A note from Dr. Derenne and Dr. Hill
Rates of eating disorders have skyrocketed and hospital admissions for eating disorders have doubled in the last few years.¹,² Between isolation, mental health struggles, and social media, young people are particularly vulnerable to eating disorders. The good news is that eating disorders are treatable with early detection and proper treatment. Unfortunately, most medical schools and clinical programs don’t provide adequate education on them. Below you'll find educational resources to help with screening, workups, and referral options for proper treatment. Please don’t hesitate to reach out!
Katherine Hill, MD
VP, Medical Affairs, Former Stanford Clinical Assistant Professor
Jennifer Derenne, MD
VP, Clinical Care Delivery & Head Psychiatrist, Stanford Clinical Professor
What providers need to know
Eating disorders have the second highest mortality rate of any mental illness and might be hiding in your office. Here's what you need to know to help your patients get the right care.
30 million Americans (10% of the population) will be affected by an eating disorder in their lifetime⁴
5 million Americans will develop an eating disorder this year⁴
80% of Americans will never receive treatment and less than 20% of them will receive evidence-based care that works⁵
Eating disorders have the 2nd highest mortality rate of all mental illnesses, following opioid addiction³
Families don’t cause eating disorders but are critical in helping loved ones recover
Eating disorders don’t have a “look” and affect people across genders, races, ages, ethnicities, and body sizes
Screening and care guide
How to screen for an eating disorder
A guide for healthcare providers
Signs in the history
- Changes in food intake and behavior: Food restriction, binging, new diets, wearing baggy clothing, avoiding family meal time, becoming vegetarian/vegan/gluten-free, disappearing to bathroom after meals
- Overexercise or compulsive exercise: Is your patient exercising when sick, tired, or injured? Do they never take a day off?
- Physical complaints: Fatigue, hair loss, fainting or near-fainting spells, abdominal pain, constipation, cold hands and feet
- Mood changes: Worsening depression or anxiety, poor concentration, irregular or absent menses
- Noticeable weight changes
- Temperament traits: Perfectionism, overachievement
Clues in the growth chart, vital signs, and physical exam
- Rapid weight loss or weight gain
- In growing children, slowed height velocity or falling off growth curve (regardless of where on BMI chart)
- Vital signs suggesting medical instability
- Common physical exam findings: bradycardia, alopecia, cold or bluish extremities, enamel erosion or enlarged parotid glands (signs of purging), lanugo, Russell sign (callous on knuckles from purging), decreased bowel sounds or palpable stool
What to say or not say
Language is important
- If you’ve noticed a patient has lost weight, it may be harmful for them to hear “wow, you look great, what have you been doing?” Instead, consider saying, “I’m noticing that your weight has changed since you were last here. Tell me what's been going on.”
- Modeling body positive attitudes is important. When interacting with kids and teens, consider commenting on a bright smile, the sparkle in their eyes, or their passions rather than their image or appearance. Ask their opinions, be interested in their ideas, and make it clear who they are is more important than what they look like.
- Don’t make disparaging comments about your own weight, shape, or eating habits. Be mindful about comments about food, body, and the messages they send.
- Even the most well-intentioned conversations can have unintended consequences. Patients often start restricting food after a healthcare provider shared concerned about their weight or shape. We encourage you to follow up with kids and teens shortly after such conversations to see if they are preoccupied by it.
What not to say
“Oh, I wish I had that, I have no self control around food.”
“Wow, you look great, what have you been doing?”
“Oh, I have to take a long run after work to make up for those cookies I ate at lunch.”
What to say
“I’m noticing that your weight has changed since you were last here. Tell me what has been going on.”
“I had the most delicious cookie at lunch today. Do you have a favorite flavor?”
How Equip treatment works
Equip’s care model was built on the foundation of Family-Based Treatment (FBT), which empowers families to help their loved ones through recovery, and was then amplified with our 5-person care team.
How we build upon FBT
Family-Based Treatment (FBT), built from the Maudsley Method, is the primary evidence-based model for lasting recovery in children and adolescents. In FBT, parents and family members work with their care team to renourish their loved one and help eliminate eating disorder behaviors.
Parents plan, prepare, and plate all meals and snacks with close monitoring by medical provider and planning with a dietitian. They are focused on empowerment and alignment with their child and team.
Child begins to slowly and gradually regain independence under observation and supervision.
Child is eating independently, focus shifts to normal adolescent concerns.
The Equip Model
Created by clinical experts in the field and people with lived experience, Equip’s model fills the gaps in existing treatment and enhances FBT.
Coordinated circle of care
Each family has a dedicated five-person care team, including a peer mentor, family mentor, medical provider, therapist, and dietitian. FBT works, but it’s not easy. The provider team is there to support the family through all of it.
Virtual by design
Treatment is 100% virtual so families can help loved ones navigate personalized care from the comfort of home–for families of all configurations.
The power of lived experience
Peer and family mentors know what it’s like to go through treatment and recovery, and they’ll be there for your family with emotional and practical support.
FBT empowers families to be at the heart of their loved one’s treatment through skills and resources that help make recovery possible.
Our patients are getting better
After eight weeks of treatment, Equip families are well on their way to healing
average weekly weight gain for those who need it*
7 in 10
patients report a decrease in eating disorder behaviors*
of patients report improvements with depression or anxiety*
Medical evaluation guide
How to do a medical workup
A guide for primary care providers and pediatricians
Take a closed (formerly known as blind) weight
- Weight numbers can be triggering for patients with eating disorders. We recommend weights are taken in a gown standing backwards on the scale.
- Tip: Sometimes, patients with eating disorders may hide weights in their clothes, hair, or drink a lot of water to artificially increase their weight. If this is a concern, consider testing the patient’s urine – if it is very dilute, they might be water loading.
- The weight number should not be shared with the patient. Instead, discuss general trends–up, down, stable. A height should be obtained to calculate BMI.
Take orthostatic vital signs
- Lie for 5 minutes: The patient should lie flat and still for 5 minutes–check and record heart rate and blood pressure
- Stand for 2 minutes: Patient should stand for 2 minutes–check heart rate and blood pressure
Run baseline labs and screening tests
- When an eating disorder is suspected, the following labs are recommended for an initial workup.
CBC + differential
It is common to see leukopenia, anemia, and thrombocytopenia in states of malnutrition due to bone marrow suppression or iron or vitamin deficiencies (B12, folate)
Comprehensive metabolic panel
with magnesium and phosphorus
- Ensure potassium is > 3.5, magnesium is > 1.8, and phosphorus is > 3.0
- An elevated bicarbonate level may suggest purging behaviors
- AST and ALT can be elevated in states of malnutrition
TSH, Free T4
A low T3 with normal TSH and Free T4 is not a problem with the thyroid, but a marker of malnutrition
Vitamin D 25-hydroxy
If Vitamin D 25-hydroxy level is under 30, treat with ergocalciferol 50,000 I.U. once a week for 8 weeks
LH, FSH, estradiol
In bio females with irregular or absent periods
LH, FSH, and estradiol are often suppressed in states of malnutrition–estradiol needs to be above 30 for regular menses
Assess for arrhythmias, prolonged QTc, bradycardia
- Celiac disease screen if patient reports GI distress, bloating, fatigue, unexplained rashes
- PCOS screen, pregnancy test if irregular or absent periods
- Fecal calprotectin if significant GI distress to look for IBD (inflammatory bowel disease)
- If prolonged amenorrhea (>6-12 months) or significant fracture history: DXA scan to assess bone density
Criteria for medical stabilization
When your patient might need to be admitted
- We recommend the Society for Adolescent Health and Medicine guidelines for determining if your patient may need admission for medical stabilization. If your patient meets any of the criteria included here, please call your local children’s hospital or eating disorder medical unit for consultation.
heart rate < 50 beats per minute (daytime) or <45 beats per minute (with sleep)
Orthostatic increase in pulse
(>20 beats per minute) or decrease in blood pressure (>20 mm Hg systolic or > 10 mm Hg diastolic) upon standing
blood pressure < 90/45
Severely low body weight
(less than 75 percent of the median BMI for age), losing a large percentage of body weight rapidly, or precipitous fall off their growth chart line
Potassium < 3.5, Phosphorus < 3.0, Magnesium < 1.8
Prolonged QTc on EKG
- Asch DA, Buresh J, Allison KC, et al. (2021). Trends in US Patients Receiving Care for EDs…Before and During the COVID-19 Pandemic JAMA Netw Open, 4(11).
- Otto, A. K., Jary, J. M., Sturza, J., et al. (2021). Medical Admissions Among Adolescents With Eating Disorders During the COVID-19 Pandemic. Pediatrics, 148(4).
- Chesney E, Goodwin GM, Fazel S.(2014). Risks of all-cause and suicide mortality in mental disorders. World Psychiatry, 13(2).
- Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007).The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61(3).
- Hart, L., Granillo, M., Jorm, A. and Paxton, S. (201 Unmet need for treatment in the eating disorders. Clinical Psychology Review, 31(5).
- Loeb, K. L., LeGrange, D. (2009). Family-Based Treatment for Adolescent Eating Disorders. International Journal of Child Adolescent Health, 1–13.
Read Our New Research Paper!
Equip's breakthrough study in Eating Disorders proves that our virtual Family-Based Treatment is just as effective as in-person care.
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