Kids' Wellness Matters Podcast Ep. 19: Recognizing Eating Disorders in Children

Eating disorders have been on the rise in children and adolescents following the COVID-19 pandemic and the Eating Disorder Program at Lurie Children’s is equipped to offer comprehensive care that is practical and tailored to meet the needs of this population. In this episode, Gregg Montalto, MD, MPH, a leader in the Eating Disorders Program, talks about the complexities of eating disorders, emphasizing their nature as brain disorders rather than behavioral choices, discusses different types of eating disorders, the importance of early recognition and intervention and the need for equitable treatment options. 

 ”Getting rid of the misconception that only certain kinds of people develop eating disorders is important. It's looking for dramatic changes in somebody's approach to eating or exercise and activity is usually the key.”

- Dr. Gregg Montalto 

Show Notes

• Dr. Montalto says it is important to understand that eating disorders like anorexia nervosa are brain disorders, not behavioral choices. He likens the fear of eating to an irrational phobia that alters normal responses and behaviors
• Beyond anorexia nervosa, conditions like ARFID (Avoidant Restrictive Food Intake Disorder) and binge eating disorder require specialized care. Some disorders may overlap, such as progression from anorexia to binge eating.
• Early signs that a child may be experiencing an eating disorder include: drastic weight changes, dramatically different eating habits and preoccupations with body image. Eating disorders affect people of all backgrounds, not just specific demographics (e.g., affluent, white females). Symptoms can include excessive exercise or physical complaints and may initially be misdiagnosed as gastroenterological issues.
• Family-Based Treatment (FBT) places parents in the initial control of meals to restore the child’s weight and reduce stress. Later, with the support of traditional therapy, autonomy is reintroduced to normalize eating habits. Effective FBT requires unified, consistent parenting and prioritizing the child’s health over other commitments.
• Dr. Montalto discusses systemic issues in the U.S. healthcare system that hinder equitable access to care, particularly for low-income families. Lurie Children's works to bridge gaps by accepting Medicaid and tailoring care to diverse needs.
• The correct leverage and motivation for each patient is unique, but will help guide recovery. On average, half of patients achieve full remission, while others reach partial recovery or face chronic relapses.
• Parents can help foster healthy eating habits from an early age, avoiding the use of labeling food as “good” or “bad” and trusting healthcare providers as their key sources for guidance over social media influencers.

Transcript

[00:00:00] Dr. Nina Alfieri: Welcome to Kids Wellness Matters. I'm Dr. Nina Alfieri.

[00:00:07] Dr. Rob Sanchez: And I'm Dr. Rob Sanchez. We are both parents and pediatricians at the world renowned Ann and Robert H. Lurie Children's Hospital of Chicago. On this show, we'll chat with a wide range of experts about caring for children from newborn to young adult. Because Kids Wellness Matters.So Nina, I was reading with my older son the other day and we came across a book that we had picked up along the way that I think someone had given us. And I kind of liked it, it was like bodies are cool. And what I really liked about it is that it had all these different representations of different types of bodies. And I just thought that was really nice. Growing up, I don't remember necessarily always having the best representation of body types and how it was presented. But have you seen some good books that you read with your kids? Do you feel like it's been improving lately?

[00:00:55] Dr. Nina Alfieri: Yeah, absolutely. And I think it's so important as someone who grew up in a generation of very homogenous Barbies as toys, I think it's really important that kids are exposed to diversity in many ways, including in different body types. And so that they can start from an early age to build that confidence and feel proud to be in their body and start to form their own identities.

[00:01:16] Dr. Rob Sanchez: I thought it was really heartening. Right. And what you say makes it feel that way too, just in that, representation, like the exposure, can happen in a very positive way in a very healthy way, which I thought was really nice. But, we think about it, we know it as pediatricians, that we do worry about some of the images and representation that can be there because we worry about something that can be really significant, things like eating disorders, anorexia, those kinds of conditions. Unfortunately, we've seen in recent years, especially after the pandemic, that they've been on the rise. And it's been something that. is on my mind something that I sometimes talk with families about just in terms of, body image, eating habits, things like that.

[00:01:50] Dr. Nina Alfieri: Yeah, absolutely. Even in the way that we talk about healthy habits visits or regular well checks, this is always in the back of my mind. How can we promote people having a healthy relationship with food and with the world and with their body? And this is something that kids struggle with and I think has gotten more significance in social media has come about. So it's something that I think every parent should know about and should know also from an optimistic perspective about the treatment options that exist and the fact that kids with the right treatment can recover from this. So I'm excited to dive in and hear a little bit more about your conversation with Dr. Montalto.

[00:02:25] Dr. Rob Sanchez: Yeah, no, I was lucky to talk with Gregg Montalto. He works in our adolescent division at Lurie Children's and he focuses a lot on eating disorders, both for the care of families, and their children, in the hospital setting, but he also talks about treatment, after hospitalization or an outpatient and different types of treatment modalities, including working with the family using a very multidisciplinary approach. Bring it in therapies and things like that, that can be helpful. And yeah, he shed some light on not just things to watch out for in terms of things like signs and when parents should be worried, but also shed some light that this can affect different populations. So it's not just a certain group that's always affected. Although he does talk about how young, girls and females are more affected by it, but he's very committed to having equity in the recognition and treatment of eating disorders and anorexia. And that can be regardless of your socioeconomic status, your racial ethnic background. Even your gender, we had a good conversation about how this can present in boys and young men. And so, it was just a really good conversation. He definitely talks about how there's a lot of opportunities for treatment and ways for success but that it is challenging and I thought he offered some really nice ways of modeling good behaviors and really talking and connecting with, families might be struggling with this, with their child.

[00:03:36] Dr. Nina Alfieri: Well I'm really excited to hear more about this and for anyone who's listening who may be struggling with this, either as a child or a parent, I hope this episode gives you some helpful information and just the knowledge that there's help out there for you and that there's definitely something brighter on the other side. So, looking forward to hearing this episode. 

[00:03:59] Dr. Rob Sanchez: Eating disorders are more common than parents may realize. And, in recent years, the number of pediatric emergency department visits for eating disorders has greatly increased. In fact, these visits doubled among adolescent females during the COVID 19 pandemic. Here at Lurie Children's, a team of providers lead evidence based, comprehensive care for children with eating disorders through our Eating Disorder Program. Effective treatment can be life changing, and, in some cases, life saving. Dr. Gregg Montalto is a leader in this program and joins me today to discuss this topic. He's an attending physician in adolescent and young adult medicine, and associate division head for clinical practice in adolescent and young adult medicine. Dr. Montalto, welcome.

[00:04:38] Dr. Gregg Montalto: Thanks for having me, Dr. Sanchez.

[00:04:40] Dr. Rob Sanchez: I wanted to jump right in and talk about just people's perceptions of eating disorders. So many people may think of eating disorders or disordered eating as a behavioral choice, but it's, in fact, a brain disorder. Why is it important for parents to really understand this distinction?

[00:04:55] Dr. Gregg Montalto: That's a great question because it gets at the heart of how we actually treat eating disorders and more specifically, anorexia nervosa. One of the big myths is that it's a choice or that it is a sense of control and on the outside it appears that way. It certainly appears to be, I am trying to control what I eat, I'm trying to control how my body looks. But in reality, if we look at it as a complete loss of control to do a normal human function. To do something that we require in order to live it makes it a little bit easier to get our hands around treatment. I look at kids as being terrified to eat. And if, you know, I have never struggled with eating, I do not know what it's like to not want to have a slice of pizza. And a lot of parents are the same way. A lot of clinicians are the same way. And so I ask everybody, because pretty much everybody has an irrational fear. And, you know, maybe that irrational fear is of heights. And most of my patients know that I have an irrational fear of bats, you know, the kind that fly around. And, if it's dusk and family's outside by the fire pit and having a good time and there are bats flying overhead, I have to go inside. I don't like it. They spooked me out. And I realized that is not rational. I know I do not need to go inside for any reason, but I choose to. And if you asked me to sit in this office that I'm sitting in with a bat flying around five or six times a day, every day for the rest of my life, it's going to change who I am. I might lash out at my parents. I might throw food across the room. I might refuse to eat because it's a fight or flight sort of response. And, you know, when we start to see anorexia nervosa in that light, I think it gives us better opportunities to find ways to treat it.

[00:06:54] Dr. Rob Sanchez: That shift in the way that we frame it, the way that we think about it must be so powerful, especially in working with providers who want to help, but also with parents or family or friends who struggle to understand. Is that an experience that when you frame it that way, the response that you get from folks who are really encountering it for the first time?

[00:07:13] Dr. Gregg Montalto: Yeah, like I said, most of my patients know that I'm terrified of bats. But I think a lot of parents, a lot of families will struggle with that, that's just not my kid. You know, I don't know what happened. And, it's a child, an adolescent, a young adult has gone from having a normal ish, comfortable life, and then all of a sudden, it becomes excruciatingly difficult to eat and it's terrifying to eat. And so, it's a constant state of being activated and on edge and terrified. And I think as parents start to see it that way, it's a little bit easier to be able to absorb, you know, a lot of the anger that kids will be spewing at them.

[00:08:01] Dr. Rob Sanchez: That first step in understanding that must be so huge in trying to make those inroads. talked about anorexia nervosa, but there are other eating disorders that you treat within the program. Can you speak to those as well ?

[00:08:13] Dr. Gregg Montalto: The majority of the patients that we see on the inpatient side, because we have both inpatient and outpatient programs. On the inpatient side, it's probably 90 percent anorexia nervosa. On the outpatient side, it's still the majority. There are kids who have restricting type where it's exactly as it sounds. Their disease shows up as restricting what they eat. And then there's a binge purge type where there might be episodes of binge eating that are mixed with long periods of restricting. And sometimes purging by vomiting or using laxatives or diuretics and even though technically exercising is not considered a form of purging. I do kind of see it as a form of purging as a compulsive response to having maybe eaten too much. That's the majority of what we see. We see some patients with avoidant restrictive food intake disorder, ARFID which is an extreme form of selective eating. So it's not just a kid who is a picky eater. It's a kid who's a picky eater, who is losing weight. A kid who's a picky eater and they're so selective that they have certain micronutrient deficiencies. You know, it's a kid who's a picky eater and has the sequelae of malnutrition. That's what ARFID is. Picky eaters. I mean, I got a couple of them at home. But it goes way beyond that. So we do see kids with ARFID. And we also see some patients with binge eating disorder too .Which sometimes there can be overlap with patients who start off with a picture of anorexia nervosa and they actually might do a really good job at the beginning in weight restoration, and then they may start binge eating. And so some of our patients with binge eating, started off with anorexia nervosa. And so it's important to make sure that when you're getting care for any eating disorder that you are working with experienced therapists, experienced dietitians, because there are lots of things to look out for.

[00:10:22] Dr. Rob Sanchez: You talk about, in the range of those conditions, pretty severe symptoms and parts of those conditions that you're working with to treat. And it really runs the gamut in terms of ages that you see. Through your outpatient treatment program you can treat children as young as nine. At what age should parents begin to look for some of these signs of eating disorders? What are some of the things you have them kind of look out for or would like parents to know about?

[00:10:44] Dr. Gregg Montalto: That's a very important topic because one thing that we do know, and this is speaking about, mostly about anorexia nervosa the earlier that we find it and the earlier that we provide treatment, the better the outcome. We want to identify these things early. You know, we don't want to freak people out if somebody decides that, you know, Hey, I want to cut back on the amount of soda I'm drinking because that might be a healthy choice. I have seen kids as young as seven or eight who had anorexia nervosa. And it can be different when it shows up in kids that are much younger, just because of the way that they might express their different feelings , maybe they're coming across as being a picky eater, when in reality they have some of these thoughts about, like I'm fat. I don't like the way that I look. Other people don't like the way that I look and it's being seen in younger and younger kids, which is unfortunate. I mean, things to look for are like dramatic changes in how a kid is eating. So, if my kid comes home, says, Hey, I just joined the swim team and I am going to be healthier and I want to exercise more because I want to be good. That for the most part, like all of that, sounds very positive. If I find that he's getting up at three in the morning and exercising, because he doesn't want me to know that he's exercising at three in the morning. If he is not eating. It's one thing to say, I'm going to eat whole grain bread and I'm going to eat lean meat because I want to be like Michael Phelps and be an Olympic swimmer and I need to eat well to do that. That's one thing. It's another thing when you are eating far less of everything in addition to changing what you are eating. So, if a kid goes from eating all the time and then you're like, wow, you'd never eat, you'd never finish your dinner. You're just picking at things. You notice that they're starting to lose a little bit of weight. They might be commenting on how they look in a selfie that somebody put up on Instagram. You know, just little hints like that early on address it. I mean, it's okay to talk about those things with our kids.

[00:12:56] Dr. Rob Sanchez: Those examples that you bring up, are things that I see commonly in my, well child visits, even in that age range, and oftentimes it does come with some concern from the parents of, you can get a broad statement, oh, they never eat in general, but you always kind of, look a little deeper, right? I always bring up their growth charts and say they're actually doing well. This is good growth from what we're seeing from before, but sometimes it does offer opportunities to dig a little deeper. Hey, there is a significant change. How do you feel about that? What patterns are you noticing differently? That's what I'm hearing from you is like, those are the signs, those are the things that you're kind of picking up on that might be a little bit more persistent than just these shorter term changes that we all know young children can go through or even older children.

[00:13:32] Dr. Gregg Montalto: Yeah. And I mean, you bring up the point of, you know, somebody comes in for their school physical. I was a general pediatrician for almost a decade and you did a lot of school physicals over the years and a lot of those conversations would be, Hey, let's figure out how you can be more active. Let's talk about, you know maybe you are drinking a few too many Monsters and, maybe we need to cut back on some of those things. And, we have an issue in America and a lot of other places with increased rates of type 2 diabetes, increased rates of high blood pressure, and a lot of that is related to obesity. And so a lot of those conversations in primary care are around, you know, trying to eat quote unquote healthier. And anybody in the eating disorder world, we don't talk about healthy foods and unhealthy foods. All food is healthy. You know, you should be able to eat all things in moderation and you should be able to enjoy a piece of cake. And talking about things as healthy and unhealthy sometimes makes it more difficult to treat kids who develop an eating disorder. But getting back to those conversations, you know, I see a kid in August and, you know, maybe their BMI is going up and I'm like, all right, well, what do you enjoy doing? Do you like playing soccer? Do you like running? Do you like swimming? Let's figure out what you can do. And talk about one thing that you can do to maybe make a change. So don't drink soda anymore and drink water and see what happens. And the mistake that I was part of this group as well, is that you see them next year and they come back the following year and you may say, Hey, good job. You're doing well. Or you might say, well, nothing really changed. And we'll have this conversation again. But then sometimes kids take things too far and they start to lose weight. And because they are predispositioned to have an eating disorder, they can't stop. So if we have that conversation with kids at a well child check, we should see them back in three months. And that way it gives us an opportunity to say, Hey, you know, great job. You really made the swim team. That's amazing. And start to acknowledge that our patients are making good changes and healthy changes, but then we're also making sure that they're not on that slippery slope to developing an eating disorder.

[00:15:43] Dr. Rob Sanchez: And so, with those visits with parents, like knowing that they can follow up with those doctors to confirm that, hey, these changes are on the healthy spectrum, that they are appropriate, to knowing that it's okay to have a follow up to make sure that things are going right. Just as you said, catching up on those things early that can make all the difference.

[00:16:00] Dr. Gregg Montalto: Absolutely. Catching these things early, addressing them early, before they become ingrained is very helpful.

[00:16:07] Dr. Rob Sanchez: You know, when we talk about some of the young visits, there can be differences in terms of how these eating disorders present. What might be some common sense to look for when it comes to eating disorders in children and teenagers? That could be different, whether, you know, in boys or girls and how they present and how parents can look out for them.

[00:16:23] Dr. Gregg Montalto: Really focusing on the fact that anybody can develop an eating disorder. We look at what we were taught in medical school, if we look at what movies about eating disorders show it's rich white kids you know, rich white girls are the ones that develop anorexia nervosa. And that's as far from the truth as, I mean, we see patients from every walk of life, every socioeconomic group. Patients with means. I've had a patient who, as soon as there was a question of an eating disorder, mother hired a chef and I have patients whose parents have to work two or three jobs to make sure that they put food on the table. And so it's, getting rid of the misconception that only certain kinds of people develop eating disorders is important. It's looking for dramatic changes in somebody's approach to eating or exercise and activity is usually the key. It might be that, kid starts running and they're running two, three miles a day, which is reasonable. And then all of a sudden they're running 10 miles a day and they're losing weight and they're tired all the time. So looking for dramatic changes in that exercise pattern, that eating pattern, looking for somatic symptoms or just like the pains where if you take an x-ray or do a lab or something like that, you're not going to find anything. And that pain is, you know, it's legit, it's real. But I can't eat because my stomach hurts. I can't eat because it makes me feel a way that I don't really enjoy. I get full too fast. And some of these things might be real. A lot of kids, initially will get sent to see a gastroenterologist because they have gastroenterologic symptoms. GI might do a workup and they're like, we don't really see anything. And that's not uncommon for kids to start off in GI because of the abdominal symptoms. It's not a bad question to go to the pediatrician for a kid who's having a lot of abdominal pain to say, hey, maybe this is acid reflux. Maybe this is something, but do you think that maybe they're stressed out about eating in and of itself? Because a lot of times that's the answer. Another thing that we need to do a better job of articulating as medical professionals is that, anorexia is every bit as real as acid reflux or asthma or high blood pressure. We just don't understand it as well. And so it's not as if we need to go looking for something when we already know what it is.

[00:19:10] Dr. Rob Sanchez: Sometimes those topics can be tough to bring up. What are some ways that might be helpful for them to, you know, ask about that? What are some questions that might be helpful in those scenarios?

[00:19:18] Dr. Gregg Montalto: Yeah. I think that the common theme in my answer is going to be talk to your kid about it. And the responses may be vastly different. A lot of patients that we see, if a parent has asked, you know, Hey, I see that you have been just kind of picking at your food and I see that you seem a little bit more stressed out. Do you want to talk about it? I've had patients who are like, thank you for asking because they are not wanting to bring it up because of a variety of different reasons, and sometimes it's liberating to a kid with an eating disorder for their parents to say, hey, you know, are you doing okay? How's that eating going? And then there are times when, a patient with anorexia nervosa, parent might say, Hey, how are you doing? And you're going to get completely shut out and met with a lot of anger. And a lot of times that means that you're onto something that there might be something there, but I think talking about it just gives us a lot of good information. If there's nothing there, there's nothing there.

[00:20:24] Dr. Rob Sanchez: I could imagine as a parent, they're probably often trying to toe that line of, well, am I expressing support and concern in the right way? I don't want to nag too much. Are those the kind of conversations that you find are much more fruitful in terms of trying to express that concern, trying to provide that support to have those conversations?

[00:20:40] Dr. Gregg Montalto: Yeah. And parents might do everything they can to be supportive for somebody who has that intense fear, that fight or flight, and you're poking the bear, and you might get lashed out at, and that is hard to absorb as a parent. It's also important to understand that you might be on to something and then, come get help, come talk to us.

[00:21:07] Dr. Rob Sanchez: Yeah. And you also, talked about this already, but making sure that there's equity in eating disorder treatment is something that you're really passionate about. I'd love to hear more about just why that's so important to you and how you really try and affect change in that area.

[00:21:20] Dr. Gregg Montalto: I spent 25 years practicing medicine in the Navy and within the Department of Defense, we have universal health care in our bubble. If you enlist today, you get the same health care as an admiral or general at the Pentagon. And you don't have to know what somebody's formulary is. You don't have to know what's covered because everybody has access to the same care. And I retired from the Navy. And by far the hardest thing for me to accept is how the U. S. healthcare system works and how it does not work for far too many people. And I think that it is appalling that I need to look in somebody's chart to see what their insurance is, to know whether or not they're going to have access to certain kinds of care. That's one of the reasons why I actually love working at Lurie Children's, that we accept every form of Illinois Medicaid. And so I don't need to turn kids away. However, we provide inpatient treatment for patients who are medically unstable. So kids whose blood pressure is low, they're passing out, their electrolytes are all wacky, you know, their heart rate is too low. We can admit those kids until they become medically stable, and then we can provide outpatient family based treatment. But there are times when kids need a higher level of care. They need to go to a residential treatment program. They need to go to a partial hospitalization program and they're not available to everybody. And, you know, Illinois Medicaid does not cover residential treatment. And so that's not an option. There are sometimes options to do a partial hospitalization program, but you know, that's five or six days a week from eight to four or five, and you need to get them there and back every day. So getting back to families where both parents work they may or may not have transportation you know, it's so to say it's available on paper is one thing. To say that it's available in reality is something completely different. So that's why we are doing everything that we can to focus on the inequities in eating disorder care. The research that we do, looking at differences in inpatient outcomes and length of stay based on insurance status you know, looking at how our Latine parents and families do with eating disorder care. And those families make up 30%, and this has been consistent in the four years I've been here, 30 percent of our patients come from Spanish speaking homes. We need to make sure that we can meet patients and families where they are in their context, because unlike a lot of other diseases, we put a lot of the treatment responsibility on parents and families. And so we need to figure out how do we best support when the treatments are designed for the rich kid.

[00:24:25] Dr. Rob Sanchez: It's great to hear you speak to that because I definitely, in the work that I do and the colleagues that we have, we share in that kind of just worthy effort to try and make that care as equitable as possible and connect them with the services that they need. You talked a little bit about in the cases where you can connect families with treatment services. Can you tell me about what this family based treatment approach is?

[00:24:45] Dr. Gregg Montalto: Yeah, absolutely. So decades ago, the thought process for eating disorder clinicians was that, okay, parents, you screwed up, you couldn't feed your kids, step out of the way. And essentially they would just remove the parents from treatment. They'd put kids in residential programs for a long time. People started to ask, it's like, well, kids spend a lot of time with their parents and families and they spend a lot of time in schools. And so why are we excluding some very valuable treatment resources? And so that's how the concept of family based treatment first started. And the evidence does support it. It does not mean that it is easy to do. It is not because a lot of kids, I mean, imagine telling any teenager that you're going to do family therapy. It's not family therapy. It's not what you think of as therapy. It's family based treatment. The T is treatment, not therapy, because kids don't want to talk about their feelings with their parents. And so I reassure them, you don't have to talk with your parents about your feelings yet. So it's broken into three phases and they're on paper, three distinct phases, but there are varying transitions between those phases. The first phase is focused on weight restoration. We don't take our eye off the fact that we need to get a kid back to a healthy weight. And a healthy weight is argued even in the eating disorder field. If somebody has consistently been growing at the 75th percentile since they were a kid, that's where their set point is. That's probably where their body's going to be healthiest. If they were at the 85th percentile, same thing. If they were at the 10th percentile, same thing. And so oftentimes we get growth curves that are, you know, it's like, wow, this kid really was consistent before this all happened. When we talk weight restoration, it's getting them back to their old growth trajectory. And everything is based on how do we get this kid to gain weight? And it involves food, you know, food is medicine. There are no medicines for appetite. There are no medicines for anything that is going to help other than these kids just need more food. And so it is structured and every meal is decided on by parents and the timing of meals by parents. Kids don't go grocery shopping. They don't make a grocery list. They can't select what foods that they want to eat because what they had been choosing up until that point wasn't working. And so, parents take control of nutrition. Think about being a 14 year old kid who is trying to, cause it's normal adolescents to want to, start to work on that independence and autonomy and things like that. And it's getting ripped away from them. So normal adolescence is going to fight back against that. There are some kids who are like, thank you, because this was just too hard for me to do, and they didn't want to ask. But bottom line is phase one, we look to restore a kid back to their growth trajectory and parents take control. And why parents take control is like I said, you know, what the kids were choosing for themselves wasn't working. But also, choice for a lot of patients with anorexia nervosa is really difficult. You ask a kid, what's it like to go to a restaurant with a big menu? And it's terrifying because in their head, they're thinking, Ooh, am I making the right choice? Does this have fewer carbohydrates than that one? Oftentimes we find that they're unable to make a decision because they second and third and fourth guess themselves. So giving parents control over everything it removes that. And initially it's met with a lot of resistance. A lot of times after doing it for a couple of weeks, it's accepted. And sometimes it's not. But that's the first phase. Second phase, we start to return some of that autonomy back to kids. You know, kids who want to get back to a sport. It's like, okay, you know, let's see, you were a runner. Let's see if you can run a half mile a day and eat a little bit more because this is an energy equation. And if more energy is being used, we need more energy put into your body. So you start slowly, you can come home and you can pick your afterschool snack. And if a kid picks like an apple with peanut butter and a granola bar, great. That's a great choice. If they pick celery sticks and Tajin, then they're not ready. You know, they're not ready to make that decision. And so there's a little bit of trial and error. It's not as if they go from having no choice over activities to all choice over activities. And so there's some testing the water as we go between phase one and phase two. The third phase ultimately, will be more of what you see as traditional kinds of therapy where the therapist might be talking to a kid about, this is how you might reframe things when you're feeling stressed out, when you go to a party and somebody asks you if you want to slice a birthday cake. And so the more traditional therapy, what we think of as working with a psychologist or a social worker or a therapist is, what you see in the third phase.

[00:30:11] Dr. Rob Sanchez: Those steps to the therapy are involved. As you said, the treatment involves engagement from the parents. Are there qualities that parents can have to help make treatment a success? And are there ways to help, around that resistance, that strong resistance? What have you seen, between parents or providers, that really helps to make this home family based treatment a success?

[00:30:32] Dr. Gregg Montalto: The most important thing, and this is not a quality of a parent, but the most important thing is finding the right therapist who is going to be a coach for that parent. At Lurie Children's, we have psychologists and we have licensed clinical social workers. There are eating disorder therapists who are LMFTs or Licensed Marriage and Family Therapists. There are therapists who are LCPCs. And so it comes down to, is that therapist trained in family based treatment? And are they there as a coach, because parents do feel beat up. They will feel demoralized. They will feel as if they're ineffective. You know, and it's a lot easier as a parent to remember when we screw up, then remember when we do something really well, cause it makes you feel guilty. So initially early on that eating disorder therapist is going to be that parent's lifeline. They're coaches, they are teachers and it's important to have the right person. Being consistent is important. If kids know that as long as you get past X number of minutes, X number of tries, that you're off the hook, then they're going to drag things out. One thing that we will tell parents sometimes is like, look, your kid's health is more important than school. And so we want to make sure that they are getting the medicine that they need and that medicine is food. So if breakfast takes three hours and they're late for school, that is okay. Now, again, perfect world. Parents might be running off to go to work. You know, perfect world, you sit there until that meal is eaten. If a kid doesn't eat the rice at dinner, then rice is part of breakfast the next day. And so, being tenacious is an important quality. Another important quality is making sure that treatment is provided with a unified front. Spouses have different personalities and different qualities, and sometimes you might find that one is the softy. And, you know, the anorexia is going to look for the path of least resistance. And if they know ooh, you know, all they need to do is just kind of ask mom about this, they might be able to get by with eating less or doing less. Or, you know, I know that dad just doesn't have the patience for this. So both parents need to make sure that they're in it together and both parents need to support each other, provide respite for one another, because sometimes you just need to get out and get some fresh air. So a parent who takes care of him or her or themself is an important attribute as well, because it's a battle.

[00:33:42] Dr. Rob Sanchez: So much of what you mentioned, the commitment, the consistency, you know, that unified part, so key in all of parenting, but especially when you're dealing,with such a significant condition, but also knowing that they're not alone, that in good, supportive programs, such as Lurie Children's, They're going to have a therapist. They're going to have a coach who can support them. And I imagine being a part of that with your work is tremendous. And I'm sure it takes a lot of effort, takes a lot of time, but it has to be so worthwhile.

[00:34:09] Dr. Gregg Montalto: Yeah, no, we have an amazing team and it's growing. It's relatively new that we're providing eating disorder care at Lurie Children's. But the group that we get to work with from, our therapists, our dietician, our nurses, nurse practitioners, you know, we interact with an entire unit on the 17th floor and their nursing team is amazing. And, being able to problem solve with each other to be able to grow a program so that we're able to provide better, more comprehensive care as we continue to develop, I mean, that's essential in anything that you do. And this is an amazing group to work with. And the days might be long, but you know, it's rewarding.

[00:34:56] Dr. Rob Sanchez: For those families that are able to have success through treatment, they might be kind of graduating from either Pediatric care or making transitions. What are some of their outcomes like? Is long term recovery something that children or patients achieve? What do you see for them and how do you guide families through that process?

[00:35:13] Dr. Gregg Montalto: The presentation of Anorexia nervosa is evolving and it is probably evolving for a variety of reasons. You know, kids are exposed to media at a younger age. More or less kids have unfettered access to, you know, TikTok influencers and so the way that patients are presenting is, it definitely seems to be different now than it was 10 or 20 years ago. When we talk about outcomes data, that's based on those patients from 20 years ago. And so we're still learning and we still need to continue to learn. We need to continue to research because Anorexia nervosa is not going away. It's been with humanity since the beginning. And we need better ways to identify it, better ways to treat it. And to also look at those outcomes so that we know what works, what didn't work, what risk factors might be. When we look at the information that we have, about half of all patients diagnosed with anorexia nervosa will achieve full remission, which essentially means they go back to the days before, when they eat without thinking about it. There's no anxiety related to it. And, they maintain a healthy weight and everything is back to the way that it was. And, you know, that doesn't mean that people can't see themselves in a selfie and say, like, I really need to hit the gym. Like that could be a normal human thought. And I can tell you that I have that thought sometimes. And, you know, when you have that thought and then you can't do anything for the rest of the day, because you're thinking about that, then it's a problem . So the good news is that half of the kids do really well. Of the other half, about half of them will get to a point of partial remission where physically they're okay. Their weight stays in a good range. There's a lot of stress and anxiety and work that goes into it. We probably all know people who fall into this category. And, most people, once you figure out ways to help with that anxiety, they may benefit from some of that cognitive behavioral therapy that we were talking about before in a longterm way. A good number of patients, even though they don't fully recover, they still do pretty well. And there are patients who, unfortunately, are back and forth to the hospital multiple times. And, it might go on for years. And we do everything that we can to try to prevent that from happening. We do everything that we can to support patients, to support their families, to figure out what leverage we have over the disease. I talk about that a lot with families or other physicians, nurses that I work with . Our quest is to look for what leverage do we have over anorexia, which is very powerful. And for each kid, it's a little bit different what that leverage is. Sometimes it's their sport, sometimes the leverage is just that they got admitted to the hospital and they're so scared that, oh my God, this really was a big deal. Sometimes that's what it takes. Sometimes that leverage is, I've had a patient where she was really struggling and her parents made the very difficult decision for her to take a gap year before going to college because they realized that if she went off to college, that it was not going to go well. And her parents were crushed and she was crushed, but you know what? The following year, she was weight restored. She was doing well. She went off to school and she's thriving. And so, we don't give up, you know, it might go on a long time, but we might not have found that leverage for that individual patient to get to a better outcome. So that's, you know, we just tenacious said that twice today.

[00:39:10] Dr. Rob Sanchez: You should, because it's such an important quality in this work, and it's really helpful to hear about those outcomes of what folks can anticipate. But, you know, as pediatricians, we are passionate about prevention and I imagine there are parents out there who understand that times are changing, that social media has a big influence on this, and that, things like eating disorders are strongly associated with these body image concerns and things that can take root early on. For families, for parents, how can we help children have that healthier body image, starting from a young age?

[00:39:38] Dr. Gregg Montalto: There's so much that we need to fight back against just because of the pervasiveness of social media. If there are times where you're talking about food again, there aren't good foods and bad foods, foods in moderation, all foods are good. Letting a kid enjoy an extra piece of birthday cake or an extra slice of pizza at a party. That's important. if somebody brings up a body image concern, like, Is my weight okay? Then, you know, the answer is, yes, your weight is okay. Let's talk to your pediatrician if maybe their weight is contributing to, you know, high blood pressure or type 2 diabetes or something like that. But we need to look at weight and eating in a completely different way, in a world where we're both working against an epidemic of obesity, which has its negative effects and an epidemic of TikTok. And, navigating those two is very challenging for a lot of parents.

[00:40:47] Dr. Rob Sanchez: Being mindful of that messaging, right? Of things that the children are hearing from social media, but also from ourselves, from parents of how we talk about our families, how we talk about our own bodies, how we talk about others, or even how other members of our family might talk about our children. Being mindful and awareness of that, I imagine that probably contributes a big amount as well.

[00:41:05] Dr. Gregg Montalto: Yeah and if a kid has a question, then, go to your pediatrician and talk about it. I would rather have information about nutrition being provided by a kid's pediatrician or family physician or nurse practitioner, and not an influencer on TikTok, which unfortunately, is where a lot of kids are getting their information.

[00:41:29] Dr. Rob Sanchez: That reliable source, that's so important in this day and age. And even more so, I just want to say that we're so grateful to have had you join us for this episode. To be able to share those resources, share some of that knowledge with families who care about this, to know what to look out for and understand a little bit more about these conditions and what can be done. And as always, just as you mentioned, to use this as a resource if they need to talk with their pediatrician, talk with their trusted care provider, and also talk with their kids about these things and provide them with that good support so that they can lead healthy lives.

[00:41:59] Dr. Gregg Montalto: We have additional information on our Lurie Children's website. If you Google Lurie Children's Adolescent Medicine, and if you click on the eating disorder link, there are ideas on books that might be helpful. There are handouts that some of our clinicians have developed. Most of those are available in both English and Spanish. Because again, everything that we do, we try to break down those inequity, barriers that we face.

[00:42:28] Dr. Rob Sanchez: Which is so true. And those are resources that we'd also be glad to share, with the podcast episode. Dr. Montalto, thank you so much for taking the time today for all the impactful work that you do, and certainly we hope that this can go on to help lots of families. Thank you again.

[00:42:41] Dr. Gregg Montalto: Thank you so much. It's been a pleasure.

[00:42:43] Dr. Rob Sanchez: Thanks for listening to Kids Wellness Matters.

[00:42:48] Dr. Nina Alfieri: For more information on this episode and all things kids wellness, please visit LurieChildrens.org