Monday, July 6, 2009
Eating disorders such as anorexia nervosa and bulimia nervosa are damaging to the body and in some cases, are life threatening. We'll talk about the causes of eating disorders and the latest treatments to help people who suffer from them.
MAUREEN CAVANAUGH (Host): I'm Maureen Cavanaugh. You're listening to These Days on KPBS. If you want to get an idea of our culture's mixed messages about food and appearance, just watch television. The commercials tell you to eat, and eat and eat while the TV shows star very thin people. It may be fair to say, in such a conflicted atmosphere, many of us, especially many women, have odd eating habits. Sometimes we eat too much, sometimes not enough. But when you take these mixed messages to the extreme and add in a variety of personal mental health issues, then doctors say we can get ourselves into some serious trouble. People who suffer from the self-starvation disorder, anorexia nervosa, have the highest rate of death of any psychiatric illness. Then there's the binge and purge syndrome of bulimia, and, another disorder receiving attention these days: binge eating. Researchers say we are now beginning to understand more about why people develop these disorders, and that is leading to more effective treatment. Which is very good news, because when these eating disorders really take hold, they are extremely damaging to the body and very difficult to cure. My guest this morning to talk about eating disorders is Kerri Boutelle. She is Professor of Psychiatry and Pediatrics with UCSD's Eating Disorders program. And, welcome, Kerri.
DR. KERRI BOUTELLE (Professor of Psychiatry and Pediatrics, UCSD Eating Disorders Program): Thank you.
CAVANAUGH: And we'd like you to join the conversation. We'd like to hear your thoughts on eating disorders like anorexia or bulimia. Maybe you know someone who has these disorders, maybe you've struggled with them yourself. Give us a call at 1-888-895-5727, that's 1-888-895-KPBS. Now, Kerri, I did my best with the definition but I think you should really clarify and explain what is an eating disorder?
DR. BOUTELLE: So there are three main categories of eating disorders. These are all the three that you just mentioned. The first is anorexia nervosa and that's people typically think of as an eating disorder. It's where someone maintains a weight that's lower than is safe for their health, and we have a lot of technical descriptions for these but it's less than 85% of what you should be for your age and height. They often have body image disturbance where they see themselves as being bigger than they actually are. They have a fear of weight gain and in then, in addition, they have amenorrhea where they lack their menstrual periods. So that is the typical definition of anorexia. For bulimia, it's the usual binge-purge cycle that you mentioned before. But I do want to point something out, that binging can be either perceptions of binging, like feeling out of control, or actual overeating. And both of those are important components when you talk about mental health, especially the perceptions of feeling out of control. In addition, people often think about bulimia as including vomiting but it also can include over-exercising and other methods such as diet pills, laxatives, any way that someone tries to get rid of calories. And then the last category that you mentioned is called binge-eating disorder. This includes all the same binge features that we see in bulimia nervosa, including feeling out of control and overeating, but it doesn't include the purging part. But may I say that these three categories encompass a percentage of people but there are also people that share a lot of these features that are still impaired by their eating disorder symptoms even if they don't fit exactly into one of those categories. That's actually the group of people that we see a lot of times in outpatient treatment.
CAVANAUGH: Right, because, as I said, you know, there are a lot of people that perhaps aren't – don't fit in the clinical definition of what these disorders are but have really crazy eating habits…
DR. BOUTELLE: Umm-hmm.
CAVANAUGH: …you know, and I'm wondering, when should those little red lights start going off in your head about, you know, this is not just me, oh, skipping a meal or, you know, doing something a little strange. You may be eating a little too much on the weekends. But this is a real problem.
DR. BOUTELLE: Umm-hmm. And this has been a discussion in the community for a long time about the difference between disordered eating and eating disorders. And I think the take-home message is that it's very normal for people, unfortunately, to talk about weight and eating, especially at like dinner parties or on the weekends, maybe over…
DR. BOUTELLE: …this 4th of July weekend.
DR. BOUTELLE: Oh, I ate too much, that kind of stuff. It's when it starts to impair your functioning. So we often ask people, you know, out of a hundred percent of your day, how much time do you spend thinking about eating and weight? And if that's a pretty high number, then it's impairing your mental health functioning. The other way we'd look at an eating disorder is if it's impairing your physical functioning. If someone's not eating enough or purging so much that they're tired and can't go to class or can't make it to their job or any one of those things, or even, in fact, if they're just purging at all, it can really move into that realm of eating disorders. And so that's the way that we really think about it.
CAVANAUGH: I'm speaking with Kerri Boutelle. She is Professor of Psychiatry and Pediatrics with UCSD's Eating Disorders program. And we'd like to invite you to join the conversation about eating disorders. If you have a question or a comment, if you've been through this sometime in your life, if you're struggling with it right now, give us a call at 1-888-895-5727. And what percentage of people have eating disorders like anorexia or bulimia?
DR. BOUTELLE: If you look at the prevalence rates in the population, it's fairly low. It's about one percent of the population has anorexia and about two to three percent has full bulimia nervosa. Again, though, when you look at college populations 20 to 30% of freshmen women have disordered eating.
DR. BOUTELLE: And, again, when that crosses from disordered eating to eating disorders is really where it becomes a problem.
CAVANAUGH: Is that – In high school and college, is that where this usually starts for people?
DR. BOUTELLE: The majority of people – I think it's over 90% of people who have eating disorders are between the ages of 12 and 25. The problem is if it persists, it can go on for a lifetime. And so it's important to get treatment early.
CAVANAUGH: And I'm wondering why? Why does it start at that age?
DR. BOUTELLE: So there are lots of different reasons. The main way of thinking about it today is that there's a genetic susceptibility, that there's a predisposition to a temperament or a biological predisposition to develop these disorders and then, ultimately, expression comes from environment, whether it be home or emotional environment with peers or friends, etcetera, that really cause, in so many words, the gun to be pulled. And so you can have a predisposition but not develop the disorder but it's rare – it's probably very unusual to – for someone to be the opposite, for not to have the predisposition.
CAVANAUGH: Really? So the current thinking is that there's a certain genetic element to this? Because for a long time, we have heard that, you know, it's teenage girls trying to assert control over their lives, they're overachievers and they feel as if they have no control and their eating is the only thing they have control over. Where does that whole psychology go now with the idea of genetics put in?
DR. BOUTELLE: Well, what you're describing is a genetic predisposition.
CAVANAUGH: Oh. Oh, okay.
DR. BOUTELLE: Somebody who has the traits of perfectionism or worries about body image and weight. Maybe they have a history of anxiety in their family or depression or substance abuse, those are kind of the three top things we look for. But what you're talking about, that personality type, is something that we believe is genetically predisposed.
CAVANAUGH: I understand now. And what about that breakdown between female and male? Many more women than men, is that it?
DR. BOUTELLE: Almost always but today we're seeing more and more males and it's not as uncommon as you would think. And sometimes it's hidden in different subgroups such as people that are in professional sports that are focused on weight, etcetera. But the older numbers used to be 90% of all eating disorders are females and about 10% are males. Those numbers are starting to shift where we're starting to see more males but still the predominant gender is female.
CAVANAUGH: And are there any ethnic differences?
DR. BOUTELLE: There are and there are also socio-economic status differences. The majority of people – again, it's thought of, a disorder of the white, middle class, upper class group. However, we see people in the clinic from all ranges of ethnicities and socio-economic status and so it's really, when you look at the research studies, it looks like a disorder of people of middle class or higher class but, truthfully, when you work in a clinic, you see a range of people.
CAVANAUGH: I'm speaking with Kerri Boutelle. She is with UCSD's Eating Disorders program. We're taking your calls at 1-888-895-5727. And let's take a call. Cynthia is calling from San Diego. And, good morning, Cynthia. Welcome to These Days.
CYNTHIA (Caller, San Diego): Thank you. I just wanted to thank you, first of all, for having a show like this, having struggled with eating disorders all through high school as well as college and my early working years. Started out being very anorexic and then as – after working with the nutritionist and gaining weight, you know, that often turns into bulimia and, you know, having struggled with that, I just want to encourage all the listeners to seek help from the community and support groups because there's so many ways to find a support group and to help change that perception because it really comes down to just the perception of the self and just being able to pause in the moment and start making very baby, baby steps, but sometimes when you're struggling with it, you can feel so lost and so helpless and hopeless as well, and I just want to -- You know, thank you for having a show like this and just encourage all the listeners to go and seek that support that's out there and available to them.
DR. BOUTELLE: And, Cynthia, it's Dr. Boutelle. I just wanted to say thank you for calling. What you're saying highlights a lot of the pieces that we see. First of all, that people really suffer with these disorders for a long time and so the earlier intervention, the better. And then the second piece that you mentioned is that you also can see switchover from one category of eating disorder to the other. Either way, if it begins to take up a large chunk of your life, it really can become a problem and, as you mentioned, you struggled with it from high school to college to working years. And it can really impair someone's ability to function. So I just wanted to thank you for calling in and saying that.
CAVANAUGH: Thank you very much, Cynthia, for that. I'm wondering, when parents are seeing their daughters and sometimes their sons struggle with eating issues, is there some way to intervene so that it's not just automatically brushed aside as, you know, I don't want to hear criticism from my parents? How is it – How can parents effectively intervene?
DR. BOUTELLE: So my specialization is working with teenagers and children in particular and I have to say that there are teachable moments…
DR. BOUTELLE: …in every day with children. And what parents really need to do is be mindful of that teachable moment because there are definitely times when the teenager will not listen to the parent but there are other times when the parent can come in with empathy and say, you know, I'm very concerned about you. You seem to be not going out with your friends, you seem to be falling behind on grades, what can I do to help? And really open up a discussion rather than say, oh, you have a problem, you have to go in. The other thing that we recommend is that parents learn as much as they can because there are lots of myths out there. There are tons and tons of myths. And there are lots of ways to get the correct information but there are tons of dieting myths and exercise myths that really can hurt someone's overall prognosis in the long term unless parents get kind of the clear cut answers.
CAVANAUGH: Can you tell us a couple of those myths that are widespread and perhaps interfere with an effective treatment?
DR. BOUTELLE: Umm-hmm. One of the most controversial, I guess, topics is this idea of what's called the female athletic triad where there's disordered eating and then they develop amenorrhea and they're often in sports that have weight-related focus. So…
DR. BOUTELLE: Gymnastics, ice skating, running, and there's a idea that – or there's a perception that lighter is always better. And when taken to the extreme, it can cause real physical problems. And the other piece that goes along with that female athletic triad is osteopenia or osteoporosis, meaning that their bones aren't storing as much calcium so, ultimately, they will have more brittle bones over time. And there was – there's a controversy around whether or not that's normal for women who are athletic. And in the last five to ten years, the Academy of Eating Disorders has gotten together with a number of different college and professional sports associations to say, no, women do, in fact, have to have menses even if they're intense exercisers.
CAVANAUGH: I see. And that doesn't necessarily improve their athletic performance if, indeed, they basically starve themselves?
DR. BOUTELLE: It can to a point. But, again, the physiological damage is long term and long lasting. And so, again, lighter is not always better. More energy and the ability to function with good nutritional status is probably more important to a female athlete than being thinner.
CAVANAUGH: Let's take another call. We are taking your calls, by the way, at 1-888-895-5727. And Brandon is on the line in Encinitas. Good morning, Brandon, welcome to These Days.
BRANDON (Caller, Encinitas): Good morning. My question is related to the program's introduction. You kind of pointed out that media portrayals of bodies and body fat as well as food might contribute to eating disorders. And I'm wondering if eating disorders are a new phenomena or if there's historical precedent for these types of disorders? Or if they had been studied before modern media may have started causing these problems? I'm just curious about that correlation that was pointed out.
CAVANAUGH: Thank you, Brandon. That's very interesting. Is this a modern phenomena?
DR. BOUTELLE: Brandon, that is a good question. And while you were talking, I was thinking to myself, oh, that's clever because it really is a question almost of a chicken and an egg. So if you look at pictures of models from the early 1920s to today, I have this slide show where it shows that women just progressively get thinner and thinner over time. You know, in the 1960s, there was the Marilyn Monroe, who was much more voluptuous than models today. And then, as you mentioned, there are tons of focus on food in commercials, you can't watch television without finding some way to lose 20 pounds in 10 days. So all of that focus is true, and there is a lot of media hype around eating disorders. However, I do want to point out that the concept of eating disorders was developed easily close to a hundred years ago. And whether or not we're able to determine that there were more eating disorders now versus then might be a detection issue. We do believe that the media, along with the way our society has focused on eating and weight along with this, again, genetic predisposition, has contributed to this increase in eating disorders.
CAVANAUGH: Interesting. And is there any research on how America stacks up against the rest of the world in eating disorders? Is this an international problem or is it focused here?
DR. BOUTELLE: It used to be focused here. But the way we think about it today is that it's more focused on first world countries. There are a number of Central American countries that are having large difficulties with eating disorders. There's a couple of countries in Europe. It's not just the U.S. but it tends to be the countries that are first world.
CAVANAUGH: And I'm wondering, in the past if there eating disorders, probably they were centered around fasting for religious reasons, one would imagine, rather than for appearance. But in your study, you find in the last hundred years, they have to do with – simply with appearance and how the standards of beauty are changing for women.
DR. BOUTELLE: Again, I think there are multiple components to why we have more today than we might have a hundred years ago. If you do look, there's a large body of literature on the socio – the sociological pressures on women and men today. There's a large body of literature on that. There's a large body of literature on this genetic predisposition and the way your brain functions. In fact, we do a lot of that kind of key research at the UCSD research program. But either, you know, again, whether it's a detection issue or whether there actually is a larger prevalence, we do believe ultimately there is a larger prevalence today but there are multiple contributors. It's not just one thing or another.
CAVANAUGH: Not just one thing. We're going to continue our discussion about eating disorders with my guest, Kerri Boutelle, and we will continue to take your calls at 1-888-895-5727. Right now, though, we have to take a short break. You're listening to These Days on KPBS.
CAVANAUGH: Welcome back. I'm Maureen Cavanaugh. You're listening to These Days on KPBS. My guest is Kerri Boutelle. She's Professor of Psychiatry and Pediatrics with UCSD's Eating Disorders program. We are talking about eating disorders. Why – The causes and treatments of ailments like anorexia nervosa and bulimia and binge eating. And we're taking your calls at 1-888-895-5727. There are a lot of people who want to join our discussion. I do, however, want to start off because anorexia has been in the news lately as a possible factor in the death of singer Michael Jackson. And he's a 5'10" man. His weight was reported anywhere between 112 to 120 pounds. Is it ever healthy to be that thin?
DR. BOUTELLE: So you're bringing up a research controversy. But I will give you the main kind of lay discussion about this, is that when someone is that thin it causes a number of nutritional deficits in the body which can, in fact, lead to cardiac arrest at certain times. In fact, that's the ultimate risk for people that are low weight. There's a very small, small body of literature that suggests that people that keep their weight lower, not – again, it's a moderation issue, ultimately might develop less health issues over time. But I want to point this out that, you know, our population in general, our body sizes are moving up and so, again, the moderation issue is terribly important here. It's – Try not to be on either end of the spectrum.
CAVANAUGH: Let's take a call. Gary is in San Diego and he's on the line. Good morning, Gary. Welcome to These Days.
GARY (Caller, San Diego): Good morning and thank you for taking my call. I am a compulsive overeater and with the help of a support group have been able to maintain a normal body weight for over 20 years, so there is hope for people. I have encountered a person who is about 20 pounds under normal weight and when told about it by other people revels in the fact. So in a situation like that, what can an outsider do to encourage an adult to seek professional help?
CAVANAUGH: Thank you for that, Gary.
DR. BOUTELLE: Thank you, Gary. One of the things that we recommend for anybody, whether or not they have worries about weight-needing or not, is to, again, be a caring but firm friend. And talk – focus mainly on the health risks associated with keeping weight that low or the disordered eating behavior and not necessarily as much on the psychology unless there's some – your friend is willing to talk to you about how much it bothers them. But often what happens with people that are underweight, is that they think the rest of the world is crazy and that we're all making a big deal out of nothing. And so it's often hard to be that caring and supportive friend. But the main thing, again, is to learn as much as you can and provide education to your friend and during those moments where you're having an honest and empathic conversation, bring up your worries for that person.
CAVANAUGH: Let's take another call. Christy from Del Mar. Good morning, Christy. Welcome to These Days.
CHRISTY (Caller, Del Mar): Hi. Thank you for having this discussion. I have a ten-year-old friend that's coming to visit me at the end of the summer and she is severely underweight. Her parents are going through a nasty divorce and she's a very, very picky, controlled, finicky eater. And I have two children about the same age—they're boys—and they eat anything that doesn't eat them first. So how do I provide for the needs of my visitor without making her anxious but, on the other hand, not teaching my boys that it's okay to be cranky about what you're putting in your mouth?
DR. BOUTELLE: So that's a very interesting situation. But let me say that, first of all, a lot of eating disorders develop during times of stress or transition. And so we often see these things when there's a significant stress in the home or when children are transitioning from one school to another, such as like 6th to 7th grade or going into high school or going into college. You know, these stressful moments in a child's life are often – can be a predisposing factor to eating disorders. Let me say that if your boys eat, what did you say?
CAVANAUGH: Anything that won't eat them.
DR. BOUTELLE: Anything that won't eat them, their chances of developing picky eating are really low. Again, remember that there are multiple contributors to why someone develops picky eating or disordered eating or, ultimately, an eating disorder. And if your boys are not plagued by some of those predisposing factors, their chances of getting it are low. Now all of that said, my thought would be as a caring adult in the ten-year-old's life, it's important to pay attention to how much she is, in fact, eating. And, ultimately, the parents are going through a very stressful period but anything you can do to help them help her will probably help everyone in the long run.
CAVANAUGH: Now Kerri, you are presently conducting a study about pediatric eating disorders, is that right? Tell us about that.
DR. BOUTELLE: Yes, we are. We have a series of no-cost treatment studies going on right now at UCSD. In fact, we're doing an anorexia study which provides family therapy for teenage anorexics and their families. Everybody in that study gets treatment so they don't get randomized to drugs or something else but they get full treatment for nine months for no cost. And what we're looking at are two different kinds of family therapy but both are expected to help the patient in the end. And so, ultimately, we just want to make sure that people know about the study since it is such a rare disorder but it is a way of getting kind of cutting edge treatment today.
CAVANAUGH: And I want everybody to know you can find out more about that later today at These Days – I'm sorry, at our website, KPBS.org/TheseDays. What kind of treatment is available now for people who have anorexia or bulimia?
DR. BOUTELLE: So we use what's called a stepped care approach, in so many words. And one of the earlier callers had talked about doing pretty well with a nutritionist, so often people start off with a nutritionist or physician. When we're talking about adolescents, it's usually a physician or a teacher that brings it to the eyes of the parents, or the parents notice it and talks to their medical care providers. One of the kind of first steps of treatment is outpatient care where someone comes to a multidisciplinary treatment that includes psychiatry, medicine, nutrition and psychology, and can come once a week or every other week, depending on how well they're doing and how well they respond. The next step up from that is a more intensive program. At UCSD, we have an intensive outpatient program which is nine hours a week where people come and have meals with us. The step up from that is called a day treatment program where someone comes all day. Ultimately, there are two additional steps, one where if somebody develops medical issues they end up in the hospital and staying overnight. And then, ultimately, for people who don't respond to any of the kind of simpler steps, they can go to residential treatment where people actually live there for treatment.
CAVANAUGH: I see.
DR. BOUTELLE: So there are these large steps. When we talk about options for psychotherapy, there are individual treatments that are recommended for adults that are fairly well tested. Cognitive behavioral therapy is one of them, interpersonal therapy is the other. We often couple them with medications if appropriate because some of the studies have suggested, in particular for bulimia, that medication plus therapy can do better than either alone. For kids, though, there is a new family-based treatment which is part of what we're testing at UCSD and the outcome rates are so much better than individual therapy that it's hard to kind of do individual therapy today when you know that family therapy outcomes are so good. And, truthfully, kids live in the home, they live with their parents, it makes sense to integrate the family into the treatment of the child's psychiatric disorder.
CAVANAUGH: Let's take another call. Heidi is in San Diego. Good morning, Heidi. Welcome to These Days.
HEIDI (Caller, San Diego): Thank you. Thank you for taking my call. Yeah, I'm a licensed acupuncturist in San Diego and I just wanted to make the comment that acupuncture is actually an effective therapy, an adjunct to other treatment.
CAVANAUGH: For what kind of eating disorders?
HEIDI: For bulimia and anorexia.
CAVANAUGH: Okay, well, thank you for that. Kerri, have you found that to be effective?
DR. BOUTELLE: So our treatment program right now does not use acupuncture. There are treatment programs around the country that have used acupuncture and other versions of alternative medicine. I am never going to say that something does not work. But what I can tell you is that as of today, I don't know of any randomized studies that have tested it.
CAVANAUGH: You know, I think a lot of people see youngsters, young people, struggling with these issues and there's a tendency, I think, unless it's an extreme case to say, well, you know, he or she will grow out of it. And do you find that that, indeed, happens? That people just have a certain eating disorder when they're younger and they just get older and they lose it?
DR. BOUTELLE: So there are people who recover on their own, you know. We don't know exactly what those numbers are because these are very difficult disorders to look at just in general because there's a secretive nature to most of them. So there is – there are people that recover on their own. On the other hand, again, remember the spectrum of kind of disordered eating, unhealthy eating, and, ultimately, eating disorders, and where someone falls on that spectrum. My perception and clinical intuition is that somebody who's lower level on the disordered eating spectrum, so somebody who tests out purging or who tries dieting a bit really does have a chance of potentially growing out of it but when it moves along the spectrum into taking up more of their day, impacting their physical health, impacting their physiological health, not as many people get better on their own.
CAVANAUGH: Well, let's take another call. Marilyn is at – Marilyn is in San Diego, and good morning, Marilyn.
MARILYN (Caller, San Diego): Thank you. Good morning. Years ago I read a theory that I'd like to have you comment on. And it is that the change in women's bodies in the media during the 1960s was caused by men being threatened about the increased powers that women were getting with the feminist movement. I think that's probably true. What do you think?
CAVANAUGH: Thank you for that, Marilyn.
DR. BOUTELLE: That's an interesting theory and I've certainly read a bit about it. I don't know enough about it to comment well enough but I can say that there is a period of physiological development for women that is thought to compound the risk of eating disorder in addition to the socio-cultural pressures, so those two really fit in with what you're discussing about this idea of the sixties women starting to change and becoming more independent and more powerful and, thus, kind of conflicting some of the psychiatric processes that might go on.
CAVANAUGH: You know, we are coming up to the top of the hour and I do want to ask you, you do a lot of work about binge eating.
DR. BOUTELLE: Umm-hmm.
CAVANAUGH: Kids who just eat too much.
DR. BOUTELLE: Umm-hmm.
CAVANAUGH: And I wonder what the – is there some sort of psychological link between all of these eating disorders, between people who starve themselves and people who eat too much in this binge eating? Is there some sort of link between these disorders?
DR. BOUTELLE: That's a very complicated question to ask me at the end of the hour.
CAVANAUGH: I'm so sorry.
DR. BOUTELLE: That's okay. I'll give you the short version. We know that there are certain parts of the brain that respond to what's called reward. And for some of these kids that I work with, we say that they eat in the absence of hunger, binge eat. But kids don't really understand what binge eating is so it means that they're not responding to physiological hunger, they're just eating because it's there. When you look at people that eat that way, there's a possibility that the – the parts of their brain that respond to reward maybe feel better when they eat versus people that don't respond that way. We also know that people with anorexia are on the other end of the spectrum, that can turn down their hunger, that don't feel hunger, that are able to kind of resist physiological impulses. And these parts of the brain are thought to play a role in many of these different disorders. Again, this is kind of cutting edge research using magnetic brain imaging, and it's hard to really say yes or no but we do believe that, again, the predisposition, the brain functioning, are things that relate to these eating and eating disorders and disordered eating.
CAVANAUGH: And one of the things that I was sort of – it's troubling to learn that the frequency of binge eating among young people seems to be increasing.
DR. BOUTELLE: It is and, again, maybe it's a detection issue. But some of the studies show that up to 30% of overweight children who present at clinics have some version of binge eating. And, again, for children, in particular, binge eating is different than in adults. If you ask a ten-year-old child if they feel like they're out of control, it's really hard for them to say that. But we look more at their behaviors and this idea of kind of constantly grazing and constantly eating. That really helps us detect who are the kids that are at risk for gaining weight over the long term because of their eating patterns.
CAVANAUGH: I want to thank you so much for talking with us. This is such a wide-ranging topic and you've done such a good job…
DR. BOUTELLE: Thank you.
CAVANAUGH: …explaining it to a lay person.
DR. BOUTELLE: Thank you.
CAVANAUGH: I've been speaking with Kerri Boutelle. She's Professor of Psychiatry and Pediatrics with UCSD's Eating Disorders program. I also want to thank everyone who called. Sorry we couldn't get to everyone. Please do call again on another topic. And you can get the UCSD Eating Disorders program link by going to our website at KPBS.org/These Days. Stay with us for hour two coming up in just a few minutes. You're listening to These Days on KPBS.