Identifying and Preventing Eating Disorders

online conference transcript

Transcript from online Conference with: Holly Hoff on "Identifying and Preventing Eating Disorders" and Dr. Barton Blinder on "Understanding and Working Through Your Eating Disorder"

Bob M is the moderator.

BEGINNING

Transcript: Eating Disorders - anorexia, bulimia, compulsive overeating - identifying signs and symptoms, prevention, treatment.Bob M: Good evening everyone. I'm Bob McMillan, the moderator. I notice some new people here tonight...and I want to welcome everyone. As you know, this is Eating Disorders Awareness Week. We are doing many conferences on our site this week and you can find the schedule link at the entrance to the chatrooms when you log on. Our first guest tonight is Holly Hoff. Holly is the program coordinator for Eating Disorders Awareness and Prevention Inc. It's a national non-profit group based in Seattle, Washington. EDAP is dedicated to increasing awareness of eating disorders in general and also the prevention of them. Good evening Holly and welcome to the Concerned Counseling website. I'd like to cover two specific topics that we get questions on all the time. The first one is prevention of an eating disorder. Is that possible?

Holly Hoff: I'm glad to be here tonight. Prevention is a main part of our business. Prevention and early detection are keys to working towards eliminating eating disorders altogether. We have programs at the elementary, high school and college levels that are aimed at awareness just for that reason.

Bob M: So how does one go about specifically preventing having an eating disorder.

Holly Hoff: We feel it's important for people to have correct information about some of the unlying causes of eating disorders. It's important to consider social, family, emotional, and physical elements. Each can lead to an eating disorder.

Bob M: What is the leading cause to developing an eating disorder?

Holly Hoff: We don't have a definite answer on that. Research is being done right now. It starts for some as a result of physical, sexual, or emotional abuse. For others, it's pressure to be thin. It could be a result of feelings of inadequacy, depression, and loneliness. Troubled family and personal relationships can also play into it. One cause we work to fight is the social ideal of a perfect body, unrealistic images of beauty.

Bob M: I see more people coming in. We are talking with Holly Hoff, program coordinator for Eating Disorders Awareness and Prevention, Inc. When do most people start experiencing an eating disorder? At what age? (eating disorder facts)

Holly Hoff: There are two typical ages of onset. Adolescence and then 18-20 years old. But they can certainly happen at anytime in a person's life. The earlier periods tend to be times of major change in a person's life. Change can often cause stress and eating disorders are often more than just about food. They can be reactions to difficult times in a person's life. These are also times when a person's body changes. That's a scary thing for some teens and unfortunately we're not often taught to expect or appreciate those changes and growth.

Bob M: I know we have some parents here tonight and friends of people who may be experiencing or starting to experience an eating disorder. What are they supposed to do to help?

Holly Hoff: It's important for them to learn about eating disorders. One way to do that is by calling our office at 206-382-3587 and we will send them eating disorders information. It is also important for these people to find support for themselves because it can be a difficult experience emotionally...dealing with someone who has an eating disorder. Express concerns in a calm and caring way. Encourage the person struggling to take responsibility for their actions and seek help for eating disorders. You can also be a good role model about food, weight, and body image issues.

Bob M: Now what do you mean by, be a good role model?

Holly Hoff: Avoid speaking negatively about their own bodies. Eat a variety of foods and eat in moderation and exercise for fun rather than strictly out of a sense of obligation. Avoid concentrating too much on other people's physical appearance, including size and shape.

Bob M: One other thing I want to add to that is, try and be non-judgmental and supportive. From talking with the many visitors on our site with eating disorders, that is something they really struggle with. They complain that their friends and relatives constantly criticize them for their eating disorder, rather than being supportive and helping them find the help they need. I know one of the visitors here refers to her boyfriend or husband as the "food cop"...always monitoring how much she is or isn't eating. So Holly, how does one approach someone with a suspected eating disorder with their concerns?

Holly Hoff: Honesty is important. I agree, being the "food cop" doesn't work. It forces many people into secretive eating. That is really counterproductive. Then they start lying about their situation. Express concerns and caring. Use statements like "I've noticed", "I see", "I feel". But remember, the person struggling with an eating disorder must take responsibility in order to change their behaviors.

Bob M: Here are some comments from the audience and then I'll post a few audience questions for Holly to answer.

Scout: One way of helping prevent eating disorders, in the thin sense, is do away with the thin models and use people with normal bodies.

Jo: Bob -- the person struggling must take responsibility -- very true -- but you aren't speaking to the fact that these problems were given to us as we were growing up. When do parents recognize they are doing these things to their children?




Maigen: My mom doesn't ask me much about my eating disorder, but when she does, she is bribing me to stop. One time she offered me a car if I'd stop. How do I explain that I would stop for her and for myself if I could. She certainly has no clue and there is no support or help around where I live. Are there any certain books I could ask her to read? Anything?

Holly Hoff: Jo, that's why we are trying to educate people of all ages, so that parents can help their children. Young people and adults need to realize their comments and behaviors affect others. This is what I mean by "parents modeling healthy attitudes and behaviors." Maigen, I am having my assistant grab a reading list and I'll get to your question in a few minutes. One thing that might help is a newsletter we put out. You can get that by calling our office at 206-382-3587. It costs $15 for student memberships and $25 for the general public and $35 for professionals. Here are some of the books:

  • Surviving an Eating Disorder-Strategies for Family and Friends-by Judith Brisman
  • A Parent's Guide to Eating Disorders: Prevention and Treatment of Anorexia and Bulimia by Brette Valette.
  • And one of your audience members suggested: The Secret Language of Eating Disorders.

If anyone wants a longer list, we have a 3 page one we can send. Just call our office.

Champios: Wasted- by Marya Hornbacher is another one which gives a fairly accurate description of ed's.

Scout: Also, "The Best Little girl In the World," fictional work on anorexia.

Spiffs: I was wondering if there were any online screening tests to help determine what eating disorder you or someone you know has?(eating attitudes test)

Holly Hoff: Most of the online tests are listed "for your enjoyment only." It really takes a professional to make that assessment. Here's an 800- number for the National Screening Project and they are doing screenings this week all across the nation. 800-969-6642. And people can get more info on education at our website: http://members.aol.com/edapinc. The other thing we also tell people is that if you suspect that you, or a friend or relative has an eating disorder, then that's good enough reason to talk to a professional psychologist or psychiatrist about your concerns. Early detection is important for eating disorder recovery.

PegCoke: What can people without money do to help a friend with an eating disorder? I can't afford to make long distance calls, subscribe to newsletters, or buy books.

Holly Hoff: That's very difficult PegCoke. Because really to get professional treatment it takes either money or insurance, in most instances. You might want to try and get on medicaid through your local social services' office. We offer free information for anyone who needs it.

Rachy: What if your ED didn't just develop? I mean what if you knew what you were doing and MADE it come. I know that I played with a lot of ideas before anything stuck in.. I don't even know if I have an ED or if it just a phase.

Holly Hoff: The danger in eating disorders is that people may experiment with the behaviors. Unfortunately, they can quickly become habit and spiral out of control. I would encourage you to see a professional about your situation.

Bob M: We are talking with Holly Hoff, of Eating Disorders Awareness and Prevention. Dr. Barton Blinder will be here in about 15 minutes and we'll be discussing the latest treatments and research on the subject. Here's a few more audience comments...

Jane: Holly, I admire you for what you are doing. Somewhere and somehow it has to reach more people though because if the chain of dysfunction isn't broken it carries on and people don't seem to know how to be anything other than what they were brought up as.

Journey: I struggle with body image a lot! Any helpful ideas on how to work on seeing my body as others see me?

Bob M: Onto more questions:

Jrains: I understand that even in the medical profession, there is an ignorance about the severity and even existence of EDs. Where do you look for good professional help?

Holly Hoff: There are organizations jrains that can recommend eating disorder professionals, people with expertise in that area. The National Eating Disorders Organization-NEDO-is one. 918-481-4044. It is important to continue seeking a qualified professional, if one isn't a good fit, move onto another.

Bob M: And I want to add here, that a professional is someone who is a licensed Ph.D. psychologist or M.D. psychiatrist who specializes in eating disorders...not just knows about them. It is up to you to interview the doctor. And you have every right to do that. That's your money (whether cash or insurance) and health on the line.

Holly Hoff: I agree wholeheartedly Bob. There's another group called ANAD. 847-831-3438.

Bob M: And while I'm thinking about it...and the money angle...there are university and college research centers around the country. If money is a concern and you are serious about treatment, you might want to call around and see if you can get free, or low cost treatment, by participating in the program. By the way, Holly's group does not have an 800 number. I was getting some questions about that.

Holly Hoff: I'm not sure what you mean by the "optimal dose" but would suggest a trial of Adderall or Desoxyn.




Champios: So what is your best suggestion for those of us with eating disorders that are working on getting better on our own?

Holly Hoff: That's a very tough question. You might try support groups in your area. And as Bob mentioned, I would check on signing up for medicare if you can't afford treatment. And either NEDO or ANAD can give you the phone numbers for support groups in your area.

Bob M: Here's an audience suggestion on that champios...

Maigen: After my parents got divorced, my high school paid for my therapy. If you have a school psychologist, it is possible to get counseling therapy. You should check with your school counselor.

Jo: Bob and Holly -- this is all very well and true -- but a lot of young people don't get the help because 1st of all the parents do not let themselves recognize there is a problem and then many still have an old fashioned view that psychologists and psychoterhapy are something to be ashamed of. So they won't seek help.

Liz B: Also a lot of kids and teens do not tell their parents.

Bob M: That's a good point Liz. Holly, how does a child, or teen, confide in their parents without the fear of something "bad" happening to them?

Holly Hoff: It's definitely important to talk to an adult about what you are going through. For teenagers, getting help for an eating disorder will probably involve their parents finding out at some point. Without telling, eating disorders can be life threatening. They need immediate attention.

Bob M: And I have to believe that most parents care about and love their children. You have to be realistic and understand that your parents will be concerned, but hopefully, after maybe the shock, or surprise, or traumatic worry wears off, they will be supportive and help you get the help you need. Here's another question Holly:

Katerinalisa: What about for those who have insurance but have used it up? What can we do? How do we get treatment after starting, but running out of insurance or money?

Holly Hoff: Kat, that is very difficult. I know that some insurance policies do run out...and if you sign up for another one, there is at least a one year wait for a preexisting condition, if they will cover it at all. Again, try what Bob said. If you qualify, try for medicare or a treatment research program.

Bob M: Here are a few audience comments:

UgliestFattest: I make $333 a month and have no insurance and cannot get medicaid because I am not under 21 or not pregnant plus I am not a US citizen. I am getting therapy through the local MHMR (Mental Health Mental Retardation) center. I have a wonderful therapist and I don't pay a penny because they go by my income and I am supporting myself and putting myself through college.

Maigen: That is true Holly. My mom found out, even though I thought that I was hiding it well. I am glad that she knows. Someone should know, so you don't feel so alone.

cjan: I am in an eating disorder support group and see a therapist. One book I found to have some good self-help advice was "Overcoming Binge Eating" by Dr. Christopher Fairburn.

Bob M: This is the last question for Holly. Dr. Barton Blinder will be coming in about 5 minutes. He's a psychiatrist and eating disorder treatment and research specialist. If you have any further questions for Holly, now's the time to ask.

cjan: I find that a lot of my binges and general overeating is stress related. I am trying to find healthy alternatives to binging. Any suggestions?

Holly Hoff: Find an activity you enjoy. Something to get you away from the food. Walking, reading, talking to friends. Anything that can keep you and your mind doing other things. It's good to have someone to talk too in that situation...for support.

Bob M: Thank you very much Holly. I think we learned a lot tonight. And the one point I want to make is...you can't keep your eating disorder a secret if you need help...and secondly, not dealing with it, doesn't make it go away.

Holly Hoff: Thank you Bob and everyone for having me here tonight. I hope that some of the tips and resources I have given will be a help.

Bob M: Our next guest is Dr. Barton Blinder. Dr. Blinder is the Director of the Eating Disorders Program and Research Studies at the University of California. He is an M.D. Psychiatrist and has many years of practice in the field as well as publications to his credit. Good evening Dr. Blinder and welcome to the Concerned Counseling website. Could you start by filling us in a bit more about your expertise in dealing with eating disorders?

Dr. Blinder: I began clinical and research experience with eating disorders with residency training over 25 years ago. At the University of Pennsylvania Dept. of Psychiatry, we began systematic studies of the symptoms, diagnosis, prognosis, and experimental treatment approaches for anorexia nervosa. This included the first behavioral approach to eating disorders and the first careful evaluation of the rituals and obsessions connected with eating.

Bob M: What kind of research have you, and are you, involved in?

Dr. Blinder: In the past several years, we have completed the first successful trials of an SSRI, Prozac for the acute treatment, and more recently relapse prevention for Bulimia Nervosa. We also have accomplished the first brain imaging studies, PET scans of Bulimia Nervosa, differentiating it from depression and showing brain pattern similarities to obsessive compulsive disorder (hyperactivity in caudate nucleus of the mid brain) which may be involved in food seeking and ritual driven food related behaviors.




Bob M: From your research and knowledge, can you tell us, have scientists been able to come up with "what causes an eating disorder?"

Dr. Blinder: The causes are of course multi-determined and complex. There appears to be a moderate genetic component, certain developmental attachment disturbances which may effect the regulation of many self systems (mood, activity, aggression, and eating). Neuro transmitter abnormalities in the hypothalamus (effecting meal size, satiety, and carbohydrate craving, abnormalities in the caudate nucleus affecting food seeking and ritual behaviors). And finally abnormalities in the gastrointestinal--brain stem circuit which may perpetuate vomiting behaviors in bulimia nervosa. Certainly psychosocial and developmental phase (adolescents) may play a promoting role.

Bob M: I want to divide the treatment research information into two categories. First, we are interested in knowing what are the latest medications available, or about to be available for eating disorders treatment, and how effective are they?

Dr. Blinder: The new generation of medications will be very specific in targeting the neuro chemicals (peptides) that initiate, promote, and regulate feeding in the brain. These include Leptin (hormone with origins in the body fat signaling the brain), Neuropeptide Y (strong stimulator of feeding), Orexin (neuro hormone in hypothalamus which strongly stimulates feeding), and Galinin (neuropeptide which stimulates the eating of fat). The new medications will block/regulate/modulate these very specific neurohormones to help in regulation of feeding. Along with behavioral approaches and nutritional counseling we may also have laboratory tests to determine the excess or deficiency of these neuro hormones and thus have a rational approach to treatment for the first time.

Bob M: And what about the psychotherapy end of the treatment? Has their been any advances made in that?

Dr. Blinder: Guidelines of the American Psychiatric Association stress the cornerstones of nutritional rehabilitation, eating disorder psychotherapy, and medication along with medical and dental follow-up. Cognitive behavioral psychotherapies have the strongest evidence of positive outcome; however, family and psychodynamic therapy is extremely important in younger patients and where there has been developmental complex psychopathology. Where there is chronicity, co-morbitity, and severe developmental complexity, a treatment team should be assembled and the therapeutic approach conducted at the highest level. This may include brief medical/psychiatric hospitalization, an initial period of residential treatment, and a carefully formulated outpatient treatment plan. Limited treatment approaches are definitely not the practice standard in these disorders.

Bob M: We are talking with Dr. Barton Blinder, psychiatrist, Director of the Eating Disorder Program and Research Studies at the University of California. I'm going to ask this question and then we'll open the floor to audience questions. What is the most effective treatment for Anorexia and Bulimia available today? And can one who has an eating disorder, ever expect a full recovery?

Dr. Blinder: About 2/3 of patients with eating disorders recover in 5 years. However, 10 year follow-up studies have shown persistence of symptoms and rituals, continued medical difficulties, and a rate of suicide 10 times higher than expected for age group. The most effective treatments are those reviewed in the APA Practice Guidelines and those that have valid outcome studies. We must continue to emphasize early detection, proper diagnosis, and the best interventions at each phase of treatment. Most treatment failures are related to difficulties in the intensity of each treatment phase.

Bob M: Here are some audience questions, Dr...

UgliestFattest: Dr. Blinder does it become harder to recover from an eating disorder the longer you have it? I am 24 and have had an eating disorder ever since I could remember, which is about age 9. What is the liklihood of me ever fully recovering?

Dr. Blinder: Chronicity (persistance) of the disorder is a factor that definitely leads to treatment resistance. In most instances there are coexisting psychiatric difficulties (depression, OCD, anxiety) and autobiographical complex factors that need careful psychotherapeutic attention. Often a period of residential treatment as the first phase of a carefully sustained treatment plan can be a turning point. Hope should continue and support and understanding of family and significant others is critical.

Bob M: Earlier you quoted some statistics that 2/3 recover in 5 years, but that studies indicate the symptoms really don't ever completely disappear. With that in mind, here's the next audience question:

Champios: So the prognosis is relapse?

Dr. Blinder: No. About 1/3 continue some level of symptoms. Relapse occurs in a small percentage, but the more likely course is either reasonable recovery or chronic persistence (subtle/low level/openly apparent).

Pumpkin: Dr.Blinder, can you tell us exactly how an eating disorder is diagnosed? I know that a lot of people think that sufferers of anorexia have to be extremely underweight to be diagnosed with that disorder.

Dr. Blinder: We have been more liberal with our diagnosis recently (APA DSM IV). Anyone with 15% weight loss or maintaining level below minimum for height and age is current criteria. Obsessive ideas and rituals (including body image disturbance) and unusual food related behaviors are a part of the picture. The important thing is that the behavior is daily, unrelenting, and leads to nutritional decline and psychosocial handicap.

KJ: Information that I am receiving are things I already know. I know it's dangerous. I want to change, but can't. Even if I had the miracle cure in a bottle right in front of me, I wouldn't dare take it in fear of becoming fat. How do I go about getting rid of this?

Dr. Blinder: The fear of fat is a "code word" for a complex set of obsessions about the body and bodily control. This includes dissatisfaction with self, unusual body experiences, and pervasive sense of ineffectiveness in self care. Therefore the fear of fat is not a simple phobia, but a complicated disturbance of self perceptive regulation that needs understanding attention, slow building of trust in small steps (nutritional and psychotherapy), and restoring of hope and morale for the possibility of another approach to daily living.




cjan: I am a recovering bulimic and would be interested in more information on relapse prevention. I went over a year without symptoms of bulimia and then relapsed a year ago. I am really worried about relapse.

Dr. Blinder: We are just completing a national, multi center study of SSRI (Prozac) in bulimia nervosa relapse prevention. The data will be analyzed in the next 6 months and the results available next year. Subjects received medication or placebo for 1 year, following their initial excellent response to the medication. The relapse rate was then measured for each group. Unfortunately, I can't report impressions or results at this time.

Dewdrop: Is drug treatment truly necessary? It is almost as if you are drugging them to get them to stop purging, etc. Shouldn't they learn on their own?

Dr. Blinder: Medication really helps by reducing carbohydrate craving, meal size, food on the mind, depression, and obsessional/ritual behaviors. Along with cognitive behavioral interventions and other psychotherapies, the patients appear to have a better chance to succeed in self regulation. Studies showing the effectiveness of psychotherapy alone, I believe, have limitations in their design and convey the wrong impression of the seriousness and suffering of this illness.

Boofer: I have found that the need to purge comes when I feel fear or extreme anger. If I cannot express these feeling, I tend to purge. Is there a common factor to these feelings in bulimia?

Dr. Blinder: Mood-linked eating disturbance is very common. Triggers are detachment, depression, anxiety, anger. The way this operates is complex---through mental images/memories and a complicated connection to the neuro hormones which stimulate and inhibit feeding. [see the paper: Eating Disorders in Psychiatric Illness, sited in the CV on my website]

Bob M: and we'll be giving everyone that address before the end of the chat.

Gloria: Dr., is there anything I can do to help a co-worker? Many of us worry and care very much about this person, but don't know the best way to help.

Dr. Blinder: Sometimes "gentle" intervention-like methods are helpful involving friends and family often arranging for the presence of a professional, if feasible. Giving the person understandable written information, reference to a personal published memoir or even websites that are informative. Starting with a physical exam can often be a less threatening initial pathway to treatment.

Bob M: By the way Gloria, Amy Medina- who is actually "Something Fishy" will be here tomorrow night to share her battle with anorexia...which should give people an insight to what an eating disorder is all about. Her battle continues to this day. Here's an audience comment re: the ongoing struggle:

Marge: I was at The Rader Institute for ED's in L.A. for 3 weeks. It helped, but only for awhile. Now I'm back where I started, or worse.

Bob M: If I understand what you said earlier Dr. Blinder, even if you get treatment and have dealt with your eating disorder successfully for awhile, you really need to continue on with therapy and monitoring to "keep it under control"? Am I right about that?

Dr. Blinder: Absolutely correct---it is a long, arduous, and sustained process---courage and family support is crucial.

Dan15: I am a 15 year old male. I was anorexic for 6 months before I started an out-patient program just before Christmas. I have been eating very well, but now I am supposed to add the "BAD FOODS" to what I eat (candy, cake, cookies, pie, etc.). I tried to do this, but I don't like the feeling I get when I eat them. I don't feel guilty about eating it. I don't know what I feel. It is like I don't know how to enjoy it. Any suggestions?

Dr. Blinder: Nutritional rehabilitation is now both a science and an art. You need to work carefully with the nutritionist to increase food selection in small steps (food mixing helps, going over previous favorites). The relationship should be one of teacher-mentor-friend with trust and honesty. The American Dietetic Association has some very valuable steps and guidelines for working with a nutritionist in eating disorder rehabilitation.

Joanne: What do you do when your sibling rejects you when you engage in purging, refuses to understand the illness because she believes it is unacceptable and all in the sufferer's hands to stop?

Bob M: And that goes for not only those who have an eating disorder, but for those with mental illness in general. They are rejected by family and friends. What's your suggestion on dealing with the rejection, the isolation?

Dr. Blinder: We call it "stigma"--very common in all psychiatric illnesses. Sometimes families are judgmental, rejecting, critical, and withdrawing. They must be forgiven ultimately. Then educated slowly, gently, about the realities of the suffering and the difficulties with free choice of control in these illnesses. Family therapy helps and should be a part of all intensive treatment efforts. Putting the family in touch with NAMI and other family support groups can be helpful.

Bob M: I know that time is moving on. One thing I want to touch on is your research programs. Can anyone with an eating disorder enroll in your research programs. If so, how? And do they get free, effective treatment out of it?

Dr. Blinder: The research programs vary with specific enrollment criteria, exclusion criteria and time limits. In general, some continued treatment is funded, but often this is very limited, unfortunately.

Champios: Is residential or in-patient treatment your recommendation for most patients? I'm a bulimic that is working on recovery without the help of therapists or counselors and wanted to know your opinion.

Dr. Blinder: Residential treatment is only necessary as the first phase of an intensive treatment attempt where other treatments have failed, or chronicity, psychiatric co-morbidity, medical complications and complex developmental factors work against any reasonable chance for success of an outpatient approach.




Donnna: Dr, is the drug, Remeron, known to help with eating disorders? I've been suffering with both for 25 years and I am very tired of the illness. What can I do?

Dr. Blinder: I know of no published studies involving Remeron (mitrapazine) in eating disorders.

Jessa: Can I train my children not to eat to comfort themselves?

Dr. Blinder: Children derive satisfaction from many social, game, and educational activities. Differential reinforcement of these other activities can be done tactfully and gently, giving children alternatives to eating. Peer influence is important in determining eating choices and behavior of children. It might be useful to find a friend with better habits and invite them over.

Donnna: How can you begin to unlearn the behaviors of bulimia when they have become an automated response to almost any situation?

Dr. Blinder: I know of no published studies involving Remeron (mitrapazine) in eating disorders.

Maigen: I'm 16 and have recently been put on Prozac for bulimia. I didn't like the side effects and I stopped taking it. Are there any other effective drugs that you know of in the treatment for bulimia, that don't have the side effects that could interfere with my "daily female teenage life?"

Dr. Blinder: Any of the other SSRI's (, Paxil, Luvox) might under careful supervision be tried. If the side effects are related to serotonin they are likely to recur, unfortunately. The new generation of medication in the next 2-3 years may hold promise for bulimia and ultimately replace the SSRI's. Some of our early studies involved norpramine which was found to be effective, but has its own side effects including cardiovascular dangers, which can be worsened by low potassium from purging. Consult an informed psychiatrist for further options. Bob

Bob M: Would you like to give us your website address Dr.?

Dr. Blinder: http://www.ltspeed.com/bjblinder

Bob M: I know it's late. Thank you very much for coming tonight and staying with us. We'll be posting transcripts by the weekend. Tomorrow night, as I said, Amy Medina "Something Fishy" will be here to share her story. That's at 6 p.m. Pacific, 8 CST, 9 EST.

Dr. Blinder: Thank you, it was my pleasure and privilege.

Bob M: Good Night.



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Last Updated: 06 April 2017

Reviewed by Harry Croft, MD

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