Dr. Daniel Knoepflmacher (Host): Welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knoepflmacher. In each episode, I speak with experts in various aspects of psychiatry, psychotherapy, research, and other important topics on the mind.

Our topic today is eating disorders. It's estimated that millions of Americans will experience an eating disorder in their lifetime, and trends show these rates have been increasing over the past few decades. Eating disorders have some of the highest mortality rates among all psychiatric diagnoses and affect people across all demographics with onset typically occurring during adolescence into young adulthood. The associated economic burden in the United States alone exceeded $64 billion annually in 2018 to 2019. Beyond the statistics, eating disorders have long captured our cultural consciousness from the tragic death of Karen Carpenter in 1983, which helped bring anorexia nervosa into public awareness to today's complex landscape of social media where algorithms on platforms like Instagram and TikTok have amplified some online content promoting disordered eating behaviors.

Today, we'll dig into this important and complex topic. We'll explore the defining features of the different eating disorder diagnoses, and review the range of evidence-based approaches used to treat them effectively. To do all of this with me today, I'm fortunate to have two experts on this topic. Joining me, Dr. Evelyn Attia, Professor of Clinical Psychiatry at Weill Cornell Medicine and Director of the New York-Presbyterian Center for Eating Disorders; and Suzanne Straebler, who's the Clinical Director of outpatient Programs within the Center for Eating Disorders. Evelyn, Suzanne, thank you both for joining me today.

Evelyn Attia, MD: Thanks for having us.

Suzanne Straebler, PhD: Thank you for having us.

Dr. Daniel Knoepflmacher: I'd like to begin by asking both of you how you each developed an interest and an expertise in eating disorders.

Evelyn Attia, MD: Well, I'll get us started. My first job out of residency was on an inpatient unit that treated mood disorder patients as well as patients with eating disorders. I wasn't thinking that one group would be more likely to capture my interest than another. But as a physician, the fact that those with eating disorders and specifically those with anorexia nervosa had psychiatric conditions that affected every organ system in the body, that anorexia nervosa truly represented a mind-body condition. Well, that was very compelling to me. I became interested in the many ways that for individuals with anorexia nervosa, their behaviors lead to starvation, and that starvation in turn impacts behavior.

I was at first a clinician educator in the field. I directed a teaching unit at Columbia that offer treatment for patients with eating disorders. And over time, I developed lots of clinical questions about medications and other treatments and whether they worked in these populations. And while I hadn't initially thought of myself as a researcher, I had wonderful mentorship with mentors who let me know that my questions were answerable and that the process of setting up a study to answer those questions was indeed clinical research.

My first study back in the 1990s was one that examined whether fluoxetine would be helpful for individuals with acute anorexia nervosa. And while we found that fluoxetine was not any more helpful than a placebo, that work got me hooked on research and wanting to engage in research to get answers that would in turn help my patients. I've spent the last 30 years dedicated to study and delivery of biological and behavioral treatments for eating disorders, and to teaching others how to create programs that can successfully deliver state-of-the-art care.

Suzanne Straebler, PhD: I'm so inspired hearing your story, Evelyn. My journey was quite different. And it was one of those happy accidents that sometimes happen in life. I needed to select a topic for my undergraduate honors thesis. And I really wanted to look at the impact of birth order on psychological wellness. And I presented this to my advisor who said, "There's really not an honors thesis in that topic, so go away and think of something else."

And I remembered, many years earlier, there had been this segment on the television show 20/20, where a woman was describing novel treatments for women with severe anorexia nervosa. And similar to what you were saying, Evelyn, I was really struck by the physical aspects of this psychological illness and hearing the women themselves speak about just the impact that this illness was having on their life. I thought maybe that's an area I could spend my year researching. So, I presented it and my advisor said, "I think that's a good idea, and why don't you look into effective treatments if we have any."

So, I did and I was entirely gripped from the moment I started just doing this research, you know, here was this psychological or psychiatric illness that had such a profound impact on the body. There were so many physical side effects and that really married up my previous experience in biomedical science and psychology. And I was learning that we did have some treatments. And I wanted to learn more and more about these treatments, so much so that, some years later, I moved to the United Kingdom to work at the Center for Research on Eating Disorders at Oxford University, where a lot of the randomized controlled trials on psychological therapies were being conducted. And through that work, I saw many of my patients overcome these incredibly complex and serious illnesses, sometimes with relatively short courses of psychological therapy as a treatment.

And so, I was learning that, okay, we have these treatments and we know that very few people actually ever get to have access to these therapies. So, the next step in my career was to think about how do we increase access to these effective treatments. And so, the topic of my doctoral work for my PhD was on creating scalable evidence-based training in eating disorders so that we could train up a workforce able to implement these effective treatments. And so, when I look back on this career that I have just been so captivated with and so interested in, I really do owe it to an advisor who told me when I was an undergrad that I couldn't look into birth order and to find a different topic because I'm so pleased that I did.

Dr. Daniel Knoepflmacher: It's so great always to hear how two people who are experts in a field develop that expertise and came to it really initially. And both of you mentioned mentors as being very important. So for all of you who are listening earlier in your careers in psychiatry or mental health, that's something to keep in mind.

You also mentioned, Suzanne, 20/20. This was something you saw on TV that captivated you and eating disorders have been recognized in our culture over the past few decades. I mentioned Karen Carpenter in my introduction. But actually, if you look at the history, there's accounts of voluntary self-starvation being recorded as far back as ancient Greece, probably maybe even before, I don't know. And certainly, over history, I think there are maybe religious focus for these kinds of things as there was in the whole world in ancient times. But then later, entering into the 19th century, there was a focus on this in a more medical context.

I'm curious if one of you could provide our listeners with just a brief history of how eating disorders developed into what is our modern conceptualization of them as a medical condition.

Evelyn Attia, MD: You're right that eating disorders are old illnesses, and this often takes people by surprise. Anorexia nervosa was described in medical textbooks in the 1600s and onwards and received its current name, its current label in the 1800 when Sir William Gull described and labeled and wrote about anorexia nervosa.

And you're right too, that the cultural context of the disorder has changed a little bit over the years. There were times in history when the motivation for the food restriction was about religious beliefs, pursuit of purity, or a sense of moral superiority that came with fasting. And more recent times, when the pursuit of thinness and ideas about the thin beauty ideal became the motivation for the behaviors of illness. But the long history of anorexia nervosa and the persistent nature of the symptoms once they take hold have really been unchanged over this entire period.

Anorexia nervosa and bulimia nervosa were described in the earliest versions of the modern day diagnostic manual for psychiatrists, the DSM. And additional diagnoses that describe other patterns of eating, other eating problems were added when the field had enough data to be able to describe presentations, course, prognosis for these other conditions. So, more recently described, eating disorders include binge eating disorder, for example, as well as avoidant restrictive food intake disorder, which quickly took on the acronym of ARFID. and we'll say more about that a little bit later. We're continuing to learn, but we continue to include those early descriptions because they are as true today as ever.

Dr. Daniel Knoepflmacher: It is fascinating hearing you talk about that, Evelyn, because the idea that the culture can change around this and sense of ideals could have one point have been religious ideals. Later, it's a beauty ideal or a physical ideal. It brings to question what are the etiological underpinnings of this condition, you know, and I am wondering what do we know about the genetic neurobiological, environmental, psychological, social, et cetera, all of these factors? What do we know from research about eating disorders?

Evelyn Attia, MD: Well, we know that there's no single cause of any specific eating disorder. As you've mentioned, they're complex multifaceted disorders. And many risk factors have been identified. Though again, no single cause. It's important to understand that eating disorders are brain-based disorders affecting eating behavior. And risk factors do include genetic risk.

We believe that the genetic influences are the strongest for anorexia nervosa. And we know this from twin studies where, as an example, an identical twin with an eating disorder is more likely to have twin who's also affected, even if raised apart. And this compares with the rates of eating disorders in fraternal twins where one individual who may have an eating disorder is going to be less likely than if they were an identical twin to have their other twin, their fraternal twin affected.

Now, we have additional technologies to look at genetic risk, including genome-wide analyses. And support for genetic risk is increasing with every attempt at examining this question. We're learning more about biological differences, brain differences in individuals with eating disorders. And we do this with measures of brain and body function. So, for example, functional MRI studies that look at brain engagement while patients are actually making decisions about food choice. Those demonstrate that patients with eating disorders seem to be making decisions about food using different brain circuits, using different parts of their brain than new individuals without eating disorders. And this is amazing. I mean, we could all be selecting similar things to have for lunch, but what someone without an eating disorder may be using to make that decision is going to be something different than what happens in anorexia nervosa.

Culture plays a part as well with the pursuit of thinness and activities that emphasize weight loss or emphasize strict attention to weight. Activities like ballet dancing or weight-focused athletic activities like wrestling or physical fitness requirements that we have for military personnel. I mean, all those confer environmental risks that make eating disorders more likely for those who are biologically vulnerable.

And I make that distinction, importantly, I think, because many individuals in our society receive the onslaught of messages about thinness and many, many try a diet or some way that they eat differently in response to some of these environmental messages. But still, only half to 1% of females and about a tenth as many males develop frank anorexia nervosa. So, we really have a sense that we all may have the same environmental pressures. But there's some other biologically-mediated vulnerability that will make these illnesses begin and take hold for an individual with that propensity.

Dr. Daniel Knoepflmacher: Given that, there's obviously variability in culture across the world. So, do you see different either prevalence or presentation of eating disorders in different countries?

Evelyn Attia, MD: I always like to say that at this point in our history, there's no part of the world that's immune to the development of eating disorders. And we know this from important studies like the Global Burden of Disease Study. That's really taking a look at what affects folks all over and really across all the continents. And recent assessments of this type have demonstrated that the eating disorders are present, especially in teens and young adults when they're looking at those populations and that these areas of the world have seen significant increases in the prevalence of eating disorders, because the Global Burden of disease study from several decades back didn't look the same.

So, we actually think that our global messages are, unfortunately, affecting and being disseminated to more parts of the planet. And so, again, as human beings with whatever base rate of biological vulnerability we carry, we are seeing the unmasking, the development of these problems in places in the world that hadn't been seeing these previously.

So yes, we've got older studies that indicate that in communities, in countries, there's some very important work that took place in Fiji, for example. In areas where there was a strong cultural message of full body is healthy body, full body is a marriageable body, is successful body. When there were strong community messages from families and community leaders, there was a protective element. Eating disorders weren't seen in those times.

As television is everywhere and internet is everywhere now, some of those distinctions have really lessened, but it's helped us understand, again, these strands of influence. We've got the biological, but we do have the cultural piece that plays an important role.

Suzanne Straebler, PhD: And adding to that-- and Evelyn, I love that you bring up the Fiji study because I remember when that first came out and I was learning about it. And I think it was Anne Becker, you know, went in and was examining sort of the views of people, how they felt about their bodies. They knew that television was going to be coming in on a very clear date. Fiji was kind of being hooked up to Western TV. And so, she had an opportunity, went in and did this really groundbreaking work and assessed.

Evelyn Attia, MD: And I'll say that Ann Becker is this unusual and brilliant person who combines being a physician and a psychiatrist and an anthropologist. So, she was able to really think about these questions in these precious ways that we continue to refer to today.

Suzanne Straebler, PhD: Absolutely. And so, she assessed eating disorder behaviors-level symptoms, the view of the community of the body ideal before television arrived, and then had the opportunity to do it afterwards. And the difference was just remarkable. So, thinking about, as Evelyn said, not everyone is going to develop an eating disorder because of the environment that they are in.

Our numbers, we'll talk a bit more about prevalence later on, they're common, but not everyone who's exposed to this environment that we are in, and yet the environment does play such an enormous and influential role. And we want to bring that into the therapeutic work that we do in understanding culture. And culture can really encapsulate so many different things. It could be one's religion. It could be the people that are around, you know, Evelyn was mentioning those who are in the military. Military culture has its own defined set of ideals that go along with it. And by better understanding when our patients do come to us, what their particular culture is, how their culture defines beauty and ideals and markers of health and markers of being eligible to get married, if that's a big factor, we are much better able to personalize the treatments that we are offering.

Dr. Daniel Knoepflmacher: Well, let's slice and dice this a little more because I think one area, we can look at this, and you alluded to this earlier, Evelyn, talking about the prevalence with men versus women is gender. And obviously, there's cultural elements of that. And then when it comes to sex, biological sex. And so, I'm curious about both the prevalence and the presentation perhaps of eating disorders between men and women and maybe also those who don't fit the binary.

Suzanne Straebler, PhD: Yeah, I mean, as Evelyn mentioned, we do see these illnesses far more commonly in women, but we do see them in men. And it really depends on the eating disorder diagnosis how many men kind of make up that percentage. So with anorexia nervosa, as Evelyn said, we see it about 1% in women and about a tenth of those are men. The number edges up when we get to bulimia nervosa, and we'll define these disorders a little bit more later on.

When we get to a disorder called binge eating disorder, we really see it quite equal among the genders. and that's important for us to keep in mind. One of the things we really struggle with in our eating disorder diagnosis is the bias that has long carried into our field, probably set up by some of those ancient views of Greek and Gull's work that he did. But this idea that eating disorders predominantly affect young, white, affluent, emaciated, young females. And so when we bring that bias into determining who can get an eating disorder, we often miss men. So, the numbers are lower in men, and they may be lower no matter how we look at it, but it's very likely that we are missing out on properly diagnosing men.

And the presentations vary a bit. They're not sort of totally clear cut. But we do see with women, there does tend to be more restrictive eating, more focus on that thin ideal. Whereas men, we often see far more over exercising, far more lifting, trying to gain a muscular physique. But again, there can certainly be overlapping. And thank you for bringing up individuals who are trans or gender diverse, because we know that individuals in these categories are at higher risk, are more vulnerable to developing an eating disorder. And we really need to be thoughtful about how we implement the therapies that we have. Because when we're focused on an illness that is trying to achieve one's body ideal, and yet that body ideal is really informed by them wanting to have a body that aligns and matches their gender identity, it really can complicate how we apply the therapy ,because some of the eating disorder behaviors do help someone to achieve a body shape or a body weight that is more aligned with their gender identity. So, for example, one can lift weights to build up a more muscular body, one can restrict their eating to lose weight and reduce breast size and hip size. And it's really important that we're thoughtful about this interaction and this overlapping so that we can effectively help all individuals access the treatments that we know to be helpful.

Dr. Daniel Knoepflmacher: You alluded to biases, Suzanne, as you were speaking about this. And it brings up the topic of health disparities, which is true of all psychiatric conditions. And this, I mean, the fact that disadvantaged communities are facing more socioeconomic adversity, discrimination, and often reduced access to care. What do we know about these factors and how they play a role in the emergence and treatment of eating disorders among various groups?

Suzanne Straebler, PhD: Yeah, thank you for asking that. This is a really important area of work for Evelyn and myself and our whole clinic. And we really want to step away from those original long-held views of who got an eating disorder. And we do see, as you mentioned, Daniel, there are barriers across mental health, but there are some really specific ones that I think impact eating disorder perhaps more than they might impact other areas in mental health.

So for example, individuals who are low income, and perhaps facing food insecurity, we know that there is a lot of work to suggest that food insecurity can help to set someone up to be more vulnerable for an eating disorder. We know that it can maintain the eating disorder behaviors. So, let's say for example, someone who receives government assistance or SNAP, that money is dispensed usually at one time a month or every other week. And so, there can be periods where you have money and abundance of food because you can afford to buy it, that then trickles down while you wait for the next installment of that money.

And so, during those periods of abundance, people may be more prone to binge eat because they haven't had quality access to food, and then are forced to ration or restrict their eating as they run out of those food sources. And that can really mimic a binge eating and restriction cycle. It can further, negatively, harm people where you need a lot of calories to regain weight if that's a part of your eating disorder. And the government assistant or SNAP benefit may not be able to provide enough money to actually buy the amount of food that you may need. So, we are encountering those barriers And we need to be really thoughtful about asking questions about access to nutritious and regular food, because it does play a big role in terms of what we are able to do in our sessions and also understanding the impact. And we know that individuals who faced food insecurity as children are more vulnerable to later development of an eating disorder. It's another one of those environmental factors that Evelyn was mentioning.

Another big barrier that we face in particular in eating disorders is this idea weight stigma coming back to who can have an eating disorder. And we see weight stigma across all fields in medicine. But even within eating disorder specialists, there are studies to show that eating disorder specialists have their own weight stigma. So, this view that you're viewing someone negatively because of the size of their body, attributing negative characteristics to them, like laziness. But an eating disorder, how it interferes is that you may not identify someone who needs eating disorder treatment because they're in a regular sized body or a larger body and not think this is someone I still need to investigate in terms of if they have an eating disorder based on some of the other things they are mentioning about their eating.

Evelyn Attia, MD: And I'll just add, because I know we'll have other opportunities to talk about some of the eating disorders, but this has gotten a fair amount of attention in the current literature that, given our shift in population norm weights, individuals' baseline weights are different than they may have been at another point in history.

And so when some of the food restriction and other very, very unhealthy behaviors and attitudes that come along with those behaviors overfocus on body shape and weight and all of the rest, when it affects somebody who may be starting at a higher weight, they may get into lots of medical trouble, but at a weight that a provider, a clinician, may not recognize as low for their body systems, right? So, we call that atypical anorexia nervosa. I actually hate that term and hope that it will one day evolve into another term that we all are going to agree on, but it is a condition of very, very similar symptoms to what we see in a typical presentation of anorexia nervosa. But somebody may present at a regular, normal, all of these things are relative, but at a weight that does not appear significantly low, but for that individual really is. And for whom there may be all of those medical complications and all of those metabolic changes and all of those risks, and we need to help those individuals as well.

So, not having bias about who walks into our office across a whole range of features is very, very important. I said it about parts of the world. I'm going to say it about types of people. There's no one who's immune to developing an eating disorder. There's nothing about race, ethnicity, background or socioeconomic background that protects you and has you not be eligible for the kind of evaluation and consideration by a clinician who's thinking about an eating disorder. So, we all have to remember that.

Dr. Daniel Knoepflmacher: Well, before we dive into differentiating the eating disorders, which I want to do shortly, I want to ask one last question more generally, as we've been doing about eating disorders as a class, and that is about the developmental pattern. I mentioned in the introduction that this is often presenting in adolescence into young adulthood. But I know that there are people struggling with this across the lifespan. Can you just speak a little bit about what emerges and what things look like at different ages?

Evelyn Attia, MD: So, I'll try. Anorexia nervosa commonly does develop during adolescents or young adulthood, but younger ages of presentation are more common in recent years, and we certainly saw that during the pandemic. I have to imagine without having conducted any kind of controlled trial, because the pandemic affected all of us all at the same time that there was something about all of the social media and other screen presence that brought much more attention to image focus. And the messages that are out there to a younger , kids who normally would be in school were instead staring at screens and engaging with social media.

And the thought is that many behaviors that might have otherwise started a little bit later, started earlier still. And all over the world, hospitals were seeing higher rates of seriously affected kids, children, as well as adolescents, presenting with eating disorders, serious eating disorders. The thought is that may not be a net increase in the total number. It may just be an earlier time of onset. We're still seeing some of that. We'll see if that returns to adolescent onset over time. Bulimia nervosa usually begins a bit later and may be present for a period of time before the individual first presents for treatment. We think that's because the illness isn't as apparent by physical appearance and may not be identified by medical providers or by family members as early. And also, some folks with bulimia nervosa may begin by thinking that their behavior isn't in need of treatment, and that additionally delays when we hear about it. But we do think that it begins a little bit later than what we see in anorexia nervosa.

Binge eating disorder really a problem where there are these discreet binge eating episodes very similar to bulimia nervosa, but without some of the other behaviors that we see in bulimia may not take hold until later in adulthood, even middle age. And again, many don't know that there are treatments for binge eating or embarrassed to talk with their providers about their symptoms. And all of this may contribute to some delay, regarding when we know about it. But we do think that these conditions start somewhat later.

That ARFID diagnosis that I mentioned previously, now that develops real early often during childhood. And again, that's one characterized by restrictive eating that's not associated with the same kind of body weight or shape concern that we see in anorexia nervosa. But it still can have really significant psychosocial and medical implications. All of these eating disorders are treatable and recovery rates are substantial.

And so, when we're seeing these conditions in younger people, there are many of those people who some years after that presentation get to a place where they do not have an eating disorder anymore. But there are others who may not have that full state of recovery or maybe had a slightly later set time of onset of symptoms. And we do see eating disorders that may last well into adulthood. And so, some of the serious presentations of these eating disorders can occur when individuals are in their 40s, 50s, 60s. It's not at all impossible. Again, pointing out the importance of not judging and assuming that, when we see a 65-year-old with something that looks a lot like anorexia nervosa, there's often a thought of it's got to be medical. There must be a very, very different reason for that presentation. Not asking about symptoms that we would expect in a more classic eating disorder.

Dr. Daniel Knoepflmacher: It's so important. We have preconceived notions as psychiatrists, doctors, psychotherapists. And I think it's important always to remember that it doesn't always fit the mold. Speaking of the molds, let's think about these diagnoses, we've obviously named them, but could we start with anorexia nervosa, bulimia nervosa, and binge eating disorder, and if you could give us kind of a primer on their defining characteristics and the patterns for each?

Evelyn Attia, MD: Sure. And I'll try to do that briefly. Anorexia nervosa is an illness where there's a pattern of taking in less, right? We call it energy intake, but really it's food. It's calories taking in less than what the body needs, leading to a significantly low body weight. And it's a low body weight for that individual. So this may mean that there's been significant weight loss. But if we think about it for a growing adolescent, for someone who's younger, significantly low weight may mean failure to gain weight at the expected rate, that you'd want to expect to see during growth, right? So, I think sometimes families are confused, because they'll say, "Well, he or she hasn't lost weight, right?" But they haven't grown or they haven't, or they have grown in height some, and the weight hasn't gone up commensurate with that growth. We worry about those folks just as much.

And together, with those changes in eating and weight, there's a set of cognitive experiences, thought experiences. There's a fear of fat, fear of becoming fat that may be present. There's definitely a preoccupation with thoughts about body shape and weight. There's an overvaluing of the importance of body shape or weight, or there are some behaviors that suggest this, even if someone's not saying that, what they're thinking about, there'll be behaviors that the family or others may see. There's often a failure to recognize how serious the condition is.

There are two subtypes of anorexia nervosa. One is called the restricting subtype, and that's one where this significantly low weight is you land with that because of food restriction solely or really primarily. And the binge eating or purging subtype, that's the other subtype, we can really see any of a number of behaviors. Some binge-eating episodes, maybe some purging behaviors such as self-induced vomiting or misuse of medications that aim to prevent weight gain. We don't need the whole picture as we might see in someone with bulimia nervosa. We can have some and some. But if those are present, we identify them as that subtype because it really does inform treatment. I think that clinicians need to know what the behaviors are that the individual's going to need some assistance with. And there's some different medical implications depending on how someone's gotten to those very low weights.

Bulimia nervosa is characterized by episodes of eating more than what's usual for a given situation, together with a real sense of loss of control. So, it's not just being at Thanksgiving dinner and eating more than one is used to eating at dinner time, that kind of eating is very appropriate to the context. So, that is not considered a binge-eating episode. But for the individual who has one of these episodes, there really is a sense that once it's started, it's next to impossible to stop. You know, a package gets opened, it's impossible to stop before all the supply is gone kind of thing. And that wasn't the intent for that individual. These episodes happen at least once weekly over a period of at least three months to meet criteria for that condition. And most of the time, it's happening more often even than that.

Binge eating disorder is defined with that same definition for binge eating episode. But the inappropriate compensatory behaviors are not present. What differentiates binge eating disorder from bulimia nervosa is that the episodes of inappropriate compensation for eating those episodes of self-induced vomiting or use of laxative medications, really misuse of laxatives or misuse of maybe herbal supplements that aim to prevent weight gain or to cause weight loss. Those additional behaviors are not present in binge eating disorder. But we have real trouble with those binge eating episodes. It causes a lot of distress to the individual. A lot of guilty feelings, maybe some secretive eating, difficulty with social experiences because of those behaviors. They really are quite dramatic when they occur. And folks are coming in really trying to get help very specifically for those behaviors.

Dr. Daniel Knoepflmacher: Thank you for breaking all of that down. I want to refer to the other diagnosis that you brought up earlier, which is avoidant restrictive food intake disorder or ARFID. And can you speak about that or whatever else is in the categories of feeding and eating disorders?

Evelyn Attia, MD: Well, I'll say something about ARFID having been on that DSM-5 work group, there was really a lot of attention around a group of folks that we've known about for a long time. In fact, there was a hardly used label, an older DSM volume that tried to describe some of these eating problems that caused a lot of medical and psychological trouble, but that didn't fit neatly into the anorexia nervosa category. And we grappled with this and asked a lot of providers and really found that in the medical community, the pediatricians, the pediatric gastroenterologists, some of the folks specializing in neurodevelopmental conditions, had groups of kids who from very early age were not eating sufficiently and were very, very afraid of making changes. And that set of sustaining behaviors really were getting them into trouble. And the providers wanted there to be a label so that we could better study, better understand, develop treatments for these folks. So, the label of avoidant restrictive food intake disorder or ARFID emerged.

And this describes avoiding or restricting food, usually for one of three reasons. It doesn't have to exclusively be this way. But commonly, we're either seeing young people, and this can exist across the lifespan as well. But it usually begins early where there's a fear of an event that's associated with eating, right? So, a fear of choking or a fear of vomiting, a real concern that gets in the way, maybe someone who has an allergy and they're afraid of taking a misstep. And that gets in the way of eating anything at all. A fear of something that's associated with eating that leads to significant restrictive patterns that get that individual into trouble, whether it's nutritional, other medical, growth, or psychosocial. A kid who doesn't want to go to school or doesn't want to go to any birthday party, because they may have to confront an eating experience.

Another category of these folks, these individuals with ARFID are those with some sensory issues that get in the way of eating successfully. So, somebody who may not be able to tolerate the feel of a certain food in their mouth. The food may feel thick like a mashed potato or may feel scratchy like a potato chip. There may be a smell to a food that just feels so intense. And this gets in the way, again, globally at being able to eat healthfully and eat normatively. We see this not uncommonly in autism spectrum disorder and some other neurodevelopmental situations where there is real sensory sensitivity. And if that impacts food, there sometimes is the need for this label and for treatments that really work for this condition.

And there's a third group and those are kids who often from birth, really, aren't motivated to eat, right? And we're not talking about, again, an older adolescent or a young adult who all of a sudden develops lots of the other symptoms of an eating disorder and says, "And by the way, I'm really not interested in eating," that's not who we're talking about. We're talking about folks whose families will say the strangest thing would happen, right? A meal is on the table, or all the other siblings are coming hungry at the end of their school day, ready for dinner or whatever it might be. This child would never pursue it, never remembers it, doesn't open the lunch bag if told, "Hey, how about right now?" Maybe they'll do it. But there isn't an actual motivation for that. And, again, it's not just picky eating. That's not what this whole condition describes. It's a really significant presentation that gets someone into an area of medical or psychological trouble that needs a specialized approach, needs some kind of usually behavioral approach to get things reversed.

One of the differences in ARFID treatment is usually these individuals, whenever they present, they may present into adulthood. They're usually quite delighted to think that their weight or nutritional status may change and improve and increase and make them feel closer to everybody else in their world. We don't have the kind of reluctance. We may have fear about what it's going to be like to take those steps, but usually great relief that there are treatments that can help them move forward. So, ARFID has really been a success after it was described in this kind of detail in 2013 when DSM-V came out. And treatment trials using some behavioral approaches are currently underway, but really looking promising for the management of this condition.

Dr. Daniel Knoepflmacher: That's good news about the research showing the potential for real effective treatments. i wasn't aware of that. We've gone through these different diagnoses now. I'm wondering if we can turn to diagnosis and the process of evaluating somebody for an eating disorder. And what can you both tell us about how clinicians should be looking for these diagnoses?

Evelyn Attia, MD: So, I think we both may have some thoughts on this, because it's a lot of what we do. And usually, a comprehensive evaluation includes an interview with an individual affected as well as some physical measures. And some of that really has to do with what someone presents with and is concerned about. The interview will likely review history of eating behavior and ask some general issues, like life with family and friends and history of other psychological symptoms like mood and anxiety symptoms. And history of medical symptoms to really try to get a sense of whether there are complications here or a different cause for some of the eating change. The physical measures will certainly include vital signs such as height and weight measurements, as well as heart rate and blood pressure. And often, laboratory values in EKG to take a look at heart rhythms are recommended.

But again, some of this will vary depending on what someone presents with. And sometimes, one visit is not sufficient to fully evaluate. I think that Suzanne has a lot of experience with evaluation that really takes some time of engaging with someone and getting to know them.

Suzanne Straebler, PhD: Absolutely. And really give a strong encouragement here to screen your patients for eating disorders even if they are not coming in for eating disorder. APA practice guidelines really encourage, as part of a comprehensive psychiatric evaluation, for whatever someone is coming in to give a question for a screener for eating disorders.

These disorders are often very comorbid. And they are often not the issue that the person might want to speak about upfront. A lot of these behaviors are difficult to talk about, someone who makes themselves vomit, someone who is restricting their eating to such an extent, someone who is spending three to five hours every day at the gym. These are behaviors that might not come to the fore if we don't ask the questions. So, I would say screen and then be comfortable and practice asking these what can often feel very different to a regular evaluation, really invasive questions, things that we don't typically talk to people about. "Tell me what you eat. Can I hear a daily recall of what you're having to eat? How do you feel after you're having those foods? Do you have times where you are eating food to the extent you feel fully out of control and you're experiencing pain in your belly as a result of it? Are you taking laxatives? How many a day?" And asking questions that, again, we would normally not be asking. These are things that don't typically come up in evaluation.

And then, as Evelyn said, again, marrying up the physical and the psychiatric. We do often want to get a picture of their medical status, so labs and vitals. In particular when we're working with younger people, we want a copy of their growth curve. We often see these quite classic patterns where someone is charting beautifully. And then, all of a sudden there's this sharp fall off. And that can be very helpful in terms of diagnostic clarity, but also the direction we're going to take in our treatment. And of course, we want to get our patient's weight, which again is not something we would typically do in evaluation. So, thinking of those different aspects that we need to tie up to make sure we are providing comprehensive care for this particular illness.

Dr. Daniel Knoepflmacher: Thank you both for getting into the details of the specifics of what needs to be done to diagnose these conditions. I want to ask about suicide, because I know that there's a high rate of suicide associated with eating disorders. Can you say more about that?

Evelyn Attia, MD: So, it is important to recognize that suicide rates are higher. Across all of the eating disorders, the highest rate of suicide is associated with anorexia nervosa. And you mentioned it early in the episode here, but it's important to say again that the rate of mortality generally that's associated with eating disorders and specifically anorexia nervosa is very high.

A young person with anorexia nervosa is about five times more likely to die than a person of that same young adult age who doesn't have anorexia nervosa. And about a third to a half of the deaths associated with the condition are due to suicide. So, this is not an insignificant risk, and we do need to be asking and following and really trying to do risk reduction strategies whenever possible. I think that there's some understanding that, okay, these are medically complicated conditions, I guess sometimes, well, nothing we can do. And there's a medical risk. Someone might have an arrhythmia and die, right, sometimes. But there's a lot we can do to evaluate for, to try to assist when someone is at suicide risk.

One of the things that's a little complicated is some of the treatments we rely on for managing low mood, right? We're so comfortable as group of providers across all of healthcare at using antidepressants to help people who have depression, have. Even mild depression. Those medications don't work as successfully in individuals who have acute anorexia nervosa who are low weight. And there's some neurobiological hypotheses about why this may be.

But we need to remember that as we're dealing with a group that really may be at some high risk. So, we want to use other kind of social supports and we may want to try some antidepressant medication, but we need to stay aware that patients are not going to respond in the same way. And we really may not have that benefit. So, we got to pay attention.

Dr. Daniel Knoepflmacher: Can I ask a followup question about that? Because from a philosophical, ethical standpoint, anorexia can be quite complex. And I've seen in my career in the hospital cases where there's somebody who the level of food restriction and malnutrition is at a point where it's clear that it will lead to death, and it's the primary affliction of the anorexia nervosa. Would we classify that as suicide versus somebody who takes an active step to take their own life when they are aware that continuing on this path leads to their mortality?

Evelyn Attia, MD: So, the question is such an important one and ethics teams spend a lot of time with us in trying to parse out what elements of an individual's presentation represent who they are versus the illness they have, whether we classify some of what's going on in this way, that way, or the other way.

I don't consider-- I think these are very, very dangerous behaviors. I'm not talking about those behaviors when I talk about suicide risk. I'm talking about a suicide risk on top of the risks to the body when someone is taking in far too little. So, again, let's hold onto that and remember that we've got to evaluate as mental health professionals, as psychiatrists, as physicians who may be seeing these patients who aren't psychiatrists. We need to remember to ask about risk of self-injury, overdose, the kinds of thoughts of death, acute thoughts of death that some individuals, but not all individuals with anorexia nervosa have. Some of the people who are as starved as you describe may say, "I don't want to die, but leave me alone. I want to eat this way." And that's its own ethical conundrum. And there's a fair amount of debate out there more in the recent era as things like medical assistance and dying is getting more attention worldwide about whether individuals who say, "Leave me be. This is how I want things to go. In fact, if you want to assist me further, I'm heading in that path," whether that's acceptable or not acceptable and such.

I think of these illnesses as greatly treatable. I've seen too many cases where someone who was so severely affected at one point during their course recovers fully. I've seen others who recover partly and reclaim a lot of quality of life that they really hadn't thought possible when their weight was lower. These are folks who may not meet full criteria for psychosis in the way that we think about the loss of reality experienced by somebody with schizophrenia or some other conditions.

But I do believe that for this condition, there is sometimes a real loose connection with the realities about the importance of body shape and weight that make me believe, and I don't have everybody's opinion on this, that somebody isn't demonstrating full competency around decision-making that very specifically has to do with eating and food and sustenance and protection of life in this category while they may have other areas that are quite preserved in their cognitive function and capacities. And that's complicated. So, we are worried when someone says, "This starvation is my message of what I want, and maybe what I want is death." We try to bring those folks back from those brinks. And we want to evaluate people for other risks of dangerous behaviors because I do think that, with additional nutrition, we really have a much better chance of somebody's mood improving, anxiety symptoms, improving, preoccupations and obsessions, improving so many features that really are worsened by that state of starvation. And we want to be treating the whole person and get some of that function back as we engage with people about treatment and about future.

Dr. Daniel Knoepflmacher: That last point about getting someone out of starvation and how that will change their cognition is a perfect segue into treatment, which is what want to turn to. Just this morning, I'll tell you guys a little anecdote. I was coming up in the elevator. I ran into one of the residents in our program and said, "Oh, I'm going to record a podcast on eating disorders." And I heard right away about an intractable case in the hospital. And I think our residents are seeing the most severe cases, which as you just described, Evelyn, The complexity of that, it can be, I think, at times something that gives them a sense of helplessness about eating disorders.

But as you guys keep stressing, there are well-established treatments for these conditions. These treatments are multimodal, medical, pharmacological, psychotherapeutic. Can you get into the nitty gritty of this and describe-- let's maybe start with the medical considerations, because we're talking about that just now for somebody whose health is so significantly compromised physically by this condition.

Evelyn Attia, MD: There are a number of medical features that we pay attention to and need to be careful about. But commonly, when someone presents to a treatment program, even with many medical complications, the most potent strategy is the behavioral plan that really assists them in moving forward with more successful intake, okay? Yes, if they really are demonstrating complications with some of those initial steps, we have things that we need to do with hydration, with monitoring. These can be very dangerous states of starvation, and the medical hospitals are quite expert in figuring out how to move some of that stuff forward safely.

But even on the medical units, as we begin that process, we need to use behavioral strategies. And all of the treatments across these great disturbances and eating behavior need us to think about behavior. We don't get as far just doing some talking. We do better with a plan that really asks individuals to expose themselves to some difficult next steps and offers the support that they need to help that move forward and continue to reinforce the healthy choices and healthy behaviors and to try to disincentivize or not reinforce behaviors of illness when they emerge.

So, the core features really for all the eating disorders, when we think about anorexia nervosa, the treatments that help all have that B in the acronym, right? They all have those behavioral elements, whether it's the family-based treatment, I guess the B isn't exactly behavior, but still the family-based treatment that works with our youngest patients with anorexia nervosa is really about empowering parents to help in the refeeding to focus on needing to do that first. And when we're dealing with an adult population, we're usually using the principles of cognitive behavioral therapy. And Suzanne has really contributed masterful ability to teach others, including generalists who never in a million years thought they would be doing eating disorders work. But essentially, little time with Suzanne and they learn how to offer these evidence-based strategies so successfully. And we're really able to expand the reach of who's focusing successfully on behavior and moving things forward.

I'll just say that for bulimia nervosa and for binge eating disorder, we have more straightforward options in terms of evidence-based care. The majority of folks, really, the vast majority of individuals with bulimia nervosa, if they go through a course of cognitive behavioral therapy and/or use an antidepressant medication. So, antidepressant medications don't work very well for anorexia nervosa. They work beautifully for bulimia nervosa. And in fact, fluoxetine-- the old brand name was Prozac, so that everybody recognizes it-- but fluoxetine is the one medication that the FDA has given a specific indication for when it comes to bulimia nervosa. Lots of other things work, but Fluoxetine has that indication at a higher dose than what is used for depression treatment. So, it's 60 milligrams of fluoxetine that's been found to be effective. Twenty milligrams was no different than placebo in lots of large trials. But the idea that we've got two good treatments, one or the other, or the combination really gets vast majority of folks to stop the binge eating and purging behaviors of bulimia nervosa. That's great.

And for binge eating disorders, similarly, many of the structured treatments-- cognitive behavioral therapy, interpersonal therapy-- some of these structured treatments that all include some attention to coming in, working on eating and behavior and paying more attention to the circumstances that one is in when some of these episodes happen, tremendously helpful in binge eating disorder. And we have medications. So, the antidepressant medications and those SSRIs are very helpful, more helpful than placebo. And there too, we have one medication and it's not in that category that made its way all the way to the FDA, and that's lisdexamfetamine. It's a stimulant medication. It very much impacts appetite. And for individuals with binge eating disorder, trials had demonstrated enough strength of effect that the FDA has approved that for the treatment of binge eating disorder. It doesn't mean everyone should jump on that one medication. I do think that there are lots of other strategies that work. But for those two conditions, we really have good solid, a little bit less complex than for anorexia nervosa where we're really trying to manage cognitions that sometimes get in the way and medical features that are complicated. Sometimes that condition needs a few more parts.

Dr. Daniel Knoepflmacher: Suzanne, I want to turn to you a little bit more about the behavioral and psychological, one last question, Evelyn. Medication wise, when it comes to anorexia, I know I remember seeing a grand rounds from you speaking about a medication that we sometimes use with other disorders that has been studied for anorexia.

Evelyn Attia, MD: Sure. So, that trial, which looked at olanzapine and atypical antipsychotic medication that is commonly used for lots of other things. It's used for the psychotic disorders like schizophrenia. It's used for management of mood instability and bipolar illness and got some anti-anxiety effects. It's got some other things. But we were interested in whether it might help either the obsessing or the high anxiety or the near delusionality, the real difficulty thinking clearly around the need for eating sufficiently. Or since it's a medication that was associated with weight gain in other populations, might it help with weight increase? And sometimes I'm talking to peers and they'll say, "Well, of course it's going to cause weight gain. It causes weight gain inn lots of folks." So, many medications that are associated with weight gain in lots of other clinical populations have shown no weight impact in anorexia nervosa. It adds to this long list of medicines that don't seem to be affecting patients with anorexia nervosa in the same ways as what we see elsewhere. And probably they're so medically, biologically, brain circuitry different that we see something different.

But in that trial, we did find a modest weight effect. I mean, it really was modest. It was something like in a trial that was 16 weeks long and patients were outpatient, meeting with a psychiatrist, a physician who could prescribe weekly and getting a little bit of support around those sessions, but not other treatment; individuals on low-dose olanzapine would change their weight, on average, about one pound more per month than the individuals who were receiving a comparative placebo medication. That's not a lot of change. We didn't see a lot of change. But it was significant because everywhere we sliced it, every way we looked at it, this was across five different sites, we really were looking very carefully at what was happening. And we did see a weight improvement.

We didn't see as much of some of the psychological improvement as we had expected. We saw that many individuals were identifying feeling better, they slept better. They felt that they could sit and attend to things better. We didn't see as much of the improvements in anxiety and such as we were hoping. We think of the medication as something that really shouldn't be a standalone. It shouldn't be something that, "Okay, don't need to look any further. We can just use a medication." But it's something that we do draw upon when we need something adjunctive, something to add to the behavioral treatment, especially in someone who's only responding somewhat to the behavioral treatment. And it is one medication where we really do have medication superior to placebo effect, whereas we don't have that across so many other studies that have been carefully conducted.

Dr. Daniel Knoepflmacher: Thanks. And Suzanne, as someone who's leading lots of psychological and behavioral treatments through your program, can you speak more about that aspect of the core treatment for these disorders?

Suzanne Straebler, PhD: And I just want to touch on Evelyn and I are real believers in that treatment is effective. We've seen it happen so many times throughout our careers. But for anyone who might be listening, either a medical provider or an individual themselves who views these illnesses as not treatable or intractable, I just want to say that that is to be expected. I think most of the patients we initially start to work with, they come with the belief as well that they're not going to be able to overcome this illness. So, we bring that into the therapy.

So yeah, as Evelyn was saying, we see our psychological therapies as our frontline treatments for these illnesses and we have very specific treatments that are the recommended treatments. We have typically our CBT, so cognitive behavior therapy but it's very targeted cognitive behavior therapy That is quite different to a lot of other CBTs. And as Evelyn said, we're kind of doing the B first. And for a long time, we are really focusing on behavioral change. We are changing how someone is eating, how frequently they are feeding their body. We are restoring them nutritionally, regardless of where their ultimate weight may need to be. Those who need to regain weight need a longer course of treatment. In outpatient, we're looking at about 40 sessions over 40 weeks, which is still considered a pretty brief therapy, but we need that longer time in order to build up motivation, in order to bring people over to this idea that they can overcome this illness. And then, we have to start the very hard work of weight regain.

In an outpatient setting, and I say this to all the patients and families I work with, if you've never had to regain weight, that weight loss was caused by an eating disorder, you simply have no idea how challenging it can be. For many people out there, there's this thought that it's very easy to gain weight and it's something that we are working against doing. But for our patients, it's physically hard work. It can feel painful in the body when you start refeeding. And it's psychologically so distressing. So, it takes a long time. For eating disorders where weight regain is not required, bulimia nervosa, binge eating disorder, the treatment is significantly shorter, typically about 20 sessions over 20 weeks. But it can be even shorter if that's what that person needs, and we can extend it. We really want to personalize the treatment for the person in front of us.

And we are targeting the main driver of the eating disorder for many people, which is that overevaluation of shape and weight and all of the behaviors that are sort of maintained by that. So, we have patients who engage in lots of excessive body checking. They're mirror checking. They're taking hundreds of selfies a day. They patients who are engaging in a lot of avoidance. They may avoid being naked or intimate with their partner because of having to be exposing their body. They may avoid going on beach vacations, because they don't want to have to wear a bathing suit.

For our younger patients, as Evelyn described, the treatment is very different. Family-based therapy is the main treatment we offer for our young patients, and this is where we are more of a coach or a guide to the parents or the adults in the home in terms of them refeeding and providing the support and the therapeutic environment really in the home. It's a very different therapy to many other treatments that we do generally in psychology, where the young person is really not involved all that much. They're in the session, but they're not really participating until later on, until after we've had a chance to bring them to nutritional stabilization. And we're really working with the parents to empower them to take back the role, because the eating disorder has really corrupted their child's mind. We're empowering them to take back the role of refeeding and helping their child. And then, we pass that back on to the child or adolescent later on in treatment.

Dr. Daniel Knoepflmacher: Thank you for going into details about all of the different behavioral approaches to these disorders. We've been talking, you know, about the struggle that I think many clinicians have. And even though there are these strong evidence-based treatments that both of you have described, I think a lot of clinicians feel unprepared to treat eating disorders. So, what are the gaps that you see in professional training and are there ways to address that?

Suzanne Straebler, PhD: Sure. I mean, one of the main gaps is that eating disorder is just typically not covered as a part of medical training, nursing training, psychology training. It's building and it's starting to be added. And Evelyn and her colleagues at Columbia are doing a lot of work in terms of providing general education to all providers. But it's an area that has often been overlooked. When we're thinking more specifically about these evidence-based treatments, we know that they exist. We know that they can be helpful, especially when they're implemented well. But we don't have enough trained therapists, so we want to look for scalable ways to provide evidence-based training as well, training that we know actually moves the dial, increases a therapist or a provider's confidence in working with these eating disorders and individuals who are suffering with them, confidence in having the knowledge to implement these therapies.

And so, at the moment we're using things like online training, but particular role play, making sure we're assessing someone's actual ability to apply the treatment, checking back and hearing how they're doing it. We have rating scales to do that. And so, I would say if you are excited by what you've heard on this podcast and want to learn more, certainly reach out to us. But there are other training websites where you can get specific training in family-based treatment specific training in CBT-E for eating disorders, interpersonal psychotherapy for eating disorders. And I really encourage people to take time to do these trainings so that they have the confidence and the ability to apply the therapies.

Evelyn Attia, MD: And I will just add a plug for the training for the generalist, for the general health provider that Suzanne was mentioning that we've been working on. We have a publicly accessible free online set of short modules. They were designed for health professional students. We used a team that included medical students to help evaluate how people learn.

And the website is Prepared-- we call the training Prepared-- nyspi.org. There's actually a Spanish language version of this course as well as English, and it really is getting some reach and helpful to educational programs that don't include a small bit on medical complications or how to diagnose some of those basics.

Dr. Daniel Knoepflmacher: I'm hoping we're getting the word out with this podcast and people will come and use that resource. We're so short on time, but there's something that's been on my mind as we were preparing for this podcast. And this gets back to kind of a combination of cultural and medical factors. And that's GLP-1 agonist medications, things like semaglutide, popularly known as Zepbound or Wegovy. They've been used widely with tremendous growth first as an injection for weight loss. Now, recently are oral medications.

And based on your experience, this is fairly new, I know, but it comes to mind both in how this could be potentially misused for somebody with anorexia nervosa. But also, I was curious as you were talking about binge eating disorders, whether there might be a place for these medications therapeutically. Quickly, if we could just touch on that, because it's so much in the zeitgeist.

Evelyn Attia, MD: So, both parts of those questions are very important and relevant and timely. Every weight loss strategy over the years has captured the interest of some individuals who have or are vulnerable to developing an eating disorder. And if you're vulnerable in a particular way, such a person may go on to really get into trouble because of that vulnerability, GLP-1s are the newest of these, and they're very potent weight loss agents. They offer many significant benefits to those with overweight or obesity, and they may have a role for some individuals with binge eating disorder. The word is not out. The studies have not been done. There was one small effort at a study with somewhat equivalent findings, which is sort of interesting and may have some to do with how well they're tolerated and other kinds of things. But I think larger studies are underway and I'm eager to hear how they go.

But for someone who may be vulnerable to too much weight loss, maybe someone still with an eating disorder, maybe someone with a history of an eating disorder that was restrictive, getting started with some of these medications can get them back into trouble.

My message to providers is ask your patients about their history of problematic eating, weight fluctuation, formal diagnosis of an eating disorder. It is surprising because the medications are so impactful for some of the patients that a doctor will see, that often some of those basic questions don't get asked, and then everybody's surprised when someone develops real trouble.

So, please ask, discuss risk with a patient, and encourage patients to use human contact prescriptions for these medications. I think when everything is done with an online provider where somebody could just say, "No, I got nothing to worry about," kind of thing, it's harder to really evaluate whether someone is right for one of these medications. Medications have a place they offer some benefit, but they can be potentially problematic when someone has a history of one of these conditions.

Dr. Daniel Knoepflmacher: Thank you. And last thing that I would ask both of you is are there any resources that we could leave our listeners with that you want to share to learn more about eating disorders?

Evelyn Attia, MD: Well, I would like people to know about and let your students and trainees certainly in your programs know about our Prepared course, prepared.nyspi.org. And there are six modules that really go through some of the basics how to ask a question of someone with an eating disorder, for example, that might be very useful. We have a program website. And, Suzanne, maybe you can mention the website. It just identifies some of the different kinds of programs we have available at New York-Presbyterian Hospital. We've got inpatient and outpatient services. We have a partial hospital program. We have a number of things that really do specialized focus on the needs of individuals with eating disorders. And in that way, we are one of a few medical schools that really do have an extended set of services across the Weill Cornell and Columbia Medical Schools associated with New York-Presbyterian Hospital.

Suzanne Straebler, PhD: Absolutely. I think we're really unique in that we are able to provide that full continuum of care. We're on the nyp.org website eating disorders. And it describes our inpatient specialist eating disorder unit, our day program, and our outpatient clinic. And in addition, we have different national and international organizations. One in the US that I think is really helpful is NEDA our National Eating Disorder Association, and you can find their information at nationaleatingdisorders.org. FEAST, F-E-A-S-T, which is families Empowered in Supporting Treatment of Eating Disorder. There's a lot of information there for carers, as well as families who are offering support.

And one other I just want to point out is FEDUP-- F-E-D-U-P-- Collective. It's Fighting Eating Disorders in Underrepresented Populations. And again, a lot of really useful information on there for individuals who are in underrepresented or underresearched areas in terms of getting additional information.

Dr. Daniel Knoepflmacher: We have all of those resources up on the page so that people can find direct links. Evelyn, Suzanne, I can't say how grateful I am to the two of you for speaking on this topic. I mean, honestly, I'm leaving this with so many more questions as I'm sure many listening are, but I hope that we can collaborate on other ways to educate the public separately.

But really, thank you for teaching so much about this really important topic that I think is often misunderstood, and for all the work you do at the New York-Presbyterian Center for Eating Disorders. Just thank you for taking the time and speaking with me today.

Evelyn Attia, MD: Well, it's been a pleasure to speak with you and we're always so interested in getting the word out and letting more people know.

Suzanne Straebler, PhD: Thank you so much.

Dr. Daniel Knoepflmacher: Well, thank you and thank you to all who listened to this episode of On The Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. As I'm sure many of you know, our podcast is available on every major audio streaming platforms. You know what they are, and you can find us on them. If you like what you heard today, please give us a rating and subscribe. That way, you can stay up-to-date with all of our latest episodes. And tell your friends they should be learning about all these important topics just like you. We'll be back again next month with another episode. And until then, I'm wishing you good health in body and mind.

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