Q&A

FBT is more than just a weekly nutrition visit. Here is what’s included:

• Interdisciplinary care team coordination: weekly check ins with your child’s therapist and medical doctor to align on plan of care and weekly goals across modalities

• Expert weight assessment: target weight calculations using the most up-to-date, evidence-based clinical practice, developed by leading eating disorder professionals

• Digestible weekly goals: specific, measurable, and achievable weekly nutrition and calorie goals, developed collaboratively with you

• Skill development: teaching and deployment of CBT, DBT, ACT and exposure therapies to use during feedings, taught in tandem with your therapist

• FBT parent coaching: 1:1 coaching where we discuss strategies to navigate your most challenging meals, and tactics to alleviate your child’s emotional dysregulation at the table

• Leadership: guidance and a steady hand to steer you to your long term goals (weight restoration, recovery) through a series of weekly short term goals

FBT is the gold-standard treatment for adolescent eating disorders, in which the parents play an active role feeding at home to allow the child to weight restore and recover. Parents lead in the FBT space, with expert counsel provided by the child’s therapist, dietitian, and pediatrician. I am a firm believer in keeping children at home whenever possible, to reduce disruption and trauma during their treatment, but also because parents typically have more leverage during the recovery process compared to a treatment center. FBT is likened to a Residential Treatment Facility level of care given the level of supervision required at meal and snack times. There are three phases:

• Phase 1: This phase focuses on nutritional rehabilitation, weight recovery, and medical stabilization. Parents increase calories and thus weight regularly, adding in exposure challenges to broaden the child’s variety of acceptable foods. In this phase, you should expect to meet with me on a weekly basis to assess progress to goals, offer coaching on meal/snack exposures, target nutrients of concern, and monitor GI and other physical symptoms. In Phase 1, I typically spend ~75% of time in sessions 1:1 with parents, bringing your child in at the end of session for a brief touch base. This is because the responsibility of feeding falls 100% on parents in this phase.

• Phase 2: This phase focuses on the gradual return of age- and developmentally-appropriate responsibility and freedom back to the adolescent. This can look like finally allowing the child a choice between 2-3 options at snack time, or perhaps allowing the child to plate herself during a family meal (with redirection and correction offered by you). During Phase 2, I will gradually taper 1:1 time with parents to add more time with your child, often splitting the time 50/50. Weight restoration and maintenance must be achieved before a child can advance to Phase 2.

• Phase 3: This phase focuses on independence. During Phase 3, the child’s weight is stable and their eating disorder behaviors are extinguished. The child is then able to reclaim much of the food freedom they lost in Phases 1 & 2. At this time I will meet 1:1 with with your child, but can be available for parental check ins ad hoc and when requested.

Eating disorder treatment is extremely difficult, and FBT is no exception. And while challenging, FBT can be lifesaving. It has been the greatest joy of my career to watch kids with debilitating eating disorders find success in recovery through FBT, return to their their sports and their friends, and go on to live full lives.

When your child is undergoing nutritional rehabilitation, otherwise known as “refeeding,” at the beginning of their recovery journey, you can expect many physical, mental, and emotional changes.

As we begin the refeeding process, kids with eating disorders often report feeling overly full and uncomfortable. This is completely normal, and a sign that their bodies, while previously in “hibernation mode” during starvation, are starting to receive the nutrients they need. Gastroparesis, or slowed stomach emptying, can develop, but typically resolves itself in a few weeks or months with adequate nutritional intake. As we ramp up calories we start to see signs and symptoms of hypermetabolism, including hot flashes or night sweats, even if the child used to run cold. Digestion which was previously sluggish starts to ramp up, with symptoms like bloating and constipation resolving. During this critical time, close medical monitoring of lab electrolytes may be necessary, along with oral repletion with vitamin supplements, which is why it is essential you have established care with a pediatrician or primary care physician.

In addition to a wide array of physical changes, kids often experience mental and emotional changes during refeeding. I will be available to support you through these changes, along with the rest of your care team, to ensure symptoms are managed and your child is appropriately monitored and safe.

Success with FBT is measured in a myriad of ways. Recovery is often a constellation of the following areas:

• Weight restoration: the first measure of success is recovery to your child’s target weight range. This tells us they are back to growing along the growth curve they were at before their eating disorder started. This is where catch up growth can begin to occur if their eating disorder caused height suppression.

• Return of regular menses: the return of your child’s menstrual period is an important milestone on the return to health

• Decreased eating disorder behaviors: your child is no longer restricting, bingeing, purging, hiding food or using other ED behaviors.

• Reintroducing challenge foods: your child is able to eat fear foods, visit restaurants, and try new things, even if they feel anxiety. They have more flexibility around food, which allows for an expanded variety of acceptable foods.

• Coping at the table: your child has a toolbox of skills they use to emotionally regulate at the table, which enables them to finish even the most challenging meals.

• Independence with food: they demonstrate independence with eating, and no longer require adult supervision during meals and snacks.

• Weight maintenance at goal: your child is able to maintain a stable weight within their target weight range. Occasionally their weight might fluctuate, but if they happen to fall out of range, they are amenable to increasing portions to get back on track.