that we did. And you could absolutely do that in telehealth setting. Ordering meals in. Maybe they've been avoiding eating at a restaurant, but what if they got something in from Uber Eats, or they went to the grocery store and just got a challenge food that way. 

They could also do cooking during sessions. Sometimes these folks are really avoidant of engaging around food or cooking. Like, maybe they only eat packaged foods because they can see the exact calorie amount on the packages. So encouraging some flexibility around their portioning, those sorts of things. 

And maybe engaging in some gentle movement. Like, maybe they take you on their mindful walk while they're doing their session. Also, for someone who's really struggling with purging, you can do exposures around going to the bathroom. 

Going into that space, into the restroom space and not purging. And looking at what their suds look like and helping gradually increase that challenge. It's really an opportunity for them to develop coping strategies and distress tolerance in their own home environment, which is really fantastic. 

OK. Psychotherapy. So what do we know about evidence-based treatments? For anorexia in adolescents, that's where we have the best treatment evidence for what to do. So the research indicates that family-based therapy is the most robust option for this diagnosis and this age group. 

In this process, caregivers really take control of the eating choices, and it teaches the family how to support the child as food habits are normalized. Telehealth can really help decrease barriers to family engagement because you can just get the family right there with you. 

For adults, its evidence is less clear. Basically, all of the alphabet soup of therapeutic modalities have some evidence. There is CBT for eating disorders that is manualized. That's that enhanced CBT. Most people in the community who specialize in eating disorder treatment do a hodgepodge of things. 

I will say that working with a dietician plus therapy is better than just working with a dietician. So having a therapist on board is incredibly important. There's a lot less research around atypical anorexia and what we should be doing there, but we typically tend to do the same sorts of things that we are doing with anorexia. 

In terms of bulimia and binge eating disorder, the most evidence is for cognitive behavioral therapy. There's also some evidence for interpersonal therapy for binge eating disorder. I do really want to highlight that it is very common. There are high rates of trauma in patients with bulimia and binge eating disorder. And frequently, we actually need to treat the trauma as part of their recovery. 

So we do cognitive processing therapy where I work, EMDR, or whatever sort of evidence-based trauma modality of your choice can be very helpful for these individuals. Also for patients with anorexia with trauma too, yes, absolutely as well. 

And then in terms of some virtual interventions to be thinking about. So thinking about as basic as identifying emotions. So these patients can be very alexithymic. They struggle to identify their own emotions. And helping them to recognize them can be a helpful part of the process. 

Also skill building to help increase distress tolerance. As I described, this is a ton of exposure work basically that these individuals are needing to do, and so helping them work on increasing their tolerance to that distress is very useful. And helping them to identify and build non-eating disorder coping skills is key. 

In terms of body image interventions, this work in particular can be really hard. So typically for an individual, this isn't necessarily where we start. We need them to have a good foundation of skills around managing their distress and good therapeutic rapport. 

So some of the things that we think about doing in terms of interventions that we do with folks is creating an understanding of how they got to the point where they are with their relationship with their body. So creating a body image timeline. 

We'll also talk about separating personal values from eating disorder values. They'll do like a value sort and figure out, hey, what if this is my eating disorder, and what is actually genuinely me? Also doing exposure work around body image. These can be imaginal exposures. These can be stepping on the scale exposures. These can be looking in the mirror exposures. 

And then another important, really important part of this work is addressing and acknowledging cultural stigma and creating a space to acknowledge the very really anti-fat bias in societal and medical spaces can be really key here. 

OK, pharmacology. Meds. Anorexia, there's no FDA-approved meds. Folks who are underweight tend to be more prone to side effects. Usually we start with SSRIs. And when we think about dosing, we think about OCD level doses. So typically high end of the dosing spectrum. We avoid Wellbutrin because that can increase risk of seizures. 

And antipsychotics tend-- we've done a lot of studies on them. The results are kind of mixed. Patients don't tend to want to be on them because of the weight gain side effect. I'm pretty good at convincing people to do them anyways. But that can be a barrier and a challenge. 

Usually, the bottom line is, I am starting meds for folks to treat their comorbidities, not to treat their eating disorder. For bulimia, Prozac is actually FDA approved. Fluoxetine is, but there's really nothing special about it. You could use any of the SSRIs with probably equal benefit. Again, we're thinking high end of the dosing spectrum. Think about OCD. Also some evidence for topiramate and TCAs. 

And then finally, binge eating disorder. Typically, therapy is a lot more effective than meds, but lisdexamfetamine or Vyvanse is the one that is FDA approved. I will say it works less well for binges that are mostly at night because it has a tendency to appetite suppress and then wear off in the evening. And so then folks can end up incredibly hungry at night. 

Recovery is absolutely possible. It is very important to hold hope for these individuals even when they are feeling incredibly hopeless. And I also want to acknowledge that it's very nonlinear. It can be very two steps forward and three steps back sort of vibes. 

It also takes time. So this is from an older study of 580 patients that tracked them over time. That thick gray line at the top is like full recovery from their eating disorder, which is approaching 80%, but only if you look 10 years out. So this tends to be much more a marathon than a sprint, and sometimes we are just seeing them for a small part in their journey. So really important to hold that sort of longer hope for them. 

I realized this is labeled local treatment resources. And hearing from the beginning of the talk, you guys are from all over. So this is very self-centered local to me. So this is opportunity sort of in Western Washington. 

So Eating Recovery Center is where I work. We are actually national and have sites all across the country. There are also virtual programs equipped within our nationwide. Local to us in the greater Seattle area, Emily Program Center for Discovery, Opal, Liberating Jasper I give a shout out. They tend to have some really good breakout groups that are open to the community. 

And then in terms of resources for you, this is in no way a comprehensive list. If people have particular interest or curiosity, I'm happy to provide more resources. But this includes a link to the APA practice guidelines I mentioned. Also some of my favorite books. 

I recommend Fat Talk by Virginia Sole-Smith to literally everyone who exists in a body. Its subtitle is something about parenting in diet age. You do not need to be a parent to get really important things out of this book. I really love it. 

And then podcasts, antifat bias, I love Maintenance Phase. Burnt Toast is also fantastic. Not the food52 one, but the one that's by Virginia Sole-Smith. Also, Food Psych is a great eating disorder podcast. And then here are several websites. And then I included my own contact information there at the bottom. You are welcome to reach out. 

And so just sort of wrapping up, eating disorders are relatively common. Patients of all sizes and genders can develop eating disorders. Treating eating disorders is a team sport, and early treatment is associated with better outcome. 

And so I'm going to conclude with that. And now I know we do the end slides, which I realized got, I think, pushed to the bottom of this slide deck. So I'm going to unshare and then reshare at the right slide point. So hold tight. 

There's a lot of questions in here. The first one is, how do you diagnose ARFID? 

So for ARFID, you're going to ask those similar questions. The difference is that they're probably not going to have weight and shape concerns. I say you can have a culturally normative level of weight and shape concerns. So they're allowed to have some level, but not to the intensity of anorexia. 

And then usually I'm asking questions around like food textures. Do you have textural aversions to foods? Do you have difficulty with foods of different temperatures? Are you fearful about choking? And usually when I'm asking them about their relationship to food, they will be providing these things. I will say folks with ARFID tend to be the least secretive group with regards to what's going on with their eating disorder behaviors. They tend to be the most forthcoming. 

Also will ask them about, how does your body feel after you eat the food? Because some subset will have like, they'll eat, and then they'll have sever stomach pain. And they'll have had a full GI workup, for example. So we know it's not something medical necessarily that provides an explanation, but it can actually potentially be ARFID. So I'm sort of asking a little bit more about their relationship with the food in that way. 

And this next question relates to this. It's how do you-- so please discuss picky eaters versus ARFID, especially identifying in children and teens. 

Yeah. So I think it's helpful to think about it on a bell curve. This is true for all eating disorder, sort of a bell curve of normative behaviors. So for one thing, kids frequently go through a picky eating stage, where all they want for dinner ever is chicken nuggets. 

That kid does not necessarily need to go directly to eating disorder or treatment. If they stay on their growth curve, they're gradually able to add more variety into their life, it does feel more like a phase. I'm not necessarily putting off alarm bells there. 

If they are starting to fall off their growth curve, that's really for kids, particularly where we get concerned. Also, if the food is getting like so limited. They're only able to do one brand of yogurt and a specific chicken nuggets. Like, you're getting to a stage where it's like, oh, this is going to have a real impact on their ability to function in their life. 

There's lots of people out there who are just picky eaters, and that's fine. And they can go out to restaurants and order their one specific thing that they like, and like, it's OK. They're able to move through their life just fine. But it's when we're having medical complications, we're losing weight, we're not able to go and purchase food. Those are things that I start to raise alarm bells, that I'm like, ooh, we should get some more support around this. 

OK. Great. Thank you. The next question shifts to how do you see the problem being addressed in rural communities? What are the programs? And then there's also something around, I'm thinking it was less nutritional foods, food instability, junk food, fast food, et cetera. 

Yes. So there are huge equity issues in terms of access to eating disorder care, and there's equity issues in terms of access to food. So I didn't emphasize it in this talk. I give another talk specifically on antifat bias and the psychosocial stuff. 

But food insecurity is actually a major risk factor for developing disordered eating. And food insecurity in childhood, impacting people into adulthood, particularly precipitating for a binge eating disorder. Because if you don't know when the next food availability will be, you are going to eat the food that you have now. That is a normal-- that is a normal response that can very much develop into an eating disorder. 

We practice on the model that all foods fit. So we actually want to move away from judgments around healthy, unhealthy. I think the current obsession with processed foods and not doing processed foods, and the-- I mean, that's the new way that we say healthy, unhealthy foods. 

We want to move away from all of that. And particularly for folks who have limited access to foods, we want to encourage them to eat the food that they have. And if that means that breakfast is Pop Tarts, great. That is fantastic. If that's what they have available, that's what we want them eating. 

And this is where it can get complicated if you have a dietician involved that isn't of that mind and is trying to really hammer home the healthy eating. Because if they don't have access to whole foods, it's not helpful and can perpetuate the food scarcity. I'm not supposed to eat the foods that I have, what am I going to eat? That just adds so many more layers. 

[INAUDIBLE] Yeah, I could definitely see that. So next question, in terms of higher risks, how do women with ADHD, especially undiagnosed or late diagnosed ADHD, do? 

That is not an uncommon population that I care for at all. There's a fair-- we see a fair amount of that in eating disorder treatment. I'm not sure if anyone has-- I'm sure someone has looked at ADHD specifically in and of itself is a risk factor. 

It is definitely a component and also can be something that we have to address in treatment because it takes a lot of executive function to get from the grocery store to the food on your plate. And if you-- we see a lot of crossover with ARFID and ADHD. They tend-- that is fairly common. 

And it's like, if you're not particularly interested in food to begin with, the number of steps you have to take from there's no food in the pantry to getting food on the table, it's a lot of-- it requires a lot of planning and follow through. Like, all of those things that for folks with ADHD may have more challenges around. 

And so really working with them to be like, OK, what's the most what's feasible? How can we help decrease those barriers? And those are cases in which we might be like, yeah, if driving by McDonald's to get Chicken McNuggets, if that's the thing you can do, great. Go for it. Again, we're not going to judge that food that you are able to access. 

Excellent. Thank you. The next question, how would you address family members involved in the client's care who may come from cultures or backgrounds in which body shaming or focus on appearance is more or less normalized? Is there a way we can best support the client with potentially experiencing negative commentary from loved ones? 

Yeah. This comes up. This is very common. As I mentioned, eating disorders are heritable. So it is not uncommon that a parent or close relative will be struggling with their own stuff. And the degree to which that may impact the individual really varies. 

I think simply being able to name it and recognize it. Also, I think it's important to work from the assumption that that family member is doing the best that they can. And so how do we help educate them and shape their behavior around like, hey, instead of this, can we be doing this? 

Really showing them like how can they show up and be supportive, because they are probably trying their best, and they are probably worried about this individual for whatever reason that might be. Whatever end of the food or weight spectrum they might be at. 

And so can we get the family member on board, provide some education? There are variety-- some of those links actually include family resources. So like, Feast is a good family resource. Our organization, Eating Recovery Center, provides family days to the community for education. 

The Fat Talk book by Virginia Sole-Smith that I harp on, she specifically talks about-- more from a parenting lens, but I think also can be helpful for the children of those parents who are trying their best and maybe missing the mark. So those are some of the things that I think about there. 

So I love that. I loved your talk. I know everybody else did, because in the chat, which I'm sure you haven't had a chance to look at, there is a ton of thank you. This is helpful. Well done. 

Awesome. 

We are at time. We do have like 13 more questions that we can't get to. So thank you for all you do and for presenting for us today. And have a nice day. 

Absolutely. Thank you, guys. I really enjoyed it.