Provider News

Treatment for Eating Disorders: A Q&A and Case Study by Robyn Evans, ARNP

March 2, 2022

Robyn Evans, ARNP, is the lead nurse practitioner for Seattle Children’s Eating Disorders Clinic. She attended Yale University School of Nursing and has been at Seattle Children’s since 2013.

Q: What changes has Seattle Children’s seen during the pandemic in eating disorder referrals? 

Referrals for eating disorders have grown fourfold at Seattle Children’s in the last two years. The increase in number and severity of eating disordered patients began during the pandemic’s first summer (2020) and continues to this day. This comports with what has been reported in the medical literature over the last two years. Studies from the University of Michigan and Boston Children’s Hospital all published similar results demonstrating at least a doubling in the numbers of patients seeking care for treatment of eating disorders.

Citations:

Otto, AK, Jary JM, Sturza J et al. Medical Admissions Among Adolescents with Eating Disorders During Covid-19 Pandemic. Pediatrics. 2021; 148(4).

Lin, J, Hartman-Munick, S et al. The Impact of COVID-19 on the Number of Adolescent / Young Adults Seeking Eating Disorder-Related Care. Journal of Adolescent Health. 69 (2021); 660 – 663.

Q: How is the Eating Disorders Clinic keeping up with the high demand for services?

We have adapted our care model at Seattle Children’s to stretch resources to more patients. Beginning January 1, 2022, all patients referred to Eating Disorders with a complete referral are being offered a one-time telehealth visit with the option to join a waitlist for ongoing care based on fit of services and family interest. A complete referral must be submitted before we schedule a visit:

  • New Appointment Request Form (PDF) (DOC)
  • Orthostatic vital signs with resting heart rate – within the last 14 days
  • Weight and height – within the last 14 days
  • Growth charts
  • Labs (CBC, ALT, T4, TSH, electrolytes, BUN/creatinine, calcium, magnesium, phosphorus, sed rate) – within the last 30 days
  • EKG within the last 30 days

By transitioning to time-limited care models, our goal is to reach more families in the communities we serve.

Q: Does the telehealth visit include the patient and parent(s)?

Yes, both the patient and parent(s) attend the telemed consult. The patient may meet confidentially with the provider for a portion of the visit.

Q: How does the one-time telehealth visit work?

Once a complete referral is received, patients and families are scheduled for a 60-minute telemedicine consultation with a physician or advanced practice provider/ARNP who will discuss family and patient concerns, eating disorder symptoms and behaviors and will review supporting documentation that was provided in the referral. The family will receive an initial assessment including diagnosis, recommended treatment plan and community resources to help support their teen. These will also be forwarded to the primary care provider after the visit.

The adolescent medicine provider will coordinate with our social work team to provide additional resources such as school accommodations, supervised school lunches and parental supports such as employment accommodations (i.e., FMLA) and caregiver educational supports such as Seattle Children’s caregiver meal support class. Resources are also provided to help families find dietitians and therapists with eating disorder treatment experience.

Q: Do families meet with a social worker?

We’ve made some recent changes to the social work portion of the visit. Instead of scheduling a separate visit between the social worker and patient/family, our social work team primarily uses MyChart messaging to provide families with written resources.

Q: What is the biggest obstacle to a patient being seen quickly?

We would really like to emphasize we are unable to offer consultation for incomplete referrals that do not include required supporting clinical documentation (as listed on the Eating Disorders’ Refer a Patient page and in the bullets above).

Resources

Seattle Children’s Eating Disorders Website – Referral information and instructions

“Eating Disorders in Children Increased During the Pandemic,” Verywell Mind, Feb. 22, 2002, featuring Dr. Yolanda Evans, clinical director of Seattle Children’s Adolescent Medicine.

Condition-specific resources

Treatment-specific resources

Outside facilities with expertise in the management of eating disorders

External Links

Case Study: Eating Disorder in a 15-Year-Old Female

Author: Robyn Evans, ARNP, Clinical Lead for Outpatient Eating Disorder Care at Seattle Children’s

Date: March 2022

Summary: A 15-year-old female with an eating disorder is referred to Seattle Children’s. After evaluation, the patient and her family receive education, social work consultation, care instructions and safety planning to support them while they wait for an opening in the eating disorders outpatient treatment program at Seattle Children’s or elsewhere.

Patient History: The patient is a 15-year-old female with 15 months of weight loss. She is referred for telemedicine evaluation for an eating disorder due to accelerating rate of weight loss. She reports food restriction and food group elimination (carbohydrates) in the setting of increased levels of physical activity after she transitioned to online school at the beginning of the COVID-19 pandemic.

The patient experienced menarche at the age of 14 years and had approximately six consecutive monthly menses until they ceased 12 months ago.

Total weight loss is now approximately 20% of prior body weight.

Labs show increased CO2, low white blood cell count and iron deficiency anemia. EKG is normal except for bradycardia.

The review of systems is positive for the following: fatigue, dizziness with standing, generalized abdominal pain (worse after meals), constipation, amenorrhea, cold intolerance and hair loss.

The physical exam includes vital signs collected by the PCP two weeks ago (HR of 49 bpm with orthostatic tachycardia). During the telemedicine visit the patient is withdrawn and irritable.

Current nutritional intake includes two meals a day of two servings and one snack a day of one serving. Beverages are water only. The patient demonstrates extreme rigidity when discussing nutrition choices, sharing that she feels her food choices are “very healthy” and she will not consider making dietary changes due to fear of weight gain.

She reports an increasing number of minutes of physical activity a day, which includes getting up early in the morning to do YouTube exercise videos and running for up to an hour after school each day.

The patient earns a 4.0 GPA at school. Parents report homework is now taking significantly more time to complete as compared to before onset of weight loss. They also observe their daughter isolating herself in her room. Her social media interests revolve around nutrition and exercise. Parents observe she downloads activity and calorie tracker apps onto her phone.

Parents tried to encourage their daughter to eat more and exercise less. They are unable to provide adequate support when she becomes emotionally upset. They feel the only way their daughter can manage low mood is through exercise.

During her confidential interview the patient shares that she is struggling with passive suicidal ideation and that her only reason to live is to participate in track this spring. The teen reports no history of gender identity concerns or sexual activity. She denies all substance use.

Patient Diagnosis:  The patient’s symptoms support a diagnosis of anorexia nervosa.

Treatment/Discussion:  Eating disorders are mental health diagnoses with physiologic consequences, which can be fatal.

Best outcomes for adolescents with eating disorders are seen when patients have a multidisciplinary team consisting of a therapist, medical provider and dietitian. The therapist aids in management of the intrusive eating disorder thoughts. Dietitians support parents and teens in implementing adequate nutrition at home on a schedule that promotes recovery from malnutrition.

Given her bradycardia, the patient is advised to follow up with her primary care provider weekly to assess for need for hospitalization if her heart rate decreases to less than 45 bpm per the Seattle Children’s Refeeding Guidelines (see link in references below). Reasons to go to the Emergency Department are reviewed with the family. The PCP is recommended to order a DEXA bone scan to further evaluate for low bone density due to prolonged amenorrhea.

The family is counseled that an eating disorder is a mental health diagnosis with significant medical consequences. The importance of establishing care with a therapist and dietitian is emphasized. Social work is consulted to offer parents support in building their daughter’s treatment team. Education is provided on the effects of prolonged starvation on adolescent growth and development. Strict guidelines regarding the importance of physical rest and abstaining from all exercise are discussed.

Safety planning was completed alone with the teen and shared with her parents along with resources including the Crisis Text Line.

Reassurance was provided that abdominal symptoms will likely resolve with increased nutritional intake.

Parents are referred to Meal Support class (available twice weekly on Zoom at Seattle Children’s) to learn more about effective feeding strategies at home. The patient is offered a spot on the waitlist to receive 12 weeks of in-person medical monitoring in the Outpatient Eating Disorder Program (OPED).  Community providers are welcome to request reevaluation via telemedicine in the 90 days after the initial evaluation.

References: