Sarah Fuller Advanced Specialist Eating Disorders Dietitian What we aim to cover Myth busting Incidence of EDs Symptoms of EDs Different types of EDs Greater focus on the main types Anorexia Nervosa Bulimia Nervosa and Binge Eating Disorder ID: 915155
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Slide1
Identification and monitoring of eating disorders
Sarah Fuller
Advanced Specialist Eating
Disorders Dietitian
Slide2What we aim to cover
Myth busting
Incidence of ED’s
Symptoms of ED’s
Different types of ED’s
Greater focus on the main types: Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder
The Minnesota Study and what happens in starvation
How to get help and refer
Slide3Group discussion:
What behaviours or characteristics of someone with an eating disorder are you aware of?
Slide4Incidence of Eating Disorders
Children (12y and under):
More likely to have an ED than Meningococcal Disease
4 out of 5 children are afraid of being fat
Children as young as 6y old are receiving treatment for eating disorders Adolescents:
X 5 more likely to have an ED than T1DM
X 10 more likely to have an ED than IBD
X 2 more likely to have AN if CoeliacAN is the 3rd most common chronic condition in teenagersONLY 35% present with medical instabilityAdults:1.25 million have an ED25% are male95% of these patients are aged 12 – 26y old, BUT and occur at ANY age8% AN, 5% ARFID, 22% BED, 19% BN, 47% OSFED
Slide5What causes eating disorders?
We don't know exactly what causes eating disorders.
You may be more likely to get an eating disorder if:
If you are female
If you are an adolescentIf you are in a period of transition: changing school, moving house / job, pregnancy etc…If you, or a member of your family, has a history of eating disorders, depression, or alcohol or drug addiction
If you have anxiety, low self-esteem, an obsessive personality, or are a perfectionist
If you have been criticised for your eating habits, body shape or weight
High number of cases after young people being weighed at school and letter being sent home after being identified as overweightIf you're overly concerned with being slim, particularly if you also feel pressure from society or your job – for example, ballet dancers, jockeys, models or athletesWomen with PCOS or Diabetes (x 2.4 risk of developing an ED esp BN or BED)Those who identify as LGBTQ+If you have been sexually abused
Slide6Symptoms
Restricting oral intake
Healthy eating e.g. cutting out snacks, puddings, treats etc…
Excluding food groups e.g. carbohydrates, fats etc…
Socially acceptable restrictions e.g. vegetarian / vegan diets, fasting for religious festivals or beliefs
Hiding foods
On person e.g. in clothes, in hair, in mouth
Elsewhere e.g. given to pets, in bins, behind radiators, in umbrellas!
Poor eating behaviours e.g. long meals, smearing, Fasting / refusal to eatRemember: younger patients are at higher risk of restricting fluids and may need medical stabilisation quickly.
Slide7Symptoms
Exercising
Group exercise e.g. PE, sports, walking to/from school/work
etc
…
Additional exercise e.g. unable to stop the above, exercising in bedroom or in secret (may have to do repeated exercise routines)
Subtle exercise e.g. standing, seated
jiggeling
, abdominal crunches, the ‘seated hover’, extra steps, serial potteringKey features of compulsive exercise: Usually a daily activity that causes high levels of anxiety if missedPlanning their day around the exercise and other activities will be missed to prioritise the exercise e.g. avoiding social situationsExcessive exercisers report that they often feel like they are not good enough, not fast enough or not pushing themselves hard enough during a period of exercise. They report feeling an intense pressure to increase the duration, intensity or difficulty of their exercise routine
Slide8Symptoms
Vomiting
After meals or drinks
In secret or in public (dirty protest!)
On supervision: in showers or in tissues
You may find hidden vomit bags or in clothes etc…
Medical complications of vomiting:
Dehydration
Electrolyte abnormalities (metabolic alkalosis or hypokalemia)Oesophageal tear (rare) – either partial (Mallory-Weiss) or complete (Boerhaave syndrome)
Slide9Symptoms
Medication abuse e.g. Laxatives, diuretics or Insulin
Laxative
abuse occurs when a person attempts to get rid of unwanted calories, lose weight, “feel thin,” or “feel empty” through the repeated, frequent use of laxatives.
Laxatives work by targeting the large intestine. This means that once food passes through the small intestine, nutrients from the food have already been absorbed into the body. Any weight loss observed is solely from the loss of water- not calories or fat-and will only be temporary if the individual
Diuretics
act on the kidneys to increase the low of urine and this can be seen as a ‘quick fix’ to lose weight
Insulin
abuse is often called Diabulimia: By under dosing insulin, a diabetic will force sugar to leave his or her body through urine. The result: easy weight loss. (www.dwed.org.uk is a good resource)
Slide10Symptoms
Weight manipulation
Water loading
Hiding weights on self / inserting weights
Wearing extra clothes
Being weighed after they have already eaten
DENIAL!!!
They nearly always say 'I'm fine!' and can put up really convincing arguments to back this up
BUT… The patient may absolutely believe that they are fine due to their starved brainSO,Discussion with family members / friends is key.
Slide11DSM-5: Types of feeding and eating disorders
The most common eating disorders are:
Anorexia Nervosa
(AN)
– when you try to keep your weight as low as possible by not eating enough food, exercising too much, or both
Bulimia Nervosa
(BN) – when you sometimes lose control and eat a lot of food in a very short amount of time (binging) and are then deliberately sick, use laxatives, restrict what you eat, or do too much exercise to try to stop yourself gaining weightBinge Eating Disorder (BED) – when you regularly lose control of your eating, eat large portions of food all at once until you feel uncomfortably full, and are then often upset or guiltyOther Specified Feeding or Eating Disorder (OSFED) – when your symptoms don't exactly match those of anorexia, bulimia or binge eating disorder, but it doesn't mean it's a less serious illnessAvoidant Restrictive Food Intake Disorder (ARFID)Rumination DisorderPICA
Slide12Anorexia nervosa (AN)
Weight below 85% of that expected or BMI <17.5kg/m
2
in adults
Fear of gaining weight / becoming fat
Distorted perceptions of shape & weight
2 subtypes: restricting and
binge / purging
NOTE: Amenorrhoea in women has been removed from the diagnostic criteria
Slide13Anorexia Nervosa sufferers
Refuse food
Count and restrict calories
Are ‘faddy’ about food
Refuse to eat with others
Play with food, chew excessively and eat slowly
Take strenuous exercise
Wear large clothes or skimpy clothes to show off
Enjoy cooking for othersRefuse to maintain a normal body weightHave a fear of gaining weight
May engage in purging
Exercise / vomiting
Experience disturbance in perception of own body shape
Slide14Physical consequences of starvation
Slide15Bulimia nervosa (BN)
Recurrent episodes of binging, consisting of large amount of food in discrete period. Often experiencing tremendous guilt and a loss of control and will engage in fantastic efforts to undo these feelings
Binges are often in secret and can be excessively planned and looked forward to
Recurrent ‘compensatory’ behaviours
Binges 1 & 2 occur at least twice a week for 3 months
Self-esteem primarily dependent on perceptions of body shape and weight
Slide16Bulimia nervosa (BN)
There are two common types of bulimia nervosa, which are as follows:
Bulimia Nervosa Purging type
-This type of bulimia nervosa accounts for the majority of cases of those suffering from this eating disorder. In this form, individuals will regularly engage in self-induced vomiting or abuse of laxatives, diuretics, or enemas after a period of bingeing.
Bulimia Nervosa Non-purging type - In this form of bulimia nervosa, the individual will use other inappropriate methods of compensation for binge episodes, such as excessive exercising or fasting. In these cases, the typical forms of purging, such as self-induced vomiting, are not regularly utilized.
Slide17BN: What might you notice?
Normal
slight overweight
Fluctuations in weight
Dental erosion / tooth loss, bleeding gums
Swollen glands in the face and neckBloodshot eyes
Chronic reflux
Sore throat / esophagus – can tear
Bad breath – smelling of vomitWeakness, tiredness and fatigueBlisters on the back of the hand and fingers "Russell's sign" Deranged electrolytes and dehydrationAbility to vomit at will
Slide18BN: What might you notice?
Slide19HOW BULIMIA AFFECTS YOUR BODY
Slide20Binge Eating Disorder (BED)
Defined as ‘recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control’.
Someone with binge eating disorder may eat too quickly, even when he or she is not hungry.
The person may have feelings of guilt, embarrassment, or disgust and may binge eat alone to hide the behaviour.
This disorder is associated with marked distress and occurs, on average, at least once a week over three months.
No attempt to ‘offset’ (vomiting, fasting, exercise etc…) these calories as seen in BN
Slide21Binge Eating Disorder (BED)
The binge eating cycle
Binge eating may be comforting for a brief moment, but then reality sets back in, along with regret and self-loathing.
Binge eating often leads to weight gain and obesity, which only reinforces compulsive eating.
The worse a binge eater feels about themselves and their appearance, the more they use food to cope.
It becomes a vicious cycle: eating to feel better, feeling even worse, and then turning back to food for relief.
Slide22Binge Eating Disorder (BED)
Generally, it takes a combination of things to develop binge eating disorder—including a person's genes, emotions, and experience.
Biological causes of binge eating disorder
Biological abnormalities can contribute to binge eating. For example, the hypothalamus (the part of the brain that controls appetite) may not be sending correct messages about hunger and fullness.
Researchers have also found a genetic mutation that appears to cause food addiction.
Finally, there is evidence that low levels of the brain chemical serotonin play a role in compulsive eating.
Slide23Binge Eating Disorder (BED)
Social and cultural causes of binge eating disorder
Social pressure to be thin can add to the shame binge eaters feel and fuel their emotional eating. Some parents unwittingly set the stage for binge eating by using food to comfort, dismiss, or reward their children.
Children who are exposed to frequent critical comments about their bodies and weight are also vulnerable, as are those who have been sexually abused in childhood.
Psychological causes of binge eating disorder
Depression and binge eating are strongly linked. Many binge eaters are either depressed or have been before; others may have trouble with impulse control and managing and expressing their feelings.
Low self-esteem, loneliness, and body dissatisfaction may also contribute to binge eating.
Slide24Neurodevelopment
Profile
Attachment
Weight & Body Image Concerns
Abnormal diet, exercise and compensatory behaviours
Change events
Perinatal Experiences
Eating Disorder
Cultural Context
Family History
Simplified Model of ED Aetiology
Gender
Race
Puberty
Trauma
Personality/
Temperament
Adapted from Eating Disorders in Adolescence 3
rd
Edition (2007) Lask B and Bryant-Waugh R. Routledge, London
Slide25The Minnesota Starvation Experiment
The
Minnesota Starvation Experiment
, also known as the Minnesota Semi-Starvation Experiment, was a clinical study performed at the University of Minnesota between November 1944 and December 1945 by Ancel Keys.
The investigation was designed to determine the physiological and psychological effects of severe and prolonged dietary restriction and the effectiveness of dietary rehabilitation strategies.
The motivation of the study was: First, to produce a definitive treatise on the subject of human starvation based on a laboratory simulation of severe famine, Second, to use the scientific results produced to guide the Allied relief assistance to famine victims in Europe and Asia at the end of World War II.
Slide26The Minnesota Starvation Experiment
The study was divided into three phases:
A twelve-week
control
phase, where physiological and psychological observations were collected to establish a baseline for each subject. Everyone was on ~3200kcal/day to get to an ‘ideal’ body weight and psychological screening took place.
A 24-week starvation phase, during which the caloric intake of each subject was drastically reduced—causing each participant to lose an average of 25% of their pre-starvation body weight by reducing oral intake to ~1560kcal/day as 2 meals a day. A recovery
phase, in which various rehabilitative diets were tried to re-nourish the volunteers.
12 weeks where the volunteers were split into different groups, each receiving different calories to see the effect this had on recovery
Then 8 weeks of unrestricted calorie intake
Slide27The Minnesota Starvation Experiment
The conclusions from the study?
Confirmation that prolonged semi-starvation produces significant increases in depression, hysteria and hypochondriasis. Indeed, most of the subjects experienced periods of severe emotional distress and depression.
Participants exhibited a preoccupation with food, both during the starvation period and the rehabilitation phase.
Sexual interest was drastically reduced, and the volunteers showed signs of social withdrawal and isolation.
The participants reported a decline in concentration, comprehension and judgment capabilities.
There were marked declines in physiological processes indicative of decreases in each subject’s basal metabolic rate- reflected in reduced body temperature, respiration and heart rate.
DO THESE SYMPTOMS SOUND FAMILIAR?
Slide28The Minnesota Starvation Experiment
The Minnesota Experiment required them to
reduce their calorie intake by half to 1,560kcal to get them to lose 25% body weight.
Slide29Coxson
et al. Am J
Respr
Crit
Care Med 2004; 170: 748
Slide30Physical signs of starvation
Malnutrition:
Poor circulation (cold hands / feet),
Feeling cold / hypothermic
Dizziness on standing – is there an orthostatic drop in BP and pulse on standing,
Palpitations or abnormal ECG, Fainting or pallorThinning hair / dry skin / easily bruising
Constipation – not eating and slowing down of GI tract
Amenorrhoea or delayed puberty
Tired all the timeNot specific to a low BMI, can be very malnourished at a normal weight (but losing weight rapidly)
Slide31Psychological signs of starvation
Malnutrition can cause:
Low mood
Anxiety
Irritability
Poor concentration
Fixation around food
Apathy
Slide32Starvation is not just about food
Be aware of compensatory
behaviours:
Laxatives or diet pills
VomitingRussell's signDental erosion Excessive exercise
Slide33BEAT: www.beateatingdisorders.org.uk
Youth line
0808 801 0711
Help line
0808 801 0677
Student line
0808 801 0811
Online Support Groups
Echo Peer Coaching
Slide34How to refer
Tier 2: CARALINE
Self referral accepted
From 17y
www.caraline.com
01582 457 474Tier 3: NHS – ELFT
CAMHS
Self referral accepted
Under 18’s01582 893 308Adult ED TeamOver 18’sGP referral
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