Eating Disorders:Understanding Treatment,

Improving Relationships with Food, and Promoting Positive Body Image

Janelle Fuchs, RD CDRegistered Dietitian

Friday, February 28, 2014

ObjectivesUnderstand factors associated with eating disorder development and maintenance

Recognize medical and cognitive effects of eating disorders

Describe ways health professionals and school personnel can effectively work together to best meet

the needs of students and families Identify potential approaches to preventing eating disorders and addressing body image issues and weight concerns

Where are we trying to go?

Help adolescents…

Eat and be active in tune with the body’s needsEat when hungry and stop when satisfiedEat a variety of foods without a fear of fatAppreciate the bodyThink critically about mediaEmploy many coping skills

ED Onset and Duration

Eating Disorders are NOT about FOOD!

But…

Warning signs with food & exercise

“I already ate”

Early fullness, frequent snacking,

Frequently absent from mealtimes

Sudden change in favorite foods

Hidden stashes of food/wrappers

Conversation constantly revolves around food

Exercising even when ill or injured

Change in sleep patterns

Eating changes with end of athletic season

Standing when sitting is more appropriate

Irritable/angry when exercise routine is interrupted

Eating Disorder Psychological Impact of Poor

NutritionDepression

Dichotomous thinking

Irritability

Poor concentration

Anxiety

Ritualistic behaviors

Obsession with food

Compulsive behaviors

Withdrawal/isolation

Low body weight

Excessive body weight

Low heart rate

Low/high blood pressure

Cold sensitivity

Loss of menses or reduced testosterone

Hair loss

Dry skin

Muscle wasting

Acne

Insulin resistance / T2DM

Swollen glands in face/jaw

Edema

Memory impairments

Headaches/fatigue

Tooth decay and gum disease

Esophagus erosion,tears

Chemical imbalances

Dry skin, brittle nails

Constipation, GI problems

Eating Disorder Physical Impact of Poor

Nutrition

Eating Disorder Developmental Impact of Poor

Nutrition

Cognitive delays

Impaired memory and learning

Delayed emotional maturity

Delayed physical maturity: hormonal, amenorrhea, sex drive

Stunted growth

Bone loss / osteoporosis

Compromised organ tissue

ED cycle

Multi-factorial Nature of Eating Disorders

Food restriction

Genetics

Physical changes

Puberty/Menopause

neurotransmitters

Stressors

Identity/self-image

Personality factors

Perfectionism

Depression

Coping

Cultural factors

Pressure to “fit in”

Normalization of dieting

Media

Food restriction

Genetics

Physical changes

Puberty/Menopause

neurotransmitters

Stressors

Identity/self-image

Personality factors

Perfectionism

Depression

Coping

Cultural factors

Pressure to “fit in”

Normalization of dieting

Media

biology psychology

social/environment

Treatment: Change happens through relationships

TYPICAL TREATMENT RELATED QUESTIONS

Where to start

When, how, and to whom to refer

What does treatment entail?

Who is involved?

How is it covered?

How long does it take?

When is it done?

The Treatment Team

DIETITIAN

Meal planning

Nutrition education

Establishment of weight range

Education regarding physical aspects of ED

Weight monitoring

Strategizing food-related activities

Body image

Teach coping skills

PHYSICIAN

• Medical monitoring and treatment of medical conditions related to ED

• Medication monitoring

• Weight monitoring

• Education regarding physical aspects of ED

THERAPIST

Assess and treat

symptoms of

related diagnoses

(anxiety,

depression, Axis II,

etc. )

Monitor and

address suicidal

thoughts and self

injurious behavior

Explore etiology

and maintaining

factors of eating

disorder

Body image

Teach coping skills

Role of ED Dietitian

Provide specific and/or general nutrition information Medical consequences of eating disorder behaviors Develop a meal plan Determine ideal or goal weight range/BMI Discuss portion sizesFocus on hunger and satiety cues Strategize ideas for meals and snacksIncorporating challenging foods Make changes to the meal planPlanning for special events (parties, wedding, starting a

new job, school, relationship, etc.)Assess dietary limitations (vegetarian, lactose intolerance,

etc.)Activity assessment and recommendations

What is s/he working on?

Examining beliefs about food & body

Recognizing connections between food intake, behavior patterns, and health

Troubleshooting triggering food scenarios

Navigating resistance

Decreasing black/white thinking, increasing flexibility

Practicing challenge foods

The Treatment Team

DIETITIAN PHYSICIANTHERAPIST

THE

FAMIL

Y

“The AED stands firmly against any etiologic model of eating disorders

in which family influences are seen as the primary cause of anorexia

nervosa or bulimia nervosa, and condemns generalizing statements that

imply families are to blame for their child’s illness.”

La Grange, Lock et al IJED 2009

The Treatment Team

DIETITIAN PHYSICIANTHERAPIST

THE

FAMIL

Y

FBT –Family Based Therapy

Observing family meal dynamics

Coach for parents around meals and education of nutrition needs for

adolescent

Broken record advocate for adolescents nutrition needs

The Adolescent in Treatment at school

Adolescent may need support at meals at school

– private place to eat– eat with friends– eat in nurse’s/counselor’s office– parents may need to be present regularly

Adolescent may need to be weighed periodically

– Agreed upon weight protocol (ex. empty bladder, in gown, etc.)

Need collaboration with athletic coaches

Student may need some academic accommodations

– Tutor– Assignments to complete– Time to make up missed work

The Adolescent in Treatment at home

Needs consistent support at family meals at home

- Weight restoration

- Significant commitment in FBT

- Nutrition is #1 priority

Needs food available to meet MP goals

Clear boundaries

Specific times to address ED behaviors

Pay attention to other areas of adolescent’s life

Scales removed from home

Natural consequences for under-nutrition

Avoid commenting on food, body

Modeling healthy eating/ body image

The Adolescent in Treatment

Don’t expect perfection. Plan for “lapses”, “relapses”, and resistance

Normal ups and downs in recovery process

Write specific plans for lapse/relapse scenarios ahead of time.

They can’t just stop. ED’s are not a choice.

How to talk about the food

Ask permission

Be curious

Express a desire for understanding

Be willing to hear many possible responses

Address concerns at non-eating times

Allow space for struggles

Acknowledge “its not about the food”

Vignette

17 y/o female, AN

o/p treatment after residential

Family conflicts

Manipulating MP in anticipation of desserts in IOP

How to address?

16 y/o male, BN

Within IBW, gaining weight

Wavering trust in MP

Considers re-joining cross country team

Do People Recover?

Recovery is a process, a journey

Studies show that at least 50% of people recover fully and go on to live eating disorder free lives

Approximately 25% get better, but still use symptoms

About 20% remain entrenched in the disorder and need long-term treatment

5% die from complications of the eating disorder

What does recovery look like with food and weight for

adolescents?Freedom to choose to eat or not to eat based on physical cues and availability of food vs. anxiety, fear or compulsionAbility to enjoy social interactions involving foodAbility to participate in active play/sports for the purpose of enjoyment vs. weight controlAbility to use multiple coping skills to manage stressTolerating normal fluctuations in body weight and gains appropriate to growth

Normal Eating

Normal eating is trusting your body to make up for your mistakes in eating. Normal eating takes up some of your time and attention, but keeps its place as only one important area of your life.– Ellyn Satter

Talking about Eating Disorders

Focus on eating disorder consequences, not details

Dispel myths, ex. “everyone with an eating disorder is skinny and doesn’t eat”

Provide resources for positive body image and eating disorder information

Promote healthy body image and behaviors that support healthy body image

Emphasize moderation/balance in food, weight, and health

Discuss cultural messages around food as well as appearance

Stress media literacy

Challenge messages about food & weight:

Dieting, Intuitive Eating, and Balance

Discourage dieting and extreme weight control methodsDieting typically fails people; lost weight is regainedUnhealthful weight control behaviors can be dangerous,

do not impact weight positively, and can lead to weight gain later

Encourage Intuitive Eating

Teach/encourage trust in body’s knowledge of hunger and fullness

Avoid labeling foods as “good foods”/”bad foods” and judgment of self based on eating

Encourage balanced living

Teach stress managementFocus on development of self aside from

appearance/weightProvide supports for self-care

Recognizing our Biases

Her meal plan looks so big. How can that be healthy?

She isn’t underweight anymore so she must be okay.

He would be so much happier if he could just lose the weight.

How can his parents send dessert in his lunch when they know he has an eating disorder?

She’s eating fries.. I thought she was working with a dietitian.. Is she really supposed to be eating that?

She has BED. Shouldn’t she be losing weight, not gaining?

Her parents are overweight too. They can’t help her.

Would I eat differently today if I thought it wouldn’t impact my weight?

Health at Every Size

Diets don’t work!

The best way to improve health is to honor your body

Good health can best be realized independent from considerations of size. It supports people—of all sizes—in addressing health directly by adopting healthy behaviors

www.haescommunity.org/

Media Literacy

Media around weight, shape, food, and

appearance is hugeTeach the power of the media, but also the power of the consumer

Introduce popular cultural material as examples-or have students bring examples

Encourage assertiveness and thoughtful consumption of media

Challenge media messages about attractiveness and thinness

Support media literacy Educate! Pictures are altered before printing Educate about mixed and misleading messages sent by

media

Challenge internalization Media messages can be sensational and degradingCritical viewing of media can help prevent internalization

of message

Speak when spendingMedia is created for products that are soldUse personal resources to decrease sales one person at a

time

Increase positive messagesAddress weight related teasing

Talking to an individual you suspect is struggling

Gather data

Complete assessments, screening questionsWatch, listen, ask questions, talk to support people

Communicate concerns“It seems like you are not eating lunch very often, but are in the

library instead”“Your teammates are concerned with the amount of exercise

you doing above and beyond the team workouts.”

Elicit feedback“Can you tell me more about these things?”“What do you think about the things I’ve mentioned?”

Have information on resources available“I think it would be helpful for you to get some more assistance

with these issues. Who do you think we should talk to about this?

“I’m happy to help you and your family with making an appointment with a psychologist and/or a dietitian.”

“The Emily Program is a resource that you may be interested in. I have this brochure about their services. Would you be willing to look at it with me?

Repeat as necessary

THE WORST LONELINESS IS NOT TO BE COMFORTABLE WITH YOURSELF.

-MARK TWAIN

Contact Information

Janelle Fuchs, RD CD

Phone: 206-283-2220 www.emilyprogram.com