Eating Disorders – PediaCast 249

Join Dr Mike Patrick and Dr Terrill Bravender in the PediaCast Studio for a detailed discussion on eating disorders. From risk factors and symptoms to diagnosis and treatment, we’ll cover everything you need to know about anorexia nervosa, bulimia, and binge eating.


  • Apologies to the University of Illinois

  • Eating Disorders

  • Anorexia Nervosa

  • Bulimia Nervosa

  • Binge Eating

  • Jurassic Park 3D IMAX




Announcer 1: This is PediaCast.


Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!

Dr. Mike Patrick: Hello, everyone and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio.

It's Episode 249 for April 17th, 2013. We'll call this one "Eating Disorders". We'll be talking about anorexia nervosa, bulimia, binge eating. That's all coming your way. I would like to welcome all of you to the show.

Before we get started, I want to send my apologies to the good folks at the University of Illinois at Urbana-Champaign. A couple of episodes back, Number 247 to be exact, we had a News Parents Can Use edition of the program and we covered the story on the benefits of drinking milk for college students in order to reduce the risk of metabolic syndrome, type 2 diabetes, hypertension and heart disease. All good things, but leave it to me, I credited the study to researchers at the University of Iowa.


Dr. Mike Patrick: And, oh boy, Dr. Margarita Teran-Garcia, the lead investigator of the project at the University of Illinois, she was quick to point out my mistake. And some would like to think the Big Ten is one giant happy family, someone from the Ohio State confusing the University of Illinois and the University of Iowa. It's just downright embarrassing.

So I do want to set the record straight, the college milk research study that we talked about couple of episodes back comes from the University of Illinois at Urbana-Champaign and we want to give the right credit to the right people.

If you missed the story on the importance of college students drinking milk, be sure to take a listen to the details, Episode 247, over at I also put a link to the Up Amigos project at the Family Resiliency Center at the University of Illinois, where you can find more information on Dr. Teran-Garcia's work and I'll put that link in the Show Notes for this Episode 249 at


All right, speaking of this episode, we're talking about eating disorders today — things like anorexia nervosa, bulimia nervosa, binge eating. It's another nuts and bolts approach, kind of like ADHD a few weeks ago. We're going to cover the risk factors, causes, symptoms, complications, diagnosis, treatment, even a long-term outlook and research topics as well.

What do you do if you suspect your child has an eating disorder? How do you approach the subject? Where do you turn for help? And to help me answer these questions today, we have another great expert from Nationwide Children's Hospital, Dr.Terrill Bravender. He is Chief of Adolescent Medicine and a professor of pediatrics and psychiatry at the Ohio State University College of Medicine. He'll be joining us in a moment.

But first, I do want to remind you that PediaCast is your show. So if you have a question for me or a topic idea, or want to point us in the direction of a news story, make sure you let me know. It's easy to get in touch, just head over to, click on the Contact link. And I read everyone of those that come through, so give me a shout, Contact link.

Also, I want to remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you do have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use agreement which you can find at

All right, let's take a quick break and we will be back to talk about eating disorders. It's coming up right after this.



Dr. Mike Patrick: All right, we are back. Dr. Terrill Bravender is the chief of Adolescent Health at Nationwide Children's Hospital and a professor of pediatrics and psychiatry at the Ohio State University College of Medicine. Dr. Bravender is interested in research which involves the intersection of behavioral and physical health in adolescence with a particular emphasis on nutrition. He's director of the multidisciplinary Eating Disorders program here at Nationwide Children's. And that's why he stopped by the studio today, to talk about eating disorders.

So, welcome to the program, Dr. Bravender.

Dr. Terrill Bravender: Thanks, Dr. Mike. I'm happy to be here.

Dr. Mike Patrick: Great having you.

So let's start out with just a definition. What is meant by the term 'eating disorder'?

Dr. Terrill Bravender: Well, the term 'eating disorders' covers a rather large group of eating behaviors and that can affect children, adolescents and adults. And most people, when they think eating disorders, they think anorexia nervosa where someone is very thin but perceives himself as being overweight. But there are many, many other problems that fall into that umbrella.

And you mentioned anorexia nervosa, which is a problem of really severe malnutrition with some disordered thinking about that. But it also includes bulimia nervosa which includes episodic overeating with some kind of compensatory behavior for that overeating, and then people usually think of something like self-induced vomiting. But it can be any kind of maladaptive compensatory behavior, whether that's over-exercising after the eating or even prolonged fasting after the overeating.


But in our program, anorexia nervosa and bulimia nervosa only account for fewer than half of the kids we see in our program. The rest of them fall on this catch-all category called 'eating disorder not otherwise specified'. And that really runs the gamut, from kids who are very, very selective eaters — so kids who will only eat certain types of food or certain brands of food or who avoid most foods that other people eat — to kids who have severe body image distortion but haven't quite lost enough weight to fit criteria for anorexia nervosa. And, to think broadly, it really encompasses any kind of eating behaviors that impact otherwise normal functioning in life.

Dr. Mike Patrick: Got you. Let's talk a little bit about anorexia nervosa, specifically. So you kind of gave us a definition of that, sort of self-starvation. And what do you mean by distorted body image?

Dr. Terrill Bravender: So our patients who are suffering with anorexia nervosa really will be, to all objective measures, severely malnourished. So this means, severely low body mass index, at least 10%, 15% or 20% below where one might expect that child to be in terms of weight. Despite being very thin by these objective measures, patients will often feel that they need to lose more weight. Interestingly, some of our patients even may acknowledge globally that they might look too thin, but very specifically see parts of their body differently than other people see.

Dr. Mike Patrick: Yeah.


Dr. Terrill Bravender: So I've had patients telling me, "Oh, yeah, I might be a little too thin, but the backs of my calves are just too big. And if I lose two more pounds, they'll look right."

Dr. Mike Patrick: Yeah, yeah.

And other people around these kids can see, and absolutely there's an issue, but they don't see it themselves.

Dr. Terrill Bravender: The kids absolutely don't see it.

Dr. Mike Patrick: Yeah.

Now, moving on to bulimia nervosa, you would talk about sort of the classic that I think most people picture in their mind is someone who eats a lot and then goes to the bathroom and purges in self-induced vomiting. But you have said there are other behaviors that they do. What are some of those?

Dr. Terrill Bravender: As I said, the classic vomiting after meals is what most people think. But that can be any kind of behavior that isn't quite healthy that people use, I guess, to account for the overeating episode that they just had.

Dr. Mike Patrick: OK.

Dr. Terrill Bravender: So that can be prolonged starvation. So if somebody has a binge eating episode and doesn't eat again for 24 hours. Or if somebody has a binge eating episode and then exercises intensely for two or three hours to make up for the binge eating. That still counts as a type of purging behavior.

Dr. Mike Patrick: And then, some folks go to the extreme of using things like laxatives, enemas, diuretics to pee more.

Dr. Terrill Bravender: That's right. And it can be laxative abuse. You know, it doesn't have to be something that actually works to get rid of the calories. Interestingly, there is a fascinating research paper from the University of Toronto from about 20 years ago looking at calories retained after vomiting. And most of our patients think that when they vomit after they eat, they're going to get rid of the calories.

It's actually not true. I think everybody has experience with vomiting, we've all had viral stomach flu. And when you vomit when you've got a virus, it's because your stomach doesn't work right. Your gastric emptying is delayed and food just sits there. So everybody has had the experience of eating lunch, feeling kind of sicker and sicker throughout the day. You got home at night and then you vomit up lunch from hours ago.


And that's what our patients with bulimia think what happens. So food sits on your stomach for a long time, but it actually doesn't. And the research paper from the University of Toronto looked at a few dozen women with bulimia nervosa and actually measured both the calories they consumed during the binge and the calories left in the vomit that they vomited up. And what they found was that about little less than the first thousand calories of that binge is absorbed into the body. It's not purged at all.

And if you do the math on that, if you have those binge episodes even twice a week, that's an additional 2,000 calories per week which will account for at least two extra pounds of weight each month.

Dr. Mike Patrick: And I would suspect that folks with bulimia then are not going to show up being very malnourished like you see with anorexia nervosa.

Dr. Terrill Bravender: That's correct and most of our patients with bulimia nervosa are either normal weight or overweight.

Dr. Mike Patrick: Sure. Now, when you counsel kids and families who have this, when you explain that purging is really not that effective, do they take that to heart? Or is that something that because of the mental health aspect of this, they kind of go right back into that pattern?

Dr. Terrill Bravender: It depends on each individual patient. And I've had patients who find that out and get really ticked off and can't believe that they've been doing something that isn't working.

Dr. Mike Patrick: [Laughter] It's a lie.

Dr. Terrill Bravender: Right. And either get mad at me for telling them that or just feel upset that they've been doing these behaviors that really part of them hates doing for no apparent reason. Other patients, the vomiting takes on a different role. And it's almost a self-harm type of role and they get something else out of it.


Dr. Mike Patrick: Sure.

Dr. Terrill Bravender: So we do that kind of psychoeducation about the effects of their behaviors on their bodies and then we see kind of how they think about it and how that may or may not affect their behaviors.

Dr. Mike Patrick: Do you see some kids that just have the binge eating portion of it? And in the introduction, I have mentioned anorexia nervosa, bulimia, binge eating — do you see that without any compensatory mechanisms? So, then, afterward, they may feel guilty, ashamed but they are obese and gaining weight because of the problem.

Dr. Terrill Bravender: Now, we see a few kids at our program with that. And we do have some patients who are referred from another program here at Nationwide Children's, the Center for Healthy Weight and Nutrition, and many of those kids are overweight or obese. And if they're identified as having really severe emotional eating disturbances, we will see a handful of those kids.

Now, that may change in the future as the Diagnostic And Statistical Manual 5 comes out. Binge eating disorder will have a more solid diagnostic category than as in the fourth version of it right now. And so, we may see more kids in the future.

Dr. Mike Patrick: Now, how common are eating disorders?

Dr. Terrill Bravender: So, it depends on what your definition of eating disorders happens to be. Strictly for anorexia nervosa, this is a severe psychiatric illness with really severe physical health complications, too. It affects about half a percent of girls between the ages of about 15 and 21 in western countries, in the United States. That's one out of 200. Now, one of 200 doesn't seem like a lot, but this is really a serious, serious psychiatric illness.


Dr. Mike Patrick: Yeah. And when you think about the concentration of that one in every 200, you think of a typical public school system and this is going to be something that pretty much every school is going to face.

Dr. Terrill Bravender: Every school is going to face this. Every practicing pediatrician out there has had patients with anorexia nervosa.

Now, that's anorexia nervosa alone in girls. Now, we used to think that anorexia nervosa was dramatically more common in girls than boys. And it still is more common but not quite as dramatic a difference as we used to think. What we found is that girls are more likely to get treatment and in most treatment populations, so in-treatment programs, girls outnumber boys at least ten to one.

Dr. Mike Patrick: Wow.

Dr. Terrill Bravender: However, if you look at population-based studies — so including those boys and young men who are not seeking treatment — it looks like the ratio is more like three girls for every one boy instead of ten for every one boy.

Dr. Mike Patrick: And I would suspect that the binge eating aspect of it, once that becomes more solidified and what the diagnosis is, that you might see more boys in that category.

Dr. Terrill Bravender: We may very well, I guess.

Now, we've only talked about the rates of anorexia nervosa. Bulimia is probably much more common. The data on bulimia is less easy to access because bulimia can remain a hidden diagnosis for years. But most estimates are that bulimia may affect as many as 2% of all adolescent girls in western countries. So instead of one out of 200, we're looking at one out of 50 now.

Dr. Mike Patrick: I think in the past, we thought about eating disorders mostly in like upper-middle class and upper-class families. Is that a true socioeconomic difference or do we see it in all socioeconomic levels?


Dr. Terrill Bravender: You know, that's a very good question. And I think you've hit on kind of the stereotype of who has anorexia nervosa, over-achieving upper-middle class or upper-class white girl. I think those are the patients who come in for treatment. Eating disorders, unfortunately as we become a more egalitarian and more, in some ways, homogenous culture across the country, we see eating disorders affect kids of all demographic socioeconomic statuses.

Dr. Mike Patrick: Sure.

Dr. Terrill Bravender: And as you know, here at Nationwide Children's, we see all kids regardless of ability to pay or anything else and our program really reflects a wide range of kids from a lot of different backgrounds.

Dr. Mike Patrick: It's one of those things where, if you don't look for it, you don't find it. But when you start thinking about it and considering it as a diagnosis for patients in your population, then you start finding it more.

Dr. Terrill Bravender: Yeah, I think you're absolutely right.

Dr. Mike Patrick: So what cause eating disorders? I know this is a loaded question and there's not like an easy cause that you can put your finger on. But in terms of environmental versus genetic and there's probably a mixture of those things.

Dr. Terrill Bravender: Sure. So, I tell my patients that everybody comes to the eating disorder from their own background. The eating disorder plays a different role for every patient we see. It's like kind of a final common endpoint for whatever needs they're trying to fulfill. That said, there are some clear risk factors both for anorexia nervosa and for bulimia nervosa.

There's a clear genetic vulnerability for anorexia nervosa and it's a clear genetic contribution. There's research going on across the country in a number of centers — University of California-San Diego, University of North Carolina-Chapel Hill — looking at potential gene markers for anorexia nervosa. But we know there's a clear contribution.


Another intense area of research has to do with the epigenetic influences. So you got this genetic vulnerability, what else is it in the environment that tips these kids over the edge? We know that there are some kind of behavioral tendencies in kids that put them at risk.

So, again, if you're a teenage girl who has a family history of anorexia nervosa and you're very perfectionistic, where you want things done exactly the right way, exactly your way, but despite that, you have kind of a low self-esteem. So you never think that everything is right. So even though you have a greater than 4.0 average, even though you do everything right, you never think you're good enough, you are at the highest risk of developing anorexia nervosa than anyone else.

Dr. Mike Patrick: In part of the person having those feelings, I mean there is the genetic aspect of it, but it seems to me that there would also be a parent role in that — how a parent interacts with their child and perhaps then the child begins to feel like they're not good enough. Speak to that a little bit, what the parent's role in that is. Not the parents should be blamed, but there is a contributory factor maybe.


Dr. Terrill Bravender: Well, I'm glad you brought up the parents, because we're going to talk about parents in terms of treatment. Because parents are probably the most important member of any treatment team that we put together. I think that the more family connectivity that kids have in terms of having family meals together, parents knowing what's going on in their kids lives, that would help decrease the risk a bit.

There are some parental influences seem to be significant for development of bulimia nervosa. So, if kids get teased a lot about their weight or if parents tend to make comments about their own weight or especially about their kids' weight, that actually raises the risk of bulimia nervosa. Interestingly, families with history of substance abuse or alcohol abuse, that actually raises the risk of bulimia nervosa in their kids.


Dr. Mike Patrick: And is that the whole addiction pattern, whether it be a substance or food as a substance in this case?

Dr. Terrill Bravender: Exactly. And you know, in a very reductive way. You're going to get a lot of emails if I say this, but a very simplistic way of looking at anorexia nervosa versus bulimia nervosa is that anorexia nervosa is a disorder of intense control. And bulimia nervosa is a disorder of being completely out of control. And you can think that then that substance abuse is going to fit more with bulimia nervosa and problems like excessive compulsive disorder or anxiety disorder are going to fit more with anorexia nervosa.

Dr. Mike Patrick: Sure.

Dr. Terrill Bravender: That's a gross generalization.


Dr. Mike Patrick: Right, absolutely. Absolutely. But there's some merit to it.

Dr. Terrill Bravender: Yes.

Dr. Mike Patrick: So I think about risk factors, I think that one the big thing here is not necessarily that kids are going to recognize "Hey I'm at risk for anorexia or bulimia", but the people surrounding that child, the parents, teachers, coaches, pediatricians, that they would recognize what kind of behaviors and risk factors there are. So if it's someone who knows the family and they know there's a family history, obviously, that's going to raise a red flag. But then, excessive dieting behavior, overachieving as you mentioned, anxiety, depression, weight issues in the families, substance abuse — all of these things, at least, should tick up, "Hey, actually, I should think about eating disorders in this kid."


Dr. Terrill Bravender: I think you should. And don't get me wrong, I think overachieving and pushing yourself in school is a great thing. I love it when my kids work intensely on their own homework. I think with anything, it's when that obsessiveness begins to impact the rest of their lives. And again, I can't emphasize enough — and I tell all my patients' parents, I tell my friends, I tell my family that I can't emphasize enough — just simply spending time with your kids and the very act of having dinner together as a family on a regular basis is incredibly powerful, both for creating that kind of supportive environment as well as monitoring what your kids are actually doing.

Dr. Mike Patrick: Yup, absolutely.

And we preach that on PediaCast at regular basis as it turns out. No, I did not pay him to say that before we started. So those are kind of the risk factors. What then are some warning signs that parents, teachers, coaches, pediatricians, family practice doctors should be on the lookout for kids that should really clue them that "Hey, there could be an eating disorder here"?

Dr. Terrill Bravender: Well, I think any acute change in eating behaviors. And we talk a lot in the public health realm about the issue of childhood obesity which is a serious public health issue. Now, kids who are overweight or obese or struggling with their weight in that direction, they do have to make some behavioral changes around eating. But if you have a child who's not struggling with that, who suddenly wants to cut out significant amounts of food or eat what we always put in a "in a healthy way" — and healthy means a lot of different things to different people — parents need to pay attention to that and look at their own kinds of messages that they're giving around food.


For kids who are at risk of bulimia nervosa, again, if there's secret eating going on or the child disappears immediately after meals, or food is missing in the house, I think asking the child what's going on in a very non-confrontational, non-accusatory way is the best first step. And like with anything else, when addressing a potential hot topic, using things like "I" statements even to your child, saying "I'm worried about you." Or "I've noticed that you're not eating the full meal with us" and "I've noticed that you've lost weight. I'm worried about you. What's going on?"

Dr. Mike Patrick: And I suspect that's really important, how you approach that. And that was going to be really my next question. Because it seems from the child's point of view, it would really be easy then to put up that wall, put up the defense and deny that anything's going on. And so, really, the first time the parent approaches, it's really important, that attitude.

Dr. Terrill Bravender: It really is. And the parent acknowledging their own worry, their own concern and that despite the child's denial of any problem, the parent insisting that he or she is going to take care of that child, because that's the parent's role.

Dr. Mike Patrick: Now, let's say a parent is concerned that there could be an eating disorder there, and whether the child acknowledges it or not, but they still have this persistent concern, where do they turn?

Dr. Terrill Bravender: I think that your primary care doctor is the best first step. That interestingly, when you look at what motivates people to change their eating behavior, in adults, it's unclear. But what is the motivating factor to help them get over their eating disorder? Messages about physical health complications do not resonate very well with adults.


Kids, on the other hand, the teenagers, messages about physical complications of poor nutrition actually resonate with them. And we, as adults, often think it's self-evident that you need food to survive. Calories are the only way we get our energy. And that's all the calories is, as a unit of energy. And I tell my patients that all the time, one kilocalorie is the amount of energy it takes to raise one liter of water one degree centigrade. So it's simply a unit of energy, nothing more, nothing less.

And that seems obvious to us, but it's not to a 13 or 14-year-old. And those messages about the necessity of food for energy and to keep your body healthy very specifically about physical health can be very powerful for some of these kids. And those messages can come from the primary care physician as a first step.
Dr. Mike Patrick: Sure.

Dr. Terrill Bravender: And then, the other role that the primary care physician can play is as a non-biased observer outside of the family. If the primary care doctor says, "You know what? I think there's a problem here. You need to be seen in the eating disorder's program," then that takes the heat off the parents a little bit on this very conflictual issue. And then, the mom or dad can say to the child, "You know what, we got to do what the doctor says and it's not me making this up taking you into the program. We got to do what the doctor says."

Dr. Mike Patrick: Yup. And then, let's say they're referred to an eating disorders program like the one here at Nationwide Children's, how do you go about — I mean, because I'm sure that a lot of these kids still don't show up with a sticker that says I have an eating disorder — how do you tease out if that really is what's going on or not?


Dr. Terrill Bravender: So, I'm a medical doctor and I'm one part of our team. And all patients we're seeing at the Eating Disorders program here at Nationwide Children's see at minimum a team of three providers. So they see a medical physician. They see a dietician and they see one of our therapists. And some of our patients will also see one of our psychiatrists. They may be involved in group therapy, they may be involved in family therapy. The parents may be involved in a parent group sessions. So there are a lot of different people involved.

So, from the medical side of things, we do look for certain signs and symptoms that would alert us to presence of an eating disorder. But like with almost anything in medicine, most of our diagnosis is based on the history. And despite much of the denial of illness and denial of problem, I'd say the majority of the patients we see are straight up honest with us about what is going on.

Dr. Mike Patrick: I mean, they see the seriousness of it, and by this time, they've had interactions with their parents and with their primary care doctor. And so now, it's like…

Dr. Terrill Bravender: Well, they might not see the seriousness of it, but they're happy to acknowledge what they're doing.

Dr. Mike Patrick: [Laughter] Got you.

And now, I would suspect too that to some degree, there's also a medical… I mean, you want to make sure there's not something else going on that could cause a kid to lose so much weight. I mean, there are other medical things that could do it that you're wanting to rule out as well.

Dr. Terrill Bravender: Absolutely, and there's a clear crossover with many GI or gastroenterological illnesses, such as celiac disease, inflammatory bowel disease. We've had a handful of patients who come in diagnosed with hyperthyroidism. But based on the history, that's usually not the case, but we do a lot of screening questions as well some screening bloodwork on them.


Dr. Mike Patrick: I guess it'll be more difficult if it were a kid who's adamant that "No, this is not a problem."

Dr. Terrill Bravender: Right, absolutely. And those are the kids who get maybe a bit more of an evaluation and work-up.

Dr. Mike Patrick: So, once the teen determines that there is an eating disorder at present, how do you go about treating that?

Dr. Terrill Bravender: So, again, it is a multidisciplinary approach. And the way we formulate it at Nationwide Children's is what the way they do it at most places. There are different levels of care depending upon the severity of the eating disorder. And most of our patients are appropriate for outpatient care, which means outpatient visits with a medical provider, dietician and the psychotherapist.

And the medical provider does assessments regarding whether the patient may need something as dramatic as inpatient medical stabilization to making determinations of appropriate rates of weight gain and appropriate activity levels. The dietician helps make meal plans for the patient and some psychoeducation about various foods. But most of the work falls on the psychotherapist who helps both the child restructure thinking about food, as well as primarily helping the parents create an environment at home that allows them to feed their children appropriately.

Dr. Mike Patrick: Suere. So it really is individualized treatment and it really runs the gamut of outpatient stuff to more severe inpatient.

Dr. Terrill Bravender: True. True. Now, as I've mentioned, a handful of kids will be so severely medically compromised that they require inpatient hospitalization. There are a few things we look for at physical assessment for those kids. There are some complications with severe malnutrition that will bring them in. And we look for such things as very, very slow heart rate. So as the body tries to conserve energy, there are some serious metabolic slowing that occurs and patients can present to us with heart rates as low.3 as in the 20 and 30 beats per minutes.


We also see significant low blood pressure associated with that. They can have recurrent fainting spells. They can have low body temperature. And occasionally, really severe low weight will bring them in to the hospital, simply because we know that once patients get below about 70 to 75% of their expected body weight, then it becomes very difficult to eat enough food to regain the weight. Primarily because we know base on some research done here at Nationwide Children's that there's some stomach dysfunction that occurs that makes it, if not impossible, almost impossible to transition to eating appropriately.

Dr. Mike Patrick: And I just want to point out that some of these things can be life threatening. And once you have electrolyte disturbances, that could cause heart arrhythmia as well.

Dr. Terrill Bravender: That's right, especially if you have a patient who is severely underweight who's participating in purging behaviors. Those are the kids who are at greatest risk.

Dr. Mike Patrick: Now, so if you have a kid who can't gain weight appropriately as an outpatient, what does that look like when you admit them to the hospital? What do you do?

Dr. Terrill Bravender: So what do we do.

Dr. Mike Patrick: Do you force feed them? How do you get them to gain weight?

Dr. Terrill Bravender: So our philosophy is that kids are admitted to the hospital because they need medicine they can't get at home. And we treat, and I tell this to my patients when they're admitted that there are kids at children's hospitals who need asthma treatment more intensely than they can get at home. There are kids with leukemia who need chemotherapy that they need to get in the hospital that they can't get at home. They have very specific medicines that they need. Our patients from the Eating Disorders program have a very specific medicine that they need and that's food.


It's non-negotiable about eating. You simply have to do it. And just like when a child with leukemia gets chemotherapy, that child doesn't want to get the chemotherapy because it makes him feel bad. It makes him awful. And even if eating the food makes our patients feel awful, it doesn't matter because that's the medicine they need to save their lives.

So, we have a written out protocol for eating that we actually share with the patients and their parents.

Dr. Mike Patrick: Yeah, kind of like a contract.

Dr. Terrill Bravender: Exactly. Yup, exactly. And so, we choose all their meals. They can have a couple of exclusionary food that they honestly don't like. If they honestly don't like…

Dr. Mike Patrick: Pizza.

Dr. Terrill Bravender: Pizza, then they don't get pizza. So limited exclusion.

Dr. Mike Patrick: Yeah, yeah.

Dr. Terrill Bravender: And then, we choose their meals and they have a half hour to eat, where the nurses can see them. And then, if they don't eat their food in half hour or they leave some food on their plate, the nurses count up and estimate how many calories. And then, they have to drink a nutritional supplement like Ensure, Boost. And then, they got half hour to drink that and if they don't, then they get via a nasal gastric tube.

Dr. Mike Patrick: Yup. And that's convincing, too.


Dr. Terrill Bravender: Yeah. And again, I tell them, I don't care. It doesn't make me mad if you don't eat but you're going to get your medicine one way or the other.

Dr. Mike Patrick: Now, when we talk about various diseases, one of the things that we discuss here in the program, just to get a clear picture of the whole thing is any potential complications of the treatment. Because you want to look at risk versus benefit when you're deciding anything. And I would suspect there's not really a lot of potential complication with food from a physical standpoint, but I would suspect that these kind of treatments and the kind of inpatient treatment that you're talking about would cause anxiety, depression. And so, the mental health aspect could maybe get worse, as you're going through the treatment program.


Dr. Terrill Bravender: Well, you're absolutely right. And we know there's a high comorbidity of depression and anxiety disorder associated with eating disorders. And there is, as we begin treatment of the eating disorder, there is a process that happens that we call extinction burst. So as you begin to stop the eating disorder behavior, we have to remember that those behaviors play a significant role in our patients day to day lives and as we take away those eating disorder behaviors, there's nothing to replace them. And so the drive for those eating disorders can get even more dramatic during the initial part of treatment before they begin to get better. So part of the treatment is to help replace those with better coping mechanisms.

Now, there are a handful of potential complications associated with refeeding that are actually pretty rare. And they're actually rarer than we used to think they are. The most dramatic complication is something called refeeding syndrome or refeeding hypophosphatemia. So, this is actually discovered back post-World War II when in South Pacific, prisoners of war or American GIs who were starving on the South Sea Islands were picked up by battleships. And all of a sudden, they start eating and eating and eating and become incredibly weak, went into cardiopulmonary failure and died.

And a very famous physiologist, Ancel Keys, discovered that it was really low phosphorus levels. It has to do with metabolism of glucose in someone who hasn't seen a glucose load in a very long time.

Now, there are case reports of that occurring with refeeding with anorexia nervosa. And we worry about that and we check phosphorus levels and in severely malnourished kids, we may give them phosphorus supplements during their hospital stay. But it really is a pretty rare disorder.


Dr. Mike Patrick: Sure. What is the long-term outlook for eating disorders? Once you kind of break that cycle and they've had counseling and family therapy, is there a pretty big relapse rate or is this something that is easy to extinguish?

Dr. Terrill Bravender: Well, it's not easy to extinguish at all.

Dr. Mike Patrick: [Laughter]

Dr. Terrill Bravender: But that said, I think treatment outcomes for adolescents are dramatically better than they are for adults. And the rough estimates for adolescents are that probably half or a little over half of adolescents seen in treatment programs get completely better after a year of treatment — a year or maybe two years of treatment. They're completely better. They can talk about the illness as being something in the past. There are patients who tell me, "Oh, back when I was sick" or "Back when I was thinking that way," and they're done.

Another probably 30% or so of patients recover a normal weight, have normal eating behaviors, normal kind of social relationships, normal school performance, but at times of life stress or big life transitions, they can revert back to some of those maladaptive coping mechanisms. So these are the kids who are at risk for eating disorder relapse when they go off to college or when they're incredibly stressed out by final exams, or even later in life when they get married or transition. It doesn't have to be a bad stress or any life stress can do that.


And then, unfortunately, about 10% to 20% of patients end up having, really, a chronic illness and an eating disorder that can last for years and years and years. Those are the patients who end up in the adult care system. And we know data from adult treatment programs, is that if you're in an outpatient treatment program and you are 25 to 30 years old and you have anorexia nervosa, after three years of treatment, you still have about a 90% chance of having anorexia nervosa. .

Dr. Mike Patrick: Oh, wow.

Dr. Terrill Bravender: So I think that there is a neurocognitive developmental change that happens as we fully myelinate and solidify our frontal lobes in our brains that make whatever behaviors we have in our late adolescence will just persist through adulthood. So I think it's absolutely critical that if a child has an eating disorder to get in for treatment as early as possible.

Dr. Mike Patrick: Yeah, absolutely.

Here at Nationwide Children's, you'd mentioned a multidisciplinary approach where we have nutritionists, we have medical doctors, we have psychologists, psychiatry, social work that's involved. And as you mentioned too, this is something that's available for anyone, regardless of their ability to pay.

Dr. Terrill Bravender: That's correct. And we take referrals from all over. We get referrals. I'm amazed at how far some parents will drive to be able to come in to see us.

Right now, we offer outpatient treatment and for those kids who are severely ill, inpatient medical stabilization. This Fall of 2013, we will be opening a new program that will offer expanded levels of care. And that includes what we call an intensive outpatient program where parents and children come in three evenings a week plus Saturday mornings for monitored meal, group therapy and more intensive individual therapy.


And then, for kids who need even higher level of care, we'll be opening a partial hospitalization program. So kids come in the morning and go home in the late afternoon early evening five days a week plus Saturday morning. They have monitored meals. They'll have group therapy. They also have conglomeration of therapies that we call movement therapies. So that includes physical therapy and will include trainers to help them exercise in a healthy way, not in a destructive way. And even massage therapy which we think is very helpful for the anxiety associated with that

Dr. Mike Patrick: You know, I think it's just a wonderful thing what they've created here. And I remember a few years ago, when I was in private practice, I've had several kids with eating disorders and really there was no option other than to refer him to adult programs which really were not geared for teenagers at all.

Dr. Terrill Bravender: No, I think you're absolutely right. The treatment approach for adults and kids is very different. And one of the big transitions we've seen over the past probably 10, maybe 15 years is a real emphasis on family-based treatment. Now, our colleagues, Daniel Le Grange at the University of Chicago and Dr. James Lock at Stanford have been really at the forefront of research around family-based treatment. And prior to their work, there was no specific treatment approach that had ever been shown to be effective for treatment of anorexia nervosa. And their work with family-based treatment has really shown a lot of benefit and that has spread really throughout the country and that's the treatment approach that we use.


And at a very, again, basic level, the idea is that the parents' job is to take care of their children. And we want to help the parents acquire those skills that they need in order to feed their children appropriately.

Dr. Mike Patrick: And I just want to remind folks out there. If you suspect that your child has an eating disorder, the first line is to talk to your primary care doctor. And if it's determined that this is what's going on, you really do want a treatment program that is geared toward kids, that has experience dealing with adolescents. And so, the Eating Disorders program here at Nationwide Children's Hospital would be more than happy to see you.

Dr. Terrill Bravender: Absolutely.

Dr. Mike Patrick: And we appreciate you stopping by. I really do.

Dr. Terrill Bravender: Thanks.

Dr. Mike Patrick: And I also want to remind you there are some links in the Show Notes for today's episode which is 249. So if you head over to, you'll be able to find it. We do have a link to the Eating Disorders program here at Nationwide Children's. We also an information sheet on anorexia nervosa and another one on bulimia nervosa. They're part of the Nationwide Children's Health Library and we'll have links there as well.

And then, you'll also see a link that says "Connect Now With An Eating Disorder Specialist". And if you click that link, it will open up a referral page that you can fill out and someone from the Eating Disorders Program will get back to you. You can leave your email address, your physical address, your phone number. However you want them to contact you, you can leave that information and it will get right to an eating disorder specialist.

I don't know how to make any easier for folks.


Dr. Mike Patrick: All right, so we do appreciate Dr. Bravender stopping by.

We're going to take a quick break and I'll be back with a final word right after this.



Dr. Mike Patrick: All right, as my long-time listeners know, I usually end the show with a final word which is an effort to impart some sage advice, but also to remain humble and let you know I'm not a perfect parent. But like you, I strive to be a better one.

So a few weeks ago, during my final word, I talked about spending intentional quality time with each of your kids. Something that they want to do but something that provides an opportunity to connect one on one and something that will grab and hold their interest. And I had also mentioned my plans to do dinner and a movie with my sixteen-year-old son, because he was eager to see the re-release of Jurassic Park on the big screen this time on 3D and on IMAX. So we did it. And wow, it was not only an incredible experience but it also brought back some memories — something I haven't thought about in a while.

Back in 1993, I remember waiting in line for a midnight showing on the eve of the movie and the show release. And this is during the days when midnight showing were not a regular thing. But this was such a big movie. They were doing the midnight showing and I was going to be there. My wife and I were newlyweds. We didn't have any kids yet. And these were the days before stadium seating and digital movie projectors.

So the movie theater in an effort to turn a bigger profit, go figure that, they had jerry-rigged the film to go from one movie projector on one side of the building to another movie projector on the opposite side of the building. That way they could run two auditoriums with the same physical film, which must have seemed like a good idea on paper.

So we happened to get seats in the second theater so we were downstream. And about ten minutes into the movie, just as things were heating up, I think they had just like got to the island, the film physically broke somewhere between projector number one and projector number two. They kept the movie rolling in auditorium number one but it ended abruptly in our theater. The floodlights came on, we had to evacuate.


Now, again, you have to realize this was the movie event of the decade. I had read the Michael Crichton novel prior to the production of the movie and I seriously had anxiously awaited this show like no other movie in my life and I couldn't wait to see it. So the sudden disruption of the showing, it was like taking a Christmas present right out of the hands of a kid. I was not a happy camper. And to be honest, I was young back then and immature and my priorities were not exactly where they ought to be. So when the management offer to stick its first show the next day, it wasn't good enough. I was not happy. I wanted to see the show now. And of course, I wasn't the only one in the crowd who felt that way.

Now, my young bride, she was fine going home and catching the movie another time. Truth be told, she wasn't keen on seeing it in the first place. But to her man's credit, she put up with my ranting and the theater manager promised our unhappy mob — he didn't want any trouble — if we came back at 3am, he'll have the film fixed and he'd play a second showing just for us.

Now, looking back, sure, I could have waited until the next day. I could have waited till the next week for that matter. It was a movie, for crying out loud. But it was a big deal at that time and Karen smiled and waited with me and she's been waiting with me for 21 years now. And we attended the middle of the night showing of Jurassic Park. And that was the last time I had seen it on the big screen, four years before my son was born.

So, now, fast forward 20 years — and those of you with new kids out there, don't worry, the time is coming when you too will say what in the world happened to 20 years. Anyway, fast forward 20 years and it was a sweet time recalling old memories and definitely making new ones this time with my son. So Jurassic Park 3D, IMAX, doesn't get any better than that.

So, what is my final word this week? Well, intentional quality time with your kids, even your teenagers — maybe especially your teenagers — we've talked about it before, if you haven't gotten around to doing it, my question to you is this, what are you waiting for?

And that's my final word.


All right, I want to thank all of you for taking time out of your day to make PediaCast a part of it. Also, thanks to Dr. Terrill Bravender for enlightening us on eating disorders this week.

I do want to remind you that iTunes reviews are helpful. If you've not taken a few seconds to write a review on iTunes, we would appreciate it, as are links and mentions and shares and re-tweets and repins in all the social media sites. We are on Facebook, Twitter, Google+ and Pinterest.

And be sure to tell your family, friends, neighbors and co-workers about the show. And probably, most importantly of all, tell your child's doctor that we have an evidence-based pediatric podcast aimed at moms and dads that they could share with their patients and the posters are available under the Resources tab at

Also, one last reminder, if you have a question for me or topic you'd like us to talk about, head over to and click on the Contact link. And then, we also, in today's Show Notes, Episode 249, we have a special link "Connect Now With An Eating Disorder Specialist".

All right, thanks for stopping by. Until next time, this is Dr. Mike, saying stay safe, stay healthy and stay involved with your kids. So long everybody!


Announcer 2: This program is a production of Nationwide Children's. Thank for listening. We'll see you next time on PediaCast.


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