Laurie Fortlage MS RD CS Mott Childrens Hospital httpscreatekahootitshareeatingdisordersmythsvsfacts3f5defe171bb4daf84399f5014b77901 Objectives Eating Disorder Diagnoses Identifying Eating Disorders in your office ID: 913195
Download Presentation The PPT/PDF document "Eating Disorders: What Dietitians shoul..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Eating Disorders: What Dietitians should know and considerations for prevention in our own practices
Laurie Fortlage, MS, RD
C.S. Mott Children’s Hospital
Slide2https://create.kahoot.it/share/eating-disorders-myths-vs-facts/3f5defe1-71bb-4daf-8439-9f5014b77901
Slide3ObjectivesEating Disorder DiagnosesIdentifying Eating Disorders in your officeAssessment tools
Treatment
Promoting environments and Acting in ways that do not promote disordered eating or thoughts about eating
Slide4What is an Eating Disorder?Eating Disorders are neurobiological disorders rooted in the brain causing medical and psychological issuesThey are NOT a choice and not simply about control or weight management
Genetics, Environment, Temperament all play a role
Experienced by all genders, body sizes, SES
Slide5Types of Eating Disorders Anorexia Nervosa (AN)Restriction of energy intake; Body image disturbance
Bulimia Nervosa (BN)
Recurrent binge eating episodes and compensatory behaviors that are meant to prevent weight gain
Binge Eating Disorder (BED)
Recurring and persistent episodes of binge eating with the absence of regular compensatory
behaviors
Other Specified Eating or Feeding Disorders (OSFED)
Symptoms of an eating disorder but don’t meet full
criteria
Avoidant Restrictive Food Intake Disorder (ARFID)
Limitations on the amount or types of food intake; without distress about body shape or size or fears of fatness
Slide6Etiology of EDsImpossible to know the exact cause/causesOften referred to as the “Perfect Storm” of:
Environment
Genetics
Temperament
Stress activates this combination of
events
Individuals manage the stress by controlling food intake
Many have underlying anxiety disorders
Can’t treat the anxiety disorder until the person is nourished
Slide7Screening
Slide8Check your AssumptionsANY client can have or
could develop
an eating disorder
Don’t assume that by looking at someone you will know. EDs are
rarely
recognized by how someone looks
Initially assess in your usual manner, and keep an eating disorder in the back of your mind
EDs can’t exist if they can’t keep it a secret
Do no harm
Slide9How does a client with an eating disorder show up in your practice?GI disturbances – IBS, food sensitivities, stomach pain, bloatingAthletes
New Vegetarians/ Vegans
Lengthy or complicated dieting histories
DM, Type 1 (
diabulimia
)
“Picky Eating”; Autism Spectrum; ARFID
Bariatric Surgery Patients
Polycystic Ovarian Syndrome
Slide10AN TraitsPerfectionismPersonal self-imposed standards
Anxiety
OCD
tendencies
Rigid thinking
Risk avoidant
Experiential avoidant
Rule followers
Slide11BN TraitsImpulsiveCompulsive
Novelty – Seeking
More likely to have a chaotic environment
Slide12What to look for….Are they seeking weight loss? Weight history, desired weight
Do they count calories? What happens if they eat more than their goal for the day/meal?
Do they ever feel out of control around food?
Are there foods they won’t eat because of a belief or rule? Is there flexibility around this?
Do they “save” their calories for later in the day?
Will they eat food they haven’t prepared or don’t know the ingredients and/or calories of?
Do they avoid events with food or eating with other people?
Slide13What to look for…..Food rituals; food rigidity
Do they ever sneak food? Have they lied about having something or not having something?
Do they feel the need to compensate for the calories they ate?
Are they weighing themselves? How often are they weighing themselves? How does weight impact their food choices, mood for the rest of the day?
Do they ever feel guilty or shameful during or after eating?
What happens if they eat more than they wanted?
Slide14Screening tools for Eating DisordersEating Attitudes Test (EAT-26)EDGE Symptom SurveyBED Screening
Female Athlete Screening Tool (FAST)
SCOFF
Eating
Disorder Screening Tool for Primary
Care
(ESP)
Slide15Eating Attitude Test (EAT 26)https://www.seattlechildrens.org/globalassets/documents/healthcare-professionals/pal/ratings/eat-26-rating-scale.pdf
Slide16Binge Eating Disorder Screener (BEDS-7)https://www.vyvansepro.com/documents/Adult-Binge-Eating-Disorder-Patient-Screener.pdf
Slide17Female Athlete Screening Tool (FAST)https://uhs.nd.edu/assets/165496/female_athlete_screening_tool_2011_12.pdf
Slide18SCOFF QuestionnaireThe SCOFF questions* Do
you make yourself
S
ick because you feel uncomfortably full?
Do
you worry you have lost
C
ontrol over how much you eat?
Have
you recently lost more than
O
ne stone (14
lbs
) in a 3 month period?
Do
you believe yourself to be
F
at when others say you are too thin?
W
W
ould
you say that
F
ood dominates your life
?
*One point for every “yes”; a score of 2 indicates a likely case of anorexia nervosa or bulimia
Morgan
, Reid, Lacey, “The SCOFF questionnaire: assessment of a new screening tool for eating disorders,” British Medical Journal (BMJ), 319(7223): 1467–1468, December, 1999.
Slide19Eating Disorder Screening Tool for Primary Care (ESP) Are you satisfied with your eating patterns? (A “no” to this question was classified as an abnormal response).
Do
you ever eat in secret? (A “yes” to this and all other questions was classified as an abnormal response). •
Does
your weight affect the way you feel about yourself? •
Have
any members of your family suffered with an eating disorder? Do you currently suffer with or have you ever suffered in the past with an eating disorder?
Cotton
, Ball, Robinson, “Four Simple Questions Can Help Screen for Eating Disorders” Journal of General Internal Medicine,18(1): 53–56, January, 2003.
Slide20Assessment
Slide21Assessment ToolsHealth history, family historyLifestyle assessment including social impact of eating disorder
Review of lab results to assess nutrient status
Food
i
ntake assessment and analysis
Meal Planning
Metabolic assessment (RMR) and estimated needs analysis
Slide22Consequences of UndernutritionMedical Instability Vital Sign Abnormalities
Adaptive, compensatory response to malnutrition
“Hibernation Mode”- hypothermia, hypotension, hypoglycemia
Slide23Consequences of UndernutritionBradycardia <60 bpmHeart muscle atrophy
Severe Sinus Bradycardia <50 bpm
Often <45 while sleeping
Glucose < 60 high risk
Low glucose is a result of depletion of glycogen scores
Cold extremities
Edema
Lanugo
Hair Loss
Slide24Consequences of UndernutritionAmenorrheaNot always present even in critically ill clients
Osteopenia
With AN body loses bone secondary to low estrogen
Weight restoration is the gold standard
Birth control pill are not helpful
Keep
Vit
D levels > 30 ng/UL
Slide25Consequences of Undernutrition GastroparesisEmptying 5x slower
Decreased peristalsis
Early fullness, bloating, gassiness, nausea
Frequent meals
Challenge “safe” versus dense
foods
Brain
Loss of gray matter
Serotonin and dopamine receptors impaired (pleasure/pain/reward)
Slide264 C’s of MalnutritionCold
Crabby
Constipation
Poor Circulation
Slide27Treatment
Slide28Anorexia NervosaInitial goal: adequate
calories; dense foods are predictive of recovery outcomes
Normalized
and balanced eating will come in time
Meet
them where they are
*
Full weight restoration*
90
% IBW- about 50% relapse
%
body fat better predictor than BMI/Weight
Intuitive
Eating---takes time
Slide29Anorexia NervosaExtremely high calorie
need
Require
more calories to maintain the rate of weight gain
Post
weight restoration, these clients require more calories to maintain their weight
Hyper-metabolism
usually lasts 3 to 6 months, but can last up to a year after weight restoration
Slide30Bulimia NervosaRecurrent binge episodes
Recurrent
use of inappropriate behaviors to prevent weight gain
Both
B/P occur on average, >1/week for 3 months
Self-evaluation
focused on weight/shape
Does
not meet criteria for Anorexia
Slide31Bulimia NervosaInitial goal is to stop the purging cycle
Often
5 pound weight gain once purging stops. Fluid shifts
Regular
meals and snacks
Need
satisfying foods: fat
Find
the sweet spot: not too hungry/not too full
Slide32Binge Eating DisorderReoccurring episodes of eating large amounts of food
Feelings of loss of control during binge episode, as well as marked distress
Binge episodes occur on average >1x/week for 3 months
Slide33Binge Eating DisorderAssess timing of food intakeRegular meals and snacks
Mindful eating with focus on food
Structure areas for eating
Pacing
Weight loss is not the primary goal – leads to shame and keeps people in disordered eating patterns which increases the change of binging
Slide34What to do about WeightsThe weight of the client is not the only issue or even the main issueCrucial to develop trust
Set up plan ahead of time with client
Clients who should always be weighed: AN, laxative abuse, purging, just out of treatment center
Slide35Determining Expected Body Weight
Set at least a 5 pound range – understanding this may change along the way
Growth charts
Weight history
When do behaviors and thoughts begin to diminish?
Don’t aim too low
Slide36Working with ClientsPatients are hesitant to trustSecretive disorder
Has been the driving force of their life
You
won’t automatically be seen as an ally – even if they initiated the appointment
There is a paradox of not wanting to give up the eating disorder and also not wanting to work with someone the eating disorder can fool
They want to know you’re on their side while still challenging their eating disorder thoughts and behaviors
You cannot work on weight loss and recovery from an eating disorder at the same time
Separate the eating disorder from the person
Eating disorder will behave in ways the person client wouldn’t
Feel shameful of their eating disorder behaviors
Slide37Working with ClientsPay attention to your own assumptions
Be
neutral until you know their reaction
Know what matters to your patients – you can use this to make challenges
relevant
Learn to sit in silence with your clients
Listen to what’s not being said
Learn to ask questions differently (sometimes normalizing ED behaviors so they know you won’t be shocked/judge them)
Don’t jump in and try to fix things
Meet them where they are – let them be involved in decision making while also understanding what’s not negotiable
Actions follow thoughts
Slide38Create a Safe Environment for your ClientsHumor, kindness, compassion and empathyTough fairnessSafe environment for client to show frustration and anger
Environment to share and process the relationship with the eating disorder and support them to use alternative behaviors to cope
Explore and understand maladaptive thinking patterns that are directed at the behaviors and understanding the disease
Don’t be afraid of the client.
Slide39Treatment TeamWe cannot work with these clients aloneMulti-disciplinary team of Therapist, Physician, Psychiatrist if neededIdeally the team should be specialist in eating disorders
Obtain release of information to speak to all treatment team members
Talk with clients ahead of time about talking with parents, care takers, spouses
Slide409 Truths about Eating Disorders#
1:
Many people with eating disorders look healthy, yet may be extremely ill.
#
2:
Families are not to blame, and can be the patients’ and providers’ best allies in treatment.
#
3:
An eating disorder diagnosis is a health crisis that disrupts personal and family functioning.
#
4:
Eating disorders are not choices, but serious biologically influenced illnesses.
#
5:
Eating disorders affect people of all genders, ages, races, ethnicities, body shapes
and weights
, sexual orientations, and socioeconomic statuses.
#
6:
Eating disorders carry an increased risk for both suicide and medical complications.
#
7:
Genes and environment play important roles in the development of eating disorders.
#
8:
Genes alone do not predict who will develop eating disorders.
#
9
: Full recovery from an eating disorder is possible. Early detection and intervention are important.
Produced in collaboration with Dr. Cynthia
Bulik
, PhD, FAED and the
Academy for Eating
Disorders
, along with other major eating disorder organizations.
Slide41Prevention of eating disordersPatient centered careThink about the language and terms that we useBroaden the focus; weight is not a behavior we can change
Focus on the person – we are all unique
All weight loss is not good weight loss
Changing a client’s food intake or restriction removes a coping mechanism. Be prepared to help find alternatives and/or work closely with the client’s team so that someone is supporting them