RECOGNIZING AND PREVENTING DISORDERED EATING
Jessica Stern, MD Childce and Adolescent Psychiatrist November 9, 2016 Eating Recovery Center’s mission is to provide the very best care to patients, families and providers of care, in the treatment of and recovery from, eating disorders and related conditions.
Eating Recovery Center is the only national, vertically integrated, health care system dedicated to the treatment of serious eating and related disorders at all levels of severity and stages of the illness.
Eating Recovery Center’s unique, evidence-based, medical, psychiatric, and psychological treatment is delivered by a multidisciplinary care team that is committed to the highest quality of care and to lasting recovery.
Eating Recovery Center leads the industry in clinical experience and thought leadership, professional and consumer education, family involvement and aftercare support, research and innovation.
www.eatingrecovery.com 877-218-1344 for a confidential, free consultation by a Master’s-level eating disorders clinician EATING DISORDERS MAY BE INVISIBLE
-Eating disorders occur in males and females -People in average and large size bodies can experience starvation and malnourishment -Even clinicians may not recognize the onset of eating disorders
MORE COMMON THAN YOU MAY THINK!
Eating disorders (EDs) are the third most common chronic condition in adolescents, after obesity and asthma.
The onset of EDs usually is during adolescence, with the highest prevalence in adolescent girls, but EDs increasingly are being recognized in children as young as 5 to 12 years.
Fisher M, Golden NH, Katzman DK, et al. Eating disorders in adolescents:a background paper. J Adolesc Health. 1995;16(6):420–437
Madden S, Morris A, Zurynski YA, Kohn M, Elliot EJ. Burden of eating disorders in 5-13-year-old children in Australia. Med J Aust. 2009;190(8):410–414
Nicholls DE, Lynn R, Viner RM.Childhood eating disorders: British national surveillance study. Br JPsychiatry. 2011;198(4):295–301
Pinhas L, Morris A, Crosby RD, Katzman DK. Incidence and age-specific presentation of restrictive eatingdisorders in children: a CanadianPaediatric Surveillance Program study. Arch Pediatr Adolesc
IMPORTANCE OF SCREENING AND EARLY DETECTION
-Delay in appropriate treatment is associated with numerous med/psych/social complications that may not be completely reversible and may have long‐lasting implications on development -Longer the ED persists, the harder it is to treat -Crude mortality rate is 4 - 5%, higher than any other psychiatric disorder (Crow et al 2009). - Costs for AN treatment and quality of life indicators, if progresses into adulthood, rivals Schizophrenia (Streigel-Moore et al, 2000).
KEY FEATURES OF DSM-5 DIAGNOSTIC CRITERIA FOR ANOREXIA NERVOSA
• Restriction of food eaten leading to lower than expected body weight • Intense fear of weight gain or being fat • Body image distortion • Types: restricting or binge eating/purging
ANOREXIA NERVOSA
-Mean age of onset is early adolescence , approximately 14 years of age -Associated psychological correlates: – high levels of anxiety and depression – low self-esteem, rule bound, risk averse – interpersonal difficulties, low expressed emotion, conflict avoidant -Physical health compromise is due to malnutrition, every organ system affected. -Treatment in adolescence is usually successful, Recovery in > 70% of the cases with evidence based care -Treatment in adulthood has less predictable outcome, chronicity = poorer prognosis KEY FEATURES OF DSM-5 DIAGNOSTIC CRITERIA FOR BULIMIA NERVOSA
• Binge eating in which o a larger amount of food is eaten within a 2-hour period compared with peers; and o there is a perceived lack of control during the time of the binge • Repeated use of unhealthy behaviors after a binge to prevent weight gain: (vomiting; abuse of laxatives, diuretics, or other medications; food restriction; or excessive exercise) • Behaviors occur at least once a week for 3 months • Self-worth is overly based on body shape and weight • Behaviors occur distinctly apart from AN
BULIMIA NERVOSA
-Mean age of onset is late adolescence, approximately 17‐18 years of age
-Associated psychopathology: – High levels of anxiety and depression – Low self-esteem – Personality disorders – Impulse control problems, substance abuse disorders
-The physical health compromise is due to purging behaviors KEY FEATURES OF DSM-5 DIAGNOSTIC CRITERIA FOR BINGE EATING DISORDER
• Recurrent episodes of binge eating in which o a larger amount of food is eaten within a 2-hour period compared with peers; and o there is a perceived lack of control during the time of the binge
Bingeing episodes are associated with at least 3 of the following: o eating faster than normal; o eating until overly full; o eating large quantities of food when not hungry; o eating alone because of embarrassment about the quantity of food eaten; and o feeling badly emotionally after eating • Upset about bingeing • Bingeing behavior occurs at least once a week for 3 months
KEY FEATURES OF CRITERIA FOR AVOIDANT RESTRICTIVE FOOD INTAKE DISORDER (ARFID)
• A feeding problem that results in at least one of the following: o significant weight loss or failure to meet the expected weight or height gain in children (but without body image distortion or drive for thinness); o significant nutritional deficiency; o dependence on nonfood nutrition, such as nasogastric feedings or oral nutritional supplements; or o marked interference with psychosocial functioning
Restrictive – lack of interest in food; often starts in infancy Avoidant – based on sensory characteristics of food; usually present from a young age Aversive – fear-based, i.e. choking event; may arise at any age RED FLAGS
- change in growth trajectory -height growth arrest VERY concerning -a disregard for physical health, i.e. continuing to run with a stress fracture -irregular or lack of menses -bradycardia (resting heart rate less than 60) -hypotension or postural tachycardia -lightheadedness or passing out
RED FLAGS
-preoccupation with nutrition -reading food labels -eliminating macronutrients or food groups, i.e. avoiding fat, dairy, carbohydrates, becoming vegan or vegetarian -consistently going to restroom after eating -preoccupation with food -cooking/baking but not partaking -spending excessive amounts of time on Pinterest or watching cooking shows -skipping meals
RED FLAGS -change in mood, i.e. increased irritability -increased social isolation -increase preoccupation with physical appearance -drinking excessive amounts of fluid, i.e. trying to ―fill up‖ on zero calorie beverages -drinking excessive amounts of caffeine -chewing excessive amounts of gum
ABNORMAL MEAL TIME BEHAVIORS
-small bites -eating very slowly -smearing food -hiding food -using excessive amounts of salt, pepper, hot sauce, etc -tearing food -unusual use of utensils, i.e. cutting up a sandwich -excessive dipping, excessive use of condiments BODY IMAGE
People with negative body image have a greater likelihood of developing an eating disorder and are more likely to suffer from feelings of depression, isolation, low self-esteem, and obsessions with weight loss.
Negative Body Image -A distorted perception of your shape--you perceive parts of your body unlike they really are. -You are convinced that only other people are attractive and that your body size or shape is a sign of personal failure. -You feel ashamed, self-conscious, and anxious about your body. -You feel uncomfortable and awkward in your body.
EFFECTS OF MEDIA
-There is no single cause of body dissatisfaction or disordered eating. But, research is increasingly clear that media does indeed contribute and that exposure to and pressure exerted by media increase body dissatisfaction and disordered eating.
-Numerous correlational and experimental studies have linked exposure to the thin ideal in mass media to body dissatisfaction, internalization of the thin ideal, and disordered eating among women.
-The effect of media on women’s body dissatisfaction, thin ideal internalization, and disordered eating appears to be stronger among young adults than children and adolescents. This may suggest that long-term exposure during childhood and adolescence lays the foundation for the negative effects of media during early adulthood.
-Pressure from mass media to be muscular also appears to be related to body dissatisfaction among men. https://www.nationaleatingdisorders.org/media-body-image-and-eating-disorders SOCIAL INFLUENCES: S.I. - OVER THE YEARS
1965 2011 Dieting graphic PROMOTING POSITVE BODY IMAGE
Explain the effects of puberty. Make sure your daughter understands that weight gain is a normal part of her development, especially during puberty. Talk about media messages. Television programs, movies, music videos, websites, magazines and even some toys might send the message that only a certain body type is acceptable and that maintaining an attractive appearance is the most important goal. Check out what your child is reading or watching and discuss it. Encourage him or her to question what he or she sees and hears. Monitor Internet use. Teens use social networking sites and services to share pictures and receive feedback. Awareness of others' judgments can make teens feel self- conscious about their looks. Set rules for your teen's Internet use and talk about what she's posting and viewing. Discuss self-image. Offer reassurance that healthy body shapes vary. Ask her what she likes about herself and explain what you like about her, too. Your acceptance and respect can help her build self-esteem and resilience. Use positive language. Rather than talking about "fat" and "thin," encourage your daughter to focus on eating a healthy diet and staying physically active. Discourage family and friends from using hurtful nicknames and joking about people who are overweight. http://www.mayoclinic.org/healthy-lifestyle/tween-and-teen-health/in-depth/healthy-body- image/art-20044668?pg=2
PROMOTING POSITVE BODY IMAGE
Help establish healthy eating habits. Offer healthy meals and snacks. Counter negative media messages. Expose your child to adults who are famous for their achievements — not their appearance. For example, read books or watch movies about inspiring men & women. Praise achievements. Help your child value what he or she does, rather than his or her physical appearance. Look for opportunities to praise hir or her efforts, skills and achievements. Promote physical activity. Participating in sports and other physical activities — particularly those that don't emphasize a particular weight or body shape — can help promote good self-esteem and a positive body image. Encourage positive friendships. Friends who accept and support your teen can be a healthy influence. Set a good example. Remind your child that you exercise and eat a healthy diet for your health, not just to look a certain way. Also think about what you read and watch as well as the products you buy and the message your choices send. http://www.mayoclinic.org/healthy-lifestyle/tween-and-teen-health/in-depth/healthy- body-image/art-20044668?pg=2 PROMOTING POSITVE BODY IMAGE
Adolescents who were more satisfied with their bodies were more likely to report PARENTAL and PEER attitudes that encouraged healthful eating and exercising TO BE FIT, rather than dieting; they were less likely to report personal weight- related concerns and behaviors.
Kelly AM, Wall M, Eisenberg ME, Story M, Neumark-Sztainer D. Adolescent girls with high body satisfaction: who are they and what can they teach us? J Adolesc Health. 2005;37(5):391–396
WHAT TO DO IF YOU’RE CONCERNED
-find a team that involves YOU -improved outcomes for both eating disorders and obesity in adolescents when families are directly involved in treatment
-EXTREMELY important to find providers specializing in ED treatment -PCP, RD, & therapist -may also want to involve psychiatrist if significant co-occurring anxiety or mood symptoms -occupational therapist (OT) specializing in sensory issues can be invaluable for ARFID symptoms
Katzman DK, Peebles R, Sawyer SM, Lock J, Le Grange D. The role of the pediatrician in family-based treatment for adolescent eating disorders:opportunities and challenges. J Adolesc Health. 2013;53(4):433–440
Shrewsbury VA, Steinbeck KS,Torvaldsen S, Baur LA. The roleof parents in pre-adolescent andadolescent overweight and obesity treatment: a systematic review of clinical recommendations. Obes Rev. 2011;12(10):759–769 THE ETIOLOGY OF EATING DISORDERS IS MULTIFACTORIAL
Biology/Genetics
Social/ Psychologic Environmental traits/Temperament factors
Treatment must be focused on all three areas. ANOREXIA TREATMENT
Family Based Treatment – For children and adolescents living at home with parents – No fault approach – Manualized Therapy • Three stages, about 20 sessions, outpatient • Therapist supports parents in how best to refeed their child at home – Has best rates of long-term recovery in teens • Evidence Based for children and adolescents • 85% recovery vs. 35% recovery in 5 year study
WHAT IF MY CHILD IS OVERWEIGHT?
Per the most recent American Academy of Pediatrics Guidelines, AVOID WEIGHT BASED LANGUAGE
As a family, promote health and well-being by: - increase minutes of physical activity (that is enjoyable and fun!) -increase outdoor time -decrease screen time, increased family play time -increase fruits vegetables -increased number of family meals eaten together -don’t skip breakfast! -ensure adequate sleep
DISCOURAGE DIETING
- Dieting, defined as caloric restriction with the goal of weight loss, is a risk factor for both obesity and EDs.
- Dieting has been associated with greater weight gain and increased rates of binge eating in both boys and girls (Field et al 2003)
-Dieting behaviors were associated with a twofold increased risk of becoming overweight and a 1.5-fold increased risk of binge eating (Neumark-Sztainer et al 2007)
- Girls WITHOUT obesity who dieted in the ninth grade were 3 times more likely to be overweight in the 12th grade compared with non- dieters. (Stice et al 1999) DISCOURAGE DIETING Dieting also can predispose to EDs.
Students who severely restricted their energy intake and skipped meals were 18 times more likely to develop an ED than those who did not diet; those who dieted at a moderate level had a five fold increased risk.
Patton GC, Selzer R, Coffey C, Carlin JB, Wolfe R. Onset of adolescent eating disorders: population based cohort study over 3 years. BMJ.1999;318(7186):765–768
ENSURE ADEQUATE SLEEP FOR PHYSICAL AND EMOTIONAL WELL-BEING
- NO television in bedroom (helpful for bedrooms to be a ―screen- free zone‖)
-Children 3 to 5 years of age should sleep 10 to 13 hours per 24 hours (including naps)
-Children 6 to 12 years of age should sleep 9 to 12 hours per 24 hours
-Teenagers 13 to 18 years of age should sleep 8 to 10 hours per 24 hours RESOURCES http://www.nationaleatingdisorders.org/parent-toolkit https://www.nationaleatingdisorders.org/educator-toolkit http://www.nationaleatingdisorders.org/developing-and-maintaining-positive-body-image http://stopobesityalliance.org/wp-content/themes/stopobesityalliance/pdfs/stopobesityalliance- weighin.pdf
Preventing Eating Disorders: A Handbook of Interventions and Special Challenges 1st Edition Niva Piran (Editor), Michael Levine (Editor), Catherine Steiner-Adair (Editor)
http://www.ahaparenting.com/parenting-tools/safety/prevent-eating-disorder-child https://www.healthychildren.org/English/media/Pages/default.aspx#planview
Right Click: Parenting Your Teenager In A Digital Media World Kara Powell, Art Bamford, Brad Griffin