ED exam 3

Quest to Be Thin

"Lifestyle choice" rather than an illness Competition Blogs, Social Network Sites MySpaceMySpace FacebookFacebook Tips & tricks to hide it from friends and Tips & tricks to hide it from friends and family

Merits of Internet-based Programs for Eating Disorder Prevention and Treatment

1. Anonymity - can obtain information, participate in chat groups, and interact without disclosure2. Varying models of care 3. Program reach - can reach large numbers often with the use of school-based approaches; can also be directed to selected targeted groups4. Technological benefits provided by current Internet capabilities

Study 3: Methods

61 Hispanic, Black, White, and Asian families in Houston, TX• Across 4 conditions, children were given an individual serving dish containing an entrée along with an empty plate, a serving spoon, and fixed portions of other familiar foods• Conditions varied by amount of entrée (275 vs. 550 g) and serving spoon size (teaspoon vs. tablespoon)• Parents completed the Caregiver's Feeding Styles Questionnaire

What is amenorrhea?

A symptom, not a disease - Lack of menstrual periods, characterized by estrogen deficiency, similar to menopause Among female athletes - ~20% stop having regular menstrual periods - Sports with highest prevalence include • 19 - 44% of ballet dancers • 24 - 26% of competitive runners

Acrocyanosis and Hypercarotemia

Acrocyanosis- blue/purple hue at ends of extremities due to reduced blood flow as a result of vasoconstriction due to cold stress and volume depletion. Vanishes early in treatment.Hypercarotenemia- patients body is yellow-ish but the eyes remain white; no symptoms

A typical adolescent medicine patient

Admitted through clinic or ER For malnutrition, bradycardia, hypothermia Anorexia nervosa, Bulimia nervosa, EDNOS

Treating Anorexia Nervosa (AN)

Anorexia is a psychological disease with medical and nutritional consequences Team must be interdisciplinary Psychotherapy, medicine and nutrition "Taking the eating disorder away" Nutritional Supplements Including families

WEEK 4-5: THERAPEUTIC SKILLS

Communication Noticing versus Policing Validation Barriers to Communication Coping Distress Tolerance Caretaker Styles

Medical/physical data with nutritional implications might include the following:

Deficiency/depletion signs might include hair loss, Deficiency/depletion signs might include hair loss, skin breakdown, amenorrhea, loss of subcutaneous skin breakdown, amenorrhea, loss of subcutaneous fat, lanugo, cold intolerance, dental problems, fat, lanugo, cold intolerance, dental problems, constipation.constipation. Measurement of basal metabolic rate.Measurement of basal metabolic rate. Bone mineral changes.

weight formulas

For patients < 12yoBMI at 50th%ile for age x Ht (cm)2/ 10,000 For patients >17yoHamwi MethodMales: 106 pounds + 6 pounds for every inch over 5 feetFemales: 100 pounds + 5 pounds for every inch over 5 feet

ADOLESCENT ROLE

Give self and expect permission to eat adequately; deserve to eat. Willingness to work on mindful eating skills. Plan to eat at structured times and places. Practice focused eating exercises. Be willing to try new foods and eat until satisfied.

PROTECTIVE NATURE OF FAMILY MEALS

Greater frequency of family meals associated with less endorsement of ED behaviors Possible mechanisms: parent modeling, connecting through conversation, regular observation of teens eating behaviors and emotional health, reversal of malnutrition Protection lessened, but still significant, when family environment is less than optimal

Health Consequences of Luteal Phase Deficiency

Possible precursor to secondary amenorrhea• Infertility problems• Decreased bone mineral density• Increased risk of stress fractures and other musculoskeletal problems• Increased risk of premature osteoporosis

WEEK 3: MEAL PROCESSING

Providing feedback on experience Providing clinical observations Establishing concrete goals WEEK 3:

Growth data should include the following:

Record current weight and height. Plot weight and height on National Center of Health Statistics (NCHS) growth chart. Calculate ideal body weight. Determine percent ideal body weight.

DIVISION OF RESPONSIBILITY

STRUCTURE + PERMISSION = INTERNAL REGULATION parents = Decide what, when, and where to serve meals and snacks. kids/teens = Decide how much and what to eat from what is offered.

Study 1: Development of the Caregiver's Feeding Styles Questionnaire

Specific Aim: To develop and validate a measure of feeding styles among low-income families with preschool children

Study 2: Feeding styles, children's dietary intake, and weight status

Specific aim: To associate feeding styles with children's dietary intake and weight status controlling for correlates

Study 3: Effects of portion size on children's self-served entrée portion and intake

Specific aim: To test the effects of a pasta entrée available on children's self-served entrée portions and intake

In-depth evaluation of athletes identified as high risk for the Triad by the Screening Questionnaire

The second section of the document outlines the guidelines for the physician that should be undertaken once a female athlete has been identified at risk for the female athlete triad in the initial screening process. This section reviews important questions to ask during the History which will provide a clearer picture of the current health status of the athlete. This section focuses on details related to eating habits and attitudes towards body image. A detailed nutritional analysis of energy availability can be completed in cooperation with a registered sports nutritionist.

reatment of Relative Energy Deficiency in Sport (RED-S)

athletes categorized in the red light and yellow light zones should receive medi-cal evaluation and treatment. the treatment of ReD-S should be undertaken by a team of health professionals including a sports medicine physician, sports dietician, exercise physiologist, athletic therapist or trainer, sports psychologist / sports psy-chiatrist as needed. Patient confidentiality must be maintained. Treatment should focus on correcting the relative energy deficit through increasing energy intake and / or decreasing energy output. intake of nutrients and other vitamins should fol-low established guidelines. Repeat assessment of BmD should occur at intervals of 6 - 12 months, depending on clinical presentation and initial values.the use of an athlete contract is also recommended. (See Appendix)

purging by vomiting

hydrogen ion leaves the body when you vomit aka electrolyte abnormality so too much bicarbonate accumulates so metabolic alkalosis occur

insulin

major anabolic hormone aka refeeding syndrome. when we start eating more then insulin goes up

Demandingness feeding style

the degree to which parents do something to encourage or discourage children's eating

Physiologic Changes Skeletal System

• Osteopenia• Fractures - may include compression fractures

Sport Participation based on Risk Category

"High Risk - Red Light": no clearance for sport participation.Due to the severity of his / her clinical presentation, sport participation may pose serious jeopardy to his / her health and may also distract the athlete from devoting the attention needed for treatment and recovery. "Moderate Risk -Yellow Light": cleared for sport participation only with super-vised participation and a medical treatment plan. Re-evaluation of the athlete's risk assessment should occur at regular intervals of 1 - 3 months depending on the clinical scenario to assess compliance and to detect changes in clinical status. "Low Risk - Green Light": full sport participation.

NOTICING WITHOUT POLICING

"How was your day?" "You seem down are you okay?" "When I see (insert behavior) I feel a little worried." "Your eating seems faster today, is something bothering you?" "Do you want to sit down and make a plate with me?" Focus on hunger/satiety Promote identifying and labeling of feelings

Health Consequences of Primary Amenorrhea

(Absence of periods by age 16)• Increased risk of scoliosis• Failure to reach peak bone mass• Increased risk of osteoporosis

Physical signs of Eating Disorder:

(lanugo, parotid gland enlargement, carotonemia)

Responsiveness parenting style

(nurturance) the degree to which parents encourage individuality, self-regulation, and self-assertion by being familiar, supportive, and accepting of children's needs and demands

demandingness parenting style

- (control) parental expectation, supervision, and disciplinary efforts to promote developmentally appropriate behavior in children

Symptoms of hypokalemia:

- Nausea, vomiting- Constipation, weakness- EKG changes- Cardiac arrhythmia and sudden death

• Symptoms of hypomagnesemia

- Tremor- Nausea, vomiting- EKG changes- Tetany, seizures, coma

Renal and Electrolytes

• Hypokalemia (low potassium)- Usually due to self-induced vomiting or diuretic/laxative abuse- May result in cardiac arrhythmias: a major cause of death in EDs- Muscle myopathy- Increase renal abnormalities renal failure- May cause intestinal dysmotility, constipation, muscle myopathy, nephropathy • Hypomagnesemia- May be associated with hypocalcemia or hypokalemia- Will only resolve if magnesium is replaced• Hypophosphatemia- Can occur during refeeding • Hyponatremia (low sodium)- Can be due to excessive "water loading", dehydration of total body sodium- May result in seizures• Other electrolyte abnormalities include hyochloreima and alkalosis- These are seen with frequent purging- Hypochloremic metabolic alkalosis

Physiologic Changes Fluids and Electrolytes

• Hypokalemia• Hyponatremia• Hypochloremic alkalosis• Elevated blood urea nitrogen• Inability to concentrate urine• Decreased glomerular filtration rate• Ketonuria

Resolving the problem of female triad

• If you are struggling with balancing food intake, stress, exercise, seek counseling- physician, dietitian, counselor• Exercise 5 - 15% less and increase caloric intake and weight- sometimes less than 5 pounds makes the difference

Decrease Bone-Mineral Density (BMD)

• Increased risk of low BMD is seen in both females and males with AN; also with B- Associated with reduced bone turnover, decreased bone formation, and bone-resportion markers• Multi-factorial etiology of ↓BMD- Reduced bone accretion, high cortisol levels, hypo-estrogen, and low testosterone levels- low calcium and vitamin D intake- low body weight

5 Recommendations for Health Care Providers Preventing Obesity and ED

1. Inform young people that dieting, especially unhealthy weight control behaviors, may be counterproductive. Encourage positive eating and physical activity.2. Do not use body dissatisfaction as a motivator for change. Instead, nurture through healthy eating, physical activity and positive self-talk. 3. Encourage families to have regular meals and healthy choices.4. Encourage families to avoid weight talk; do more to help achieve weight that is healthy.5. Assume overweight children and adolescents have weight mistreatment and address this with the child.

2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionist in Eating Disorders. This document FINALLY updates the 2011 standards and was just published.

There are three levels of practice: Competent Practitioner is an RDN either just starting practice or recently transitioning to new focus are in nutrition and dietetics. Proficient Practitioner: RDN who generally has 3 or more years beyond credentialing. They likely have the CEDRD credential - which required advanced education through the International Association of Eating Disorders Professional (iaedp). Expert Practitioner recognized within the profession has master the highest degree of skin in and knowledge. Generally practice is more complex and has a high degree of professional autonomy and responsibility. Standards reconfirms: The RDN does not provide an ED diagnosis. Trigger - is an antecedent that generates or provokes an ED behavior as a copying mechanism.

Dietary patterns associated with eating disorders

Vegetarianism, ortho-rexia "Cereal lovers" Fat phobias Overestimation of calories Group support and internet chat rooms Pro Ana websites

BREAK THE CYCLE

WEEK 1: Intake WEEK 2: Family Meal WEEK 3: Processing Family Meal WEEK 4: Skills Based Learning WEEK 5: Skills Based Learning WEEK 6: Relapse Planning & Termination

Internet Weight Loss Studies 2

Weekly email contact with a human counselor resulted in significant weight losses in most studies.The range of weight losses at 6 months within the behavioral treatment groups was 4.1 kg to 7.2 kg vs 2.6 kg to 1.6 kg in the control conditions. Human email counseling group at 6 months achieved significant weight loss compared to computer-automated feedback or control groups

Societal Influences

Weight sensitive societyWeight sensitive society Expectations of thinness may be present at age 6-7Expectations of thinness may be present at age 6-7 Barbie's measurements if she were a real personBarbie's measurements if she were a real person 5'9', 110 pounds (76% IBW)5'9', 110 pounds (76% IBW) 39-18-33 39-18-33 Miss America's body weights 13-19% below idealMiss America's body weights 13-19% below ideal Many media ideals fit criteria for Anorexia Nervosa

Estimation of Ideal Body Weight

When 17 years and > : Hamwi Formula: Males: 106 pounds + 6 pounds for every inch over 5 feetFemales: 100 pounds + 5 pounds for every inch over 5 feetNote that this is for older individuals to estimate IBW

Personal History: My Comfort in Counseling Situation

Before becoming a practitioner one should also ask themselves:• Can I listen to another's struggle with food and behaviors without relating it to myself? Without talking about my own struggles?• Can I be nonjudgmental at all times?• Can I accept that my clients may have different values than I do?• Can I be patient if people don't do what I want them to do? Am I able to be flexible and change the course when something is not working?

Selection of feeding method must consider the following:

Caloric intake PTA Eating Disorder Points Menu System to gradually increase intake, without focusing on calorie level of foods. Liquid supplements orally/enterally when necessary. Relearning internal cues for appetite and an appropriate response is the optimal goal.

Feeding Style Differences in Food Parenting Practices Associated With Fruit and Vegetable Intake in Children From Low-income Families

DISCUSSIONAlthough previous literature hasshown that indulgent parents havechildren who eat less healthy foodand who have a higher weight sta-tus,8,17,19,20 little is known about themechanisms that might help explainthese relationships. The first goal ofthe current study was to examine therelationship between feeding stylesand food parenting practices. Thefindings are consistent with theauthors' theoretical conceptualizationof the 4 feeding styles. For example, uthoritative parents were highest onteachable moments and uninvolvedparents were lowest. Similarly, authori-tarian parents were highest on firmdiscipline and indulgent parents werelowest. The remaining differenceswere as expected, with the exceptionof the uninvolved and authoritativeparents not differing on firm disciplineand both showing moderate levels.These findings help validate thismeasure of food parenting practice byshowing associations with a validatedfeeding style measure.The current study also expandsprevious literature on feeding stylesby examining the second aim of the oderating effect of styles on the rela-tionship between food parentingpractices and child F & V intake. Themost important finding was thatwhen indulgent parents restrictedjunk foods when trying to controltheir children's intake, their childrenconsumed more F & V. In contrast,when indulgent parents used variouspractical methods to get their childrento consume F & V, their children con-sumed fewer servings.The first finding is in contrast withother studies that have shown feedingrestriction is associated with increasedchild intake for the restricted foods(snacks and low-nutrient energy- ng F & V was not collected. Finally,generalizability of the results may belimited because the study only fo-cused on 1 socioeconomic group (ie,low-income families). RESULTSDevelopment of the FoodParenting Practice MeasureThe development and assessment ofa food parenting practice measurethat examines moderation effects isdescribed in this study; the results ofthis measure assessment are reportedhere. The authors aggregated the datafrom the individual card sorts com-pleted by the 667 Head Start parentsto develop a group co-occurrencematrix that indicated the number oftimes that each food parenting prac-tice was sorted together with everyother practice. Proximities data werecalculated from the aggregated co-occurrence matrix and analyzed byusing a combination of multidimen-sional scaling and hierarchical clusteranalysis.42 The results of these analy-ses suggest that Head Start parentshad cognitively organized the 33food parenting practices, presented tothem in the form of individual cards,into 5 clusters consisting of between4 and 10 practices each (Table 2). Theauthors interpreted the clusters basedon face validity. Based on how thestatements were categorized, the in-vestigators decided to label the generalidea of what the food parenting prac-tices in each group described. For ex-ample, the food parenting practices''to tell your child that eating F & Vwill make them strong and healthy''and ''to use mealtimes to teach yourchild about healthy eating''wereboth categorized in the same groupby parents, and the investigators de-cided that both practices describeteachable moments. ABSTRACTObjective: To examine the moderating effects of feeding styles on the relationship between food parent-ing practices and fruit and vegetable (F & V) intake in low-income families with preschool-aged children.Design: Focus group meetings with Head Start parents were conducted by using the nominal group tech-nique. Parents completed information on food parenting practices and feeding styles. Three dietary recallswere collected on each child.Setting: Parents completed measures in Head Start centers and/or over the telephone.Participants: 667 parents of preschool-aged children participated.Outcomes: Food parenting practices and F & V intake.Analysis: Mean differences in the food parenting practices across the 4 feeding styles were establishedthrough multivariate general linear modeling using MANOVA. Moderated multiple regression analysiswas conducted to examine the moderating role of feeding style on food parenting practices and child F& V intake.Results: The indulgent feeding style moderated the relationship between food parenting practices andchild F & V intake.Conclusions and Implications: This study indicates that parents' feeding styles have a moderating effecton the relationship between the food parenting practices and children's F & V intake. This finding canfacilitate the development of interventions aimed at reducing childhood overweight.Key Words: feeding styles, food parenting practices, child, fruit and vegetable intake, focus group (J NutrEduc Behav. 2013;45:643-651.)

ED on the Web

Common Terms Pro Ana = Pro AnorexiaPro Ana = Pro Anorexia Pro Mia = Pro BulimiaPro Mia = Pro Bulimia Thinspro = thin inspiration (black, asian, male, etc)Thinspro = thin inspiration (black, asian, male, etc) Wannarexic = want to be anorexicWannarexic = want to be anorexic GW, UGW, HW, LW = goal wt, ultimate goal, GW, UGW, HW, LW = goal wt, ultimate goal, highest, lowesthighest, lowest Eddie = slang for eating disorder

Lanugo

Develops at low weight and is similar to the fine hair seen on newborns. It is most common on the back and abdomen; takes on the natural hair color of the patient; vanishes with recovery

Background information should include:

Diagnosis Age of onset Weight: pre-morbid and present Height Menses history

Female Athlete Triad

Disordered eating patterns Amenorrhea Low bone density May present as ortho-rexia May present with obsessive exercise

Treatment Difficulties

Everyone is in a way their own expert on food Symptoms are ego syntonic (AN) vs ego dystonic (BN) Defensive families Resistant patients Malnutrition may preclude effective psychotherapy May require less calories for weight maintenance; lower REE (BN)*

Internet Weight Loss Studies

Factors to consider:• Intensity of behavioral treatment• Contact with a human counselor• Frequency of visits to website• Attrition

Do you recognize anyone like this?

Female athletes participating in intense training are at risk of Developing menstrual dysfunctions that can lead to stress fractures, infertility, decreased immune function, decreased bone mineral density, and increased risk of premature osteoporosis

Internet Weight Loss Studies 3

Frequency of visits to the web site (log-ins)Human e-counseling groups generally logged in more frequently than other treatment groups(range 26-33 times over 6 months)Log-ins decrease over time in all groupsTotal log-in frequency associated with weight loss in all groups Attrition rates across studies ranged from 16-27%Attrition rates did not vary by group

Risk factors/female athlete triad

Frequent weigh ins "Win at all costs" Over-controlling parent or coach Social isolation High risk sports

Sample Nutrition Diagnoses for Anorexia Nervosa(AN)

Inadequate energy intake + Disordered eatingDiagnosis of AN or avoidant restrictive food intake disorderIncreased energy needs due to hypermetabolismLack of interest in food due to depressionObsessive desire to lose weightHarmful beliefs about eatingExcessive physical activity + Failure to maintain appropriate weightDepleted adipose and somatic protein storesBradcardia (heart rate < 60 beats/min)AmenorrheaFear of foodLaboratory values reflecting malnutritionHypoglycemiaIrrational beliefs about food effects on bodyRestriction or refusal of food or energy-dense food PES

Internet Weight Loss

Intensity of behavioral treatment results in greater weight loss

WEEK 1: INTAKE

Introduce treatment protocol Psychoeducation Beliefs about food, weight, and weight loss Family organization around food & meals Understanding family dynamics

WEEK 2: FAMILY MEAL

Join with family in understanding relationships and dynamics around food and ED Offer hope that the family can be successful in establishing healthy eating and decrease ED behaviors Provide adolescent opportunity to communicate inner conflict when eating Empower parents to help disrupt disordered patterns

Gilda

Lashing out and rage - chaotic/abuse) - unpredictable behavior. Parents overly involved with daughter's academics, dress, friends, and even pretended emergency to keep control of Gilda - enmeshed. Father is passive in the relationship - "detached" (this is not the same as disconnected).

What is the cause of amenorrhea?

Most accepted theory is "energy availability" theory• Definitions: • Energy availability = dietary intake minus exercise energy expenditure• Exercise stress = everything associated with exercise except its energy cost• Bottom line - if the person is not taking in enough calories to support the reproductive system and they're exercising excessively, body will shut down the reproductive system to provide calories to more important body functions

Edith

Mother is depressed and has mental problems - therefore disconnected a categoryWeight loss has created a crisis; mother was very possessive in the past - very enmeshed relationship - codependency of Edith and mother. Edith has an over sense of responsibility for her mother's feelings and she enjoyed being the "indispensible go-between" in the parent's marriage.

Physical Signs of Eating Disorders

Muscle Wasting

Internet Counseling and Adults at Risk of Type 2 Diabetes

One year study- Two groupsBasic internet - Internet behavioral e-counselingParticipants in e-counseling emailed information to counselor and received feedback daily for 1st month and weekly for next 11 months. Basic counseling -1 email message to submit weight each week, no feedback Results: At 12 months ITT analyses, behavioral e-counseling group lost more weight than basic internet group ( -4.4 kg vs 2.0 kg P=.04)

Continuum of Menstrual Disturbances in Athletes

Ovulatory -> Luteal Phase Defect -> Anovulation -> Oligomenorrhea -> Amenorrhea

Amenorrhea to Oligomenorrhea

Part of a continuum of normal to abnormal menstrual cycles ranging from oligomenorrhea to amenorrhea- Could be primary: absence of periods by age 16- Could be secondary: absence of 3 or more consecutive periods after they are established- Could be luteal phase deficiency: total cycle length is unchanged but luteal phase is shortened- Could be anovulation/oligomenorrhea: absence of ovulation (release of an egg) combined with abnormal cycle lengths

BREAK THE CYCLE: OBJECTIVES

Rediscover the benefits (and fun!) of family meals Develop a flexible approach to eating, enjoying a variety of foods Address factors contributing to emotional eating Implement adaptive coping skills as an alternative to emotional eating Adapt enhanced communication styles amongst family members

Study 2: Results Feeding styles and children's BMI

The indulgent feeding style was significantly associated with higher BMI in children after controlling for known correlates (ethnicity, child gender, child age, parent BMI) and specific psychosocial variables.

Oral Complications &Parotid Hypertrophy

cheeks get wider

The Female Athlete Triad ACSM 1997

disordered eating, amenorrhea, osteoporosis

Relative Energy Deficiency in Sport (RED-S) risk assessment decision making steps for determining readiness for returning to play

prior to returning an athlete to sport / physical activity following time away for ReD-S treatment, an assessment of the athlete's health and the requirements of his / her sport should be undertaken following the step-wise approach:

Self- Help Approach: Strengths and Limitations

strength: -Non stigmatizing -May be empowering -Increased perceived support -Helps to overcome denial and shame -Potentially decrease time and costs -May prepare for more intense treatment limitations: -May decrease feeling of self-efficacy -May decrease motivation -Different books may not have same comprehensive psychological education

purging by laxatives

work on large intestines but food has already been absorbed in small intestine therefore you get electrolyte abnormalities again

How Do Eating Disorders Present?

• 14 year old girl• Became a vegetarian 6 months ago• Began losing a significant amount of weight in the last several months• Exercises daily• Straight "A" student• No period for 2-3 months• Denies having issues with eating or weight

Russell's Sign

• 1979- Gerald Russell- Noticed calluses all over the dorsum of hand caused by repeated rubbing of skin against the upper incisors due to habitual vomiting induced by placement of hand in mouth- There may be 1 - 3 scars caused by repeated trauma to the hand by the teeth as fingers are forced down the throat

Treating Eating Disorders Over the Internet: Review

• 21 studies included in recent literature review of internet-based treatment of eating disorders• Internet treatments reduced:- Psychopathology- Frequency of binge eating and purging- Improved quality of life• Internet-based treatment was more effective for individuals with less co-morbid psychopathology and binge eating- More effective for individuals with binge eating disorder than bulimia nervosa• Therapist support seemed to enhance study compliance

Study 1: Methods

• 231 Hispanic and Black low-income families in Houston, TX• Measures- Caregiver's Feeding Styles Questionnaire- Child Feeding Questionnaire (food parenting practices; Birch 2001)- Parenting Dimensions Inventory (general parenting; Power 2002 )• Anthropometrics measured on the child

Physical/Medical Symptoms: Athletes with Anorexia

• Amenorrhea• Dehydration, especially in absence of training or competition• Fatigue beyond normally expected• Gastrointestinal problems (i.e. constipation, diarrhea, bloating) • Hyperactivity• Hypothermia• Lanugo - fine hair on face and arms• Muscle weakness• Overuse injuries• Significant weight loss beyond weight for adequate performance• Stress fractures

Text Messaging Programs for Weight Control

• An approach of using short message service (SMS, text messaging) for self-monitoring healthy behaviors in children• Children and parents participated in 3 in-person, 90 minute, weekly group education sessions- Increase physical activity, decrease screen time (<1 hr per day), and reduce sugar-sweetened beverages (SSB)- Mobile phones provided and required to send two text messages (one text from parent, one text from child)• Children who self-monitored via SMS technology had somewhat lower attrition rates (28% vs. 61%)• Children preferred programs that incorporated a technological device

Physiologic Changes Hematologic System

• Bone marrow suppressionanemialeukopeniathrombocytopenia• Low sedimentation rate• Impaired cell mediated immunity

Laboratory Evaluations

• Complete blood count• Electrolytes including calcium, magnesium, and phosphorus, BUN, Cr• ALT/AST• Thyroid stimulating hormone • Urinalysis and urine pregnancy test if the patient is sexually active• (Sedimentation rate); (amylase)• (Baseline electrocardiogram)

Interpersonal Psychotherapy (IPT)

• Initially developed for working with adults with depression• Focus is on current patient's life rather than seeking a deeper, underlying source for the problem- The aim is to reduce the symptoms rapidly to improve social adjustment • One-on-one sessions, 12 to 20 treatments over 3-5 months- Phase 1: problem areas identified• Binge eating- looks at triggers because behavior is often caused by interpersonal events- Phase 2: use of potential solutions to resolve problems- Phase 3: more forward looking

Fluoxetine in BN

• One study among adolescents - no controls, 10 patients, all showed improvement in depression and significant decreases in vomiting and binge-eating• Study with adult BN patients undergoing psychotherapy - no differences in eating behaviors or attitudes - ?ceiling effect?

RCT of CD-ROM Based CBT for Bulimia

• Only 2/3 of participants remained in treatment- Those who attended the majority of the CD-ROM sessions had a much higher rate of remission and reduced symptoms at 3 months than those who attended fewer session• Hypothesis #1 Could not demonstrate significant difference of the CD-ROM vs. the 7 month time point in reduction of bingeing and vomiting• Hypothesis #2 People receiving CD-ROM as first step in treatment did get assigned to fewer (5) therapy sessions- Means they showed at least a 50% reduction in purging

Physiologic Changes Gastrointestinal System

• Parotid hypertrophy and dental caries• Constipation and intestinal atony• Delayed gastric emptying• Mallory-Weiss tears• Esophagitis and Barrett esophagus• Esophageal and gastric rupture• Fatty infiltration/focal necrosis of the liver

Sample Questions for Eating Disorders Assessment (general) - Stenick 2017:

• Can you bring me up to date on what brought you here? • Describe your eating on a typical day.• Are you allergic to any foods?• do you ever worry that you will get out of control around food and eat more than you wanted to?• Can you give me an example of what you might eat that feels like way to much? How often does this happen?• What foods are your weakness? Do you avoid them?• Do you ever eat in secret? • Do you wake up in the middle of the night to eat?• Do you ever have trouble keeping food down?• Do you ever feel guilty after your eat? How to you respond to that guilt?

Keys to Refeeding

• Start out low and move slowly!• Start with approximately 30-40 kcal/kg (1000-1600 cal/day)• Increase calories by approximately 200 calories every 1-2 days• Our protocol includes supplementation with neutraphosK BID for the first 5 days of hospitalization (peak risk)• Goal = 2-3 pound gain/week in the hospital; 1 pound gain/week as an outpatient

Technology in the Delivery of Targeted Prevention for Eating Disorders - continued

• Student Bodies: an 8-10 week, Internet-based multimedia program self-help cognitive behavior approach to decrease weight and shape concerns- Psychoeducaitonal reading on body image, media influences, nutrition, dieting physical activity and eating disorders- Cognitive-behavioral exercises- Use of online body image journal to record thoughts, feelings and events that trigger body dissatisfaction- Electronic discussion board or chat room group (moderated or un-moderated)

Study 4 sub-study: Multiple pass coding system during the dinner meal

• Studies of the socialization process have focused on parental strategies used to encourage appropriate behavior• Parents who use highly directive strategies may get children to comply in the short term, but these strategies lead to non-compliance in the long-term• When parents are not there to exert external pressure, the children do not comply- Supported by earlier work on restriction and child overweight ("forbidden fruit")- Need to examine the entire range of strategies, not just the highly directive ones

Risk Management

• Concerns with Internet-delivered prevention and treatment include:- Maintaining confidentiality- Crisis management- Technical difficulties that lead to frustration and reduce compliance by participants• Risk management techniques: password protection, an automated time out of program after duration of no activity, avoidance of using protected health information • Adolescents (in 2009) 14% blogging, 73% using social networking sites (e.g. Facebook, MySpace), 8% using Twitter• 2009 - 75% of adolescents had cell phone (12 yr and older)• Just over half of children in the United States — 53 percent — now own a smartphone by the age of 11. And 84 percent of teenagers now have their own phones.

Follow-Up Nutritional Care

• Continue to keep food records• Episodes of purging or bingeing• Anorexia will often need 50 kcals/kg to gain weight - Hyperkinetic may need 80-90 kcal/kg• Protein intake- Powder supplements - milk, soy based (Vegan)• Cisapride with delayed gastric emptying- Psyllium for constipation (cautionary)• >85% IBW, increase dietary fat (to 20% kcals)

Prevalent Themes from Pro-Ana Websites

• Control- Successful weight loss leads to control of body and life• Success- Measured by weight loss• Perfection- Thinness is perfection• Isolation- People with ED are alone• Sacrifice- Necessary to forego personal relationships to have success with ED• Transformation- Change from "fat and ugly" to "thin and beautiful" • Coping- EDs can be a means of coping with difficult life occurrences such as abuse, death, etc.• Deceit- May have to deceive others• Solidarity- Websites provide an ED community and support system• Revolution- People with AN should channel strength into other areas of life than the need to reform

Studies of Feeding Styles

• Study 1 - An indulgent feeding style was associated with higher child weight status in 231 low-income Hispanic and Black families (parent-report).• Study 2 - An indulgent feeding style was associated with less optimal child eating behaviors and higher child weight status in 718 low-income Hispanic, Black, and White families (parent-report). • Study 3 - An indulgent feeding style was associated with higher child self-selected portion sizes and intake in a laboratory setting with 61 Hispanic, Black, White, and Asian children (parent-report).• Study 4 - (In progress) Examining feeding in the home in more detail by measuring the emotional climate of the dinner meal and parent-child interactions in 148 low-income Hispanic and Black families (observation).

Clearance and Return to Play Considerations

• Difficult decision to return female athletes with disordered eating behaviors to play• Risk assessment tools now available

Disordered Eating and Female Athlete Triad

• Disordered eating adopted by the American College of Sports Medicine (ACM) as part of the Position Stand on the Female Athlete Triad (ACSM, 1997):- Disordered eating- Amenorrhea- Loss of bone mineral density • Disordered eating played a role in the development of amenorrhea due to insufficient energy for physical activity and normal bodily processes- More prevalent among athletes than non-athletes- More prevalent in lean sports than non-lean sport athletes• Disordered eating role in bone health: insufficient calcium and vitamin D

Five Principles of Family Based Therapy (FBT) for Anorexia

• Take an "agnonist" view about the cause• Initially focus on symptoms• Stance of the therapist is constructive and non-authoritarian- Use circular questioning • Parental symptoms management is emphasized• Attempt to separate the disorder of AN from the adolescent- AN is a psychiatric disorder and not a "choice"

Societal Efforts

• The Eating Disorder Coalition - parents and professionals concerned about eating disorders lobby Washington DC for legislative change• American Psychological Association (APA) adopted policy statement regarding prevention of eating disorders and obesity • Tri Delta sorority - steps to end "fat talk" from 2009 but still relevant:

Prevention of Eating Disorders in Children and Adolescents

• Eating disorder prevention can be done at the individual, family, group, institutional, community or societal levels- Individuals: e.g. adolescent girls, athletes- Caretakers: e.g. parents, teachers, health care providers- One-to-one or group settings- Policies can be put in place at institutional or community levels, such as schools, youth activities, fitness centers, and clinics- Societal level - e.g. changing media images• For eating disorder prevention to be most effective, prevention probably needs to be occurring at all these levels

The Female Athlete Body Project

• Eating disorder prevention programs targeting female athletes• Becker's healthy weight (AM-HWI) intervention decreased:- 6 weeks: reduced thin-ideal internalization, dietary restraint, bulimic pathology, shape and weigh concern and negative affect - 1 year: reduced bulimic pathology, shape concern, and negative affect• Becker and colleagues incorporated AM-HWI and dissonance prevention into the Female Athlete Body (FAB) Project• FABII funding from NIH March 2012 to 2017

Primary Prevention of Eating Disorders with Sports

• Efforts should be aimed at athletes, coaches, athletic administrators and parents• Primary prevention work to expand:- athlete knowledge about healthy eating- pathological eating behaviors and consequences- what to do they or a teammate are thought to have an eating disorder• NEDA has developed a Toolkit for Coaches & Trainers on Eating Disorders

Techniques to Facilitate Change

• Traditional role (of the Dietitian) is to provide information- Devise and implement plan• Trust building- Less on nutrition information• Active listening- Show concern and interest; do not be judgemental or show disapproval• Exploration• Reflection

Treatment Guidelines for Athletes

• Try not to go more than 4 hr without eating• Eat CHO snack 2 hr before exercise• Drink 1 cup of water 15 minute before exercise and every 20 minute during exercise• Replace each 0.5 lb lost during exercise with 1 cup water• If exercise > 1 hr, sport drink may be option- Juice and soft drinks not preferred for re-hydration• Include good K and Fe source daily

IOAMC - Healthy Body Image

• Go to the link below to view the "Healthy Body Image" #3 and view the four Satisfy Your Hunger for Gold - the stories are interesting :- http://www.olympic.org/hbi• Short film stories on figure skating, gymnastics and running that illustrate points on the possible link of sport participation and eating disorders/disordered eating.• The 2020 Summer Olympics (Japanese: 2020年夏季オリンピック, Hepburn: Nisen Nijū-nen Kaki Orinpikku), officially the Games of the XXXII Olympiad and commonly known as Tokyo 2020, was postponed due to COVID-19 and was held from July 23 to August 8 2021 in Tokyo, Japan.

Examples of Questions for Restricting Behaviors

• What is your eating like throughout the day?• Are you on a diet right now?• Are there any foods you prefer not to eat? Why?• Is there anything you used to like that you don't eat now?• Do you think you are getting enough to eat?

Examples of Questions for Compulsive Exercise, Body Dysmorphia

• What kind of exercise do you like? How often do you participate• Do you ever plan rest days?• Is you eating different on days you exercise?• How much of your day are you thinking about food, eating and your weight?• How often do you weigh yourself? • How would you like to change your body? Is there one specific part that you notice the most?

Why use CBT for Treatment of Adolescents with BN & BED?

• Works well for adults• Effective therapy with anxiety and mood disorders• BN usually develops after puberty- Brain development probably at stage where CBT will be effective- Adolescents may be more "malleable" to change than adults

Bone Density

• Z scores <-1 at spine and hip for 50%, 30% of adolescents with AN; <-2 for 9% and 10%*• Mechanisms for decreased bone density:- Decreased lean body mass/BMI- Hypogonadism- Nutritionally-acquired resistance to GH- Low IGF-I levels- Increased cortisol levels- ?calcium intake, Vit D, exercise • Bone recovery may be biphasic• Data indicate osteocalcin (bone formation) increases with weight recovery• A decrease in N-telopeptide (bone resorption) occurred with return of menses• May explain why estrogen treatment alone does not improve BMD in cachectic state

• Symptoms of hypophosphatemia:

- Neurologic: paresthesias, weakness, confusion, encephalopathy, areflexic paralysis, seizures, coma, death- Cardiac: decreased stroke volume, mean arterial pressure, left ventricular stroke work; increased pulmonary wedge pressure- Respiratory: impaired diaphragmatic contractility

When Boys Fall Prey to Eating Disorders

-Eating disorders are on the rise among boys, say doctors, who think images and videos on social media are a factor. -

Signs and Symptoms of Starvation

1. Cardiovascular/respiratory - the heart and blood vessels are muscles that are affected by the decrease in muscle tone (the heart actually shrinks), so they are less able to perform their function. - Heart rate declines - a heart rate of less than 40 indicates malnutrition -Respiratory rate declines -Blood pressure declines (hypotension) -Orthostatic hypotension - a drop in blood pressure upon standing, which can cause a 'head rush' and worse -Syncope (fainting) 2.Digestion - the gut is also a muscle, and is unable to move food through if it has no strength. -GI tract motility declines -Nausea, abdominal discomfort, and constipation 3.Metabolic - the body's metabolism slows down to try and conserve energy to help preserve life. -Basal metabolism declines (so fewer calories are being used) -Cold intolerance -Ketosis develops - as the body runs out of carbohydrate as its primary (and favorite) food, it begins to burn fat stores which are converted to ketones, which are not as well used. People who are in ketosis have a peculiar smell, usually described as like nail polish remover -Lean body tissues (muscles) are lost -Mineral and electrolyte imbalances can occur, leading to heart failure -Dehydration 4.Physical - Dry skin -Hair falls out -Lethargy and fatigue set in - lack of energy for physical activity -Sleeplessness may occur -Body and breath odor from ketones become apparent -Decreased libido -Amenorrhea (lack of menstruation) in females -Immunity to illness and bacteria is compromised -Wounds do not heal well 5.Mentally - lack of food and chemical changes in the brain can caused mood and personality changes. -Irritability -Apathy

Screening Questions - Female Athlete Triad/ "Relatively Energy Deficiency in Sports (REDS)"

1. Have you ever had a menstrual period?2. How old were you when you had your first menstrual period?3. When was your most recent menstrual period4. How many periods have you had in the past 12 months?5. Are you presently taking any female hormones (estrogen, progesterone, birth control pills)?6. Do you worry about your weight7. Are you trying to or has anyone recommended that you gain or lose weight?8. Are you on a special diet or do you avoid certain types of foods or food groups?9. Have you ever had an eating disorder? 10. Have you every had a stress fracture?11. Have you ever been told you have low bone density?

"Ana Creed"

1. Thin is beauty; therefore I must be thin, and remain thin, if I wish to be loved. Food is my ultimate enemy. I may look, and I may smell, but I may not touch!2. I must think about food every second of every minute of every hour of every day... and ways to avoid eating it.3. I must weigh myself, first thing, every morning, and keep that number in mind throughout the remainder of that day. Should that number be greater than it was the day before, I must fast the entire day. 4. I shall not be tempted by the enemy (food), and I shall not give into temptation should it arise. Should I be in such a weakened state and I should cave, I will feel guilty and punish myself accordingly, for I have failed her.5. I will be thin, at all costs. It is the most important thing; nothing else matters.6. I will devote myself to Ana. She will be with me wherever I go, keeping me in line. No one else matters; she is the only one who cares about me and who understands me. I will honor Her and make Her proud.

The use of internet sources for nutritional information is linked to weightperception and disordered eating in young adolescents

A B S T R A C T The internet serves as an accessible and confidential resource for young adolescents seeking nutritional in-formation. However, the quality of information retrieved online is mixed and could have serious implications forusers. Young adolescents who perceive themselves as overweight may be disproportionately affected as they areat greater risk for disordered eating. The current study aimed to (1) assess whether the frequency of use ofdifferent internet sources to obtain nutritional information differs between healthy weight young adolescentsand those with overweight/obesity based on both objective and perceived weight status and (2) evaluate therelationships between different internet sources utilized for nutritional information and disordered eating.Young adolescents (n = 167; 10-15 years) completed the Children's Eating Attitudes Test (ChEAT; total dis-ordered eating), indicated their perceived weight status, and reported how often they obtained nutritional in-formation from the following internet sources: professional websites, personal websites, social media, com-mercial weight loss websites, and forums. Objective height and weight measurements were obtained. Youngadolescents that perceived themselves to be a little overweight or overweight reported greater use of personalwebsites (p = .012), commercial weight loss websites (p = .011), and social media (p = .019) for nutritionalinformation than those that did not perceive themselves to be a little overweight or overweight. The frequency ofuse of internet sources for nutritional information did not differ based on objective weight status. Greater use ofeach of the internet sources for nutritional information was related to greater disordered eating (p's < 0.05).While longitudinal research is needed to further examine these relationships, healthcare providers and teachersshould provide young adolescents with guidance for interpreting and using online nutritional information toencourage valid and reliable health recommendations.

Academy of Eating Disorders

A global professional association committed to leadership in ED research, education, treatment and prevention• Promote the effective treatment and care of patients with eating disorders and associated disorders • Develop and advance initiatives for the prevention of eating disorders • Disseminate knowledge regarding eating disorders to members of the Academy, other professionals and the general public • Stimulate and support research in the field • Promote multidisciplinary expertise within the Academy's membership • Advocate for the field on behalf of patients, the public and eating disorder professionals • Assist in the development of guidelines for training, practice and professional conduct within the field • Identify and reward outstanding achievement and service in the field

Academy of Nutrition and Dietetics: Revised2020 Standards of Practice and Standards ofProfessional Performance for RegisteredDietitian Nutritionists (Competent, Proficient,and Expert) in Eating Disorders

ABSTRACTEating disorders (ED) are complex mental illnesses and are not a result of personal choice. Full recovery from an ED is possible. Theseverity and inherent lethality of an ED is undisputed, and the role of the registered dietitian nutritionist (RDN) is essential. Clinicalsymptomology presents at varying developmental milestones and is perpetuated through a sociocultural evaluation of beauty anddrive for ascetic idealism. ED are globally prevalent in 4.4% of the population aged 5 to 17 years, yet affect individuals across the entirelifespan, including all cultures and genders. The Behavioral Health Nutrition Dietetic Practice Group, along with the Academy ofNutrition and Dietetics Quality Management Committee, revised the Standards of Practice (SOP) and Standards of Professional Per-formance (SOPP) for RDNs in Eating Disorders. Including the RDN in ED treatment is vital for all levels of care. The RDN must beperceptive to negative symptoms indicative of psychological triggers when exploring food belief systems, patterns of disinhibition,and nutrition misinformation with clients. Through a conscious awareness of medical, psychological, and behavioral strategies, theimplementation of the SOP and SOPP supports a dynamic and holistic view of ED treatment by the RDN. The SOP and SOPP arecomplementary resources for RDNs and are intended to be used as self-evaluation tools for assuring competent practice in ED and fordetermining potential education, training, supervision, and mentorship needs for advancement to a higher practice level in a varietyof settings.

Dissonance-based Interventions for the Prevention of Eating Disorders: Using Persuasion Principles to Promote Health

Abstract The limited efficacy of prior eating disorder (ED)prevention programs led to the development of dissonance-based interventions (DBIs) that utilize dissonance-basedpersuasion principles from social psychology. AlthoughDBIs have been used to change other attitudes andbehaviors, only recently have they been applied to EDprevention. This article reviews the theoretical rationale andempirical support for this type of prevention program.Relative to assessment-only controls, DBIs have producedgreater reductions in ED risk factors, ED symptoms, futurerisk for onset of threshold or subthreshold EDs, future riskfor obesity onset, and mental health utilization, with someeffects persisting through 3-year follow-up. DBIs have alsoproduced significantly stronger effects than alternativeinterventions for many of these outcomes, though theseeffects typically fade more quickly. A meta-analysisindicated that the average effects for DBIs were signifi-cantly stronger than those for non-DBI ED preventionprograms that have been evaluated. DBIs have produced Conclusion and Directions for Future ResearchIn sum, DBIs appear to represent a promising new directionfor ED prevention. They have produced intervention effectsfor ED symptoms and risk factors relative to an assessment-only control condition in four trials conducted by sixindependent labs. DBIs were also superior to four alternativeinterventions in multiple trials, and produced certain effectsthat persisted through 3-year follow-up. DBIs also have beenfound to produce prophylactic effects, reducing the risk forincreases in bulimic symptoms in one trial and the risk forobesity onset and bulimic pathology onset in a second trial.Based on these trials, it appears that the DBI hasreceived enough empirical support to be termed efficacious,setting it apart from other ED prevention programs. Ac-cording to guidelines set by the American PsychologicalAssociation (1995), an intervention that produces signifi-cantly stronger effects than a waitlist or measurement-onlycontrol condition in at least two trials conducted byindependent labs and significantly stronger effects than aplacebo or alternative treatment can be considered empir-ically supported. Because the healthy weight interventionhas also received enough empirical support to be consid-ered efficacious, it is tempting to consider combining thesetwo interventions, as an integrated program may yieldlarger effects. However, at this point there is insufficientevidence to suggest these approaches should be integrated,as more independent replications of the healthy weightintervention are necessary. It could be that the socialpsychological principles incorporated into both the DBI andhealthy weight programs are the important features that havecontributed to the success of both programs. More research isneeded to tease apart the specific components of each programthat make them successful. Future research should also focuson methods to enhance the magnitude and persistence of theeffects of DBIs, particularly prophylactic effects.

WEEK 4-5: NUTRITION SKILLS

Address nutrition misinformation Provide meal planning guidelines Clarify roles and responsibilities Work with teen on unstructured time (after school and late p.m.) Discuss snack options with teen

Minnesota Starvation Study

Ancel Keys, PhD Post World War IIPost World War II Nov 19, 1944 - Dec 20, 1945Nov 19, 1944 - Dec 20, 1945 Objective: to determine the physiological and psychological effects of physiological and psychological effects of severe and prolonged dietary restriction severe and prolonged dietary restriction effectiveness of dietary rehabilitation strategies effectiveness of dietary rehabilitation strategies 36 "conscientious objectors" White males ages 32-33White males ages 32-33 Healthy & psychologically normal 4 phases 12 week control (3200 kcal/d)12 week control (3200 kcal/d) 24 week starvation (1800 kcal/d)24 week starvation (1800 kcal/d) 12 week restricted rehab period (varied)12 week restricted rehab period (varied) 8 week (no limit) 8 week (no limit) Anthropometric, physiological, & psychological tests Goal - 25% body weight reduction Work tasks, 22 miles/week, personal diary Results Decreases in BMR, temperature, respiration, & Decreases in BMR, temperature, respiration, & heart rateheart rate Increases in depression, hysteria, and Increases in depression, hysteria, and hypochondriasis hypochondriasis Preoccupation with food during starvation & Preoccupation with food during starvation & recovery phaserecovery phase Decreased sexual interestDecreased sexual interest Social withdrawal & isolation

Nutritional counseling

Develop a non-judgmental communication style. Challenge non-critical thinking. Be careful not to label foods as good or bad. Plan food challenges that encourage the patient to safely expand his or her diet. One challenge per week is usually a good goal. Normalize portion sizes and meal patterns. Present all information with as little detail as possible. Frequency of visits will change as the patient progresses. The goal is to increase the time between visits so the patient is less dependent on the dietitian.

Study 2: Results Feeding styles and f & v food parenting practices

Differences were found across the feeding styles on parent's perception of the effectiveness of a number of fruit and vegetables directives• Practical methods (mixing F & V with other foods)• Firm Discipline (insisting the child sit at the table until finished)• Enhanced availability (putting F & V within reach)

Mindful Eating Questionnaire

During the CDR Weight Certification Training Program a few years ago a questionnaire was shared which can be used to assess eating habits and help clients/patients become more aware of their own mindless eating patterns. There is a scoring tool to identify components of eating which may benefit from additional counseling. Attached also is the reference (which does not reverse the scoring) from which this questionnaire was developed. Norms are NOT provided in the publication. Depending on whether or not the scores are reversed (as the scoring page indicates), higher or lower ends of the range of 1 to 4 of the average subscore may help identify areas to focus any behavioral therapy

GOALS OF NUTRITION THERAPY FOR ADOLESCENT BED

Empower parents and teen to give permission to eat adequately from wide variety of food. Restore internal regulation through structured eating. Resolve negative feelings about eating. Learn to pay attention while eating. Learn strategies for making mealtime pleasant and rewarding. Incorporate parents as supportive providers of reliable meals and snacks.

GUIDE TO THE CLINICIAN

Engage parents in discussions about the importance of making frequent family meals a priority. Provide guidance for parents on how to create familial interaction and mealtime atmosphere conducive to development of healthy food/weight-related behaviors in adolescents.

Erythema ab igne and Pellagra

Erythema ab igne- darkening of the area of the body to which the patient constantly applies heat; no symptoms; usually on lower back or abdomen; it is permanentPellagra- a dark, flaky rash over the front of the lower extremities

Study 2: Results Feeding styles and children's dietary intake

Evening intakes of fruit, juice, vegetables, and dairy were lowest for children of indulgent and uninvolved parents compared to children of authoritarian parents

Nutrition Diagnoses Binge Eating Disorder (BED)

Excessive energy intakeExcessive oral food/beverage intake + Disordered eatingDiagnosis of BED or night eating syndrome (NES) + Body fat > 32% (women) or > 25% (men)BMI > 25 (adults) or > 95th percentile for childrenWeight gainIntake of high caloric density or large portions of food/beveragesBinge eatingEating a majority of total caloric intake during the nighttime hours

Sample Nutrition Diagnoses for Bulimia

Excessive energy intakeExcessive oral food/beverage intake + Disordered eatingDiagnosis of BN Resolution of prior hypermetabolism without reduction in intake + Body fat > 32% (women) or > 25% (men)BMI > 25 (adults) or > 95th percentile for childrenWeight gainIntake of high caloric density or large portions of food/beveragesBinge eatingEmotional Eating

Medical Complications with Eating Disorders

Fluids and electrolytes: Usual nl but may have low Na, Cl, & K AN. Hypokalemic, hypochloremic, metabolic alkalosis with dehydration; Hyponatremia, diarrhea with laxative abuse BN. Metabolic: Fasting hypoglycemia, ↑ FFA, hyper/hypo cholesterol, hypercortisolism, osteopenia and ↓ bone mass AN. Same as for AN Low Zn BN. Cardiovascular: Bradycardia, hypotension, EKG changes; sudden death, MV prolapse, congestive cardiomyopathy, refeeding edema AN. Same as for AN Ipecac cardiomypopathy Pedal edema BN Pulmonary: Decreased FEV1, rib fractures, subcutaneous emphysema, pneumomediastinum AN. Bradypnea, aspiration pneumonitis BN Gastrointestinal: Constipation, delayed gastric emptying, acute gastric dilation, ↑ transaminases, ↓ alkaline phosophatase. AN. Parotid swelling, palate lacerations, impaired taste, enamel erosion, increased cariesGastroesophageal reflux, ulcers, esophageal tearing and perforation, pancreatitis, gallstones BN. Renal: Abnl. Renal function test, ↑ urea and creatinine, ↓ glomerular filtration rate, polyuria AN. Same as AN Hematuria Nephropathy Pyuria BN Endocrine: Amenorrhea; Low LH, FSH, estradiol, TSH, T3, T4; High cortisol and GH, erratic ADH AN. Menstrual irregularitiesPolycystic ovaries BN Hematological: Anemia, leukopenia, thrombocytopenia, bone marrow hypocellularity AN. Anemia secondary to blood loss BN Immunological: ↓ complement factors AN Neurological: CT, MRI, PET scan abnormalities; metabolic encephalopathy with seizures AN. Metabolic seizures BN Dermatological: Brittle hair and nails, yellowish skin due to hypercarotenemia, dry skin, lanugo hair AN. Russell's sign Muscle weakness BN

A diet history should include:

History of weight conflicts and fluctuations.History of weight conflicts and fluctuations. Weight loss techniques.Weight loss techniques. Pre-morbid intake and intake before admission, Pre-morbid intake and intake before admission, appetite changes, and patterns of elimination.appetite changes, and patterns of elimination. Dietary analysis of intake prior to admission.Dietary analysis of intake prior to admission. Level of exercise and activity.

Physiologic Changes Neurophysiologic

Impaired:• Attention and concentration• Visual associative learning• Problem-solving• Attention-perceptual motor functionAlso:• Psychomotor slowing• Poor planning; lack of insight

Internet for Weight Maintenance

In both studies, the human contact groups regained significantly less weight than the control groups(2.5 kg over 18 mon; 4 kg over 30 mon)The internet groups regained almost as much weight as the control groups. (4.7 kg vs 4.9 kg and 5.2 kg vs 5.5 kg)

POTENTIAL OBSTACLES

Parent expectations for weight loss Parent difficulty in trusting protocol Influence of social media and proliferation of misinformation Life-long beliefs and behaviors to "un-do" Divorced Families Parents own disordered eating/ED

Treating Bulimia Nervosa (BN)

Patients are ~ within 10% IBW Depression may be an associated feature Significant weight fluctuations are common Patients describe an "out of control" experience with food Unlimited binge foods PopcornPopcorn Sugar free jello

Paula

Paula was close to mother but as she starts to separate her mother tried to pull her back by reverting to former behavior to re-create closeness - enmeshed. Parents critical remarks and belittled friends of Paula to keep her to themselves. Enmeshed was the primary family type but; eventually becoming somewhat chaotic (not needed for answer).

NCHS Charts

Plot weight and height on National Center of Health Statistics (NCHS) growth chart Example: 16 yr boy, 42.1 kg,168 cm1.Stature percentiles (10-25th)2. Weight percentiles (< 5th)3. Determine child's percentiles at 50th~ 61.5 kg IBW= 42.1/61 = 68.5% IBW

Associated features

Protein energy malnutrition Physical condition precludes effective psychotherapy Marasmuspreservation of visceral proteins iron deficiency anemia is rarelow BUN refeeding syndrome Weakness, lethargy, fatigueWeakness, lethargy, fatigue Hair loss, dry skinHair loss, dry skin Inability to concentrateInability to concentrate Cerebral atrophy, shrinking of the brainCerebral atrophy, shrinking of the brain ConstipationConstipation Early satiety, feeling fullEarly satiety, feeling full Bradycardia, slow heart rateBradycardia, slow heart rate Orthostatic instability, feeling light headed and dizzy

recognition and treatment of deficient energy intake among athletes

Registered Dietitians (RDs) who work with active people and athletes recognize the deleterious effects of energy deficiency on health and performance. The International Olympic Committee (IOC) introduced the syndrome1, Relative Energy Deficiency in Sport (RED-S), in 2014 to emphasize recognition of risks described in the Female Athlete Triad to include males and various ethnicities. RED-S introduces a hub and spoke diagram to illustrate the interplay of physiologic and psychological dysfunction and morbidity, and utilizes a stoplight ('Red Light-Yellow Light-Green Light', representing high-risk, moderate-risk and low-risk athletes, respectively) as a simple means of representing to athletes the general pattern of return-to-play. Consumption of inadequate energy to meet nutritional needs may be acute or chronic and relate to decreases in appetite, lack of understanding regarding need, poor diet selection, seasonal variability, travel, time management, planning and preparation, fad diet trends and disordered eating or eating disorders (DE-EDs). DE-EDs are prevalent in sport and may accompany a deficient energy intake, through either initiation or exacerbation of under fueling. While any athlete may be at risk, DE-EDs are most common in endurance, weight sensitive, aesthetic2, and gravity defying sports.

Micronutrient deficiencies

Riboflavin Protein/energy metabolismProtein/energy metabolism Pyridoxine Depression/stressDepression/stress Zinc Sensation of taste, regulation of appetite, Sensation of taste, regulation of appetite, reproduction, growthreproduction, growth Elevated retinol Delayed clearance of lipids

Study 4: Observational study of low-income families during the dinner meal

Specific aim: To understand how the emotional climate of the dinner meal and parent-child interactionscontribute to child intake and weight status

AND Practice Groups

Sports, Cardiovascular, and Wellness Nutrition (SCAN) has now divided into two practice groups: https://www.scandpg.org/new-dpg-launch- Sports and Human Performance- Cardiovascular Health and Wellbeing• Academy of Nutrition and Dietetics has pocket guide- Second Edition updated (2016) with Jessica Setnick- Nutritional Assessment- Education Interventions- Counseling Interventions• Disordered Eating Professional Resources • Academy for Eating Disorders: - http://www.aedweb.org/

Study 4 sub-study: Bi-directional coding system to link parent/child interactions to outcomes

Sub-study aim: To develop a bi-directional coding system for use with the videotapes to code detailed parent-child interactions during the dinner meal

Female Athlete Triad versus Relative Energy Deficiency in Sports (RED-S)

The female athlete triad was officially described in 1997, by the Task Force on Women's Issues of the American College of Sports Medicine (ACSM), as a syndrome often observed in physically active girls and women with three distinct medical disorders including disordered eating, amenorrhea, and osteoporosis. The most recent Consensus Statement from the ACSM in 2017, uses new terminology to describe these three interrelated components: energy availability, menstrual function and bone health. Energy availability, as defined by the ACSM, is the amount of energy leftover and available for normal body functions after the energy expended for training is subtracted from the energy taken in from food. Low energy availability may be unintentional or a symptom of disordered eating or an eating disorder. It may be common in weight sensitive sports where leanness and body weight are important due to their roles in performance, and these athletes may be at a greater risk of disordered eating. However, the ACSM states athletes of any sport may be affected by low energy availability. While the term Female Athlete Triad may be more commonly referenced as an aspect of energy availability and performance, the concept of energy deficiency is not unique to females as noted in more recent research. Introduced in 2014, and revisited in the 2018 International Olympic Committee (IOC) Consensus Statement, Relative Energy Deficiency in Sports (RED-S), as coined by the IOC, emphasizes that the syndrome effects all athletes and not just females.Normal body functioning is impaired in RED-S due to relative energy deficiency and can affect metabolic rate, menstrual function, bone health, immunity, growth and development, protein synthesis and cardiovascular, gastrointestinal and psychological health. In addition, RED-S may lead to a gradual reduction in the athletes' performance by a number of factors including; decreased endurance, increased risk of injury, poor response to training, impaired cognitive function, decreased coordination, decreased concentration, irritability, depression, decreased glycogen stores and decreased muscle strength.Due to the implications, athletes need expert guidance regarding nutrition and its relationship to physical activity, performance and recovery. As research continues to evolve, sports dietitians must understand the complexity of these conditions, while working with a multidisciplinary team to help prevent and correct inadequate energy intake in athletes. Guidelines are available for the evaluation and treatment of both the Female Athlete Triad and the RED-S.

What is Relative Energy Defi ciency in Sport?

The syndrome of RED-S refers to impaired physiological functioning caused by relative energy defi ciency, and includes but is not limited to impairments of metabolic rate, menstrual function, bone health, immunity, protein syn-thesis, and cardiovascular health. the cause of ReD-S is the scenario termed "low energy availability", where an in-dividual's dietary energy intake is insuffi cient to support the energy expenditure required for health, function, and daily living, once the cost of exercise and sporting activities is taken into account.the potential health consequences of ReD-S are depicted in the ReD-S conceptual model (See figure 1). psychological problems can be both the result of and the cause of ReD-S.

Social network media exposure and adolescent eating pathology in Fiji Anne E. Becker, Kris

basically pre television fiji people had no EDs and then television got introduced and the rates of ED increased. Background Mass media exposure has been associated with an increased risk of eating pathology. It is unknown whether indirect media exposure - such as the proliferation of media exposure in an individual's social network - is alsoassociated with eating disorders. AimsTo test hypotheses that both individual (direct) and socialnetwork (indirect) mass media exposures were associatedwith eating pathology in Fiji. ResultsBoth direct and indirect mass media exposures wereassociated with eating pathology in unadjusted analyses,whereas in adjusted analyses only social network mediaexposure was associated with eating pathology. This resultwas similar when eating pathology was operationalised aseither a continuous or a categorical dependent variable (e.g.odds ratio OR = 1.60, 95% CI 1.15-2.23 relating social networkmedia exposure to upper-quartile EDE-Q scores). Subsequentanalyses pointed to individual media influence as animportant explanatory variable in this association. ConclusionsSocial network media exposure was associated with eatingpathology in this Fijian study sample, independent of directmedia exposure and other cultural exposures. Findingswarrant further investigation of its health impact in otherpopulations.

Return to Play Model

following clinical reassessment utilizing the 3 step evaluation outlined above, ath-letes can be re-classified into the "High Risk - Red light", "moderate Risk - yellow light" or "low Risk - green light" categories. the ReD-S Risk assessment model is adapted to aid clinicians' decision making for determining an athlete's readiness to return to sport / physical activity. the ReD-S Return to Play Model outlines the sport activity recommended for each risk category.

What is the RED-S CAT?

the ReD-S cat is a clinical assessment tool for the evaluation of athletes / active individuals suspected of having relative energy defi ciency and for guiding return to play decisions. the ReD-S cat is designed for use by a medical professional in the clinical evaluation and management of athletes with this syndrome. the ReD-S cat is based on the ioc consensus Statement on ReD-S, 2014.1 this tool may be freely copied in its current form for use by sport organizations and the athlete medical team entourage. alterations to the tool or reproduction for publication purposes require permission from the international olympic committee.NOTE: the diagnosis of ReD-S is a medical diagnosis to be made by a trained health care professional. clinical management and return to play decisions for athletes with ReD-S should occur under the guidance of an experienced sports medicine team.

Screening for RED-S

the screening and diagnosis of ReD-S is challenging, as symptomatology can be sub-tle. a special focus on the athlete at risk is needed. although any athlete can suffer from ReD-S, those at particular risk are those in judged sports with an emphasis on the aesthetic or appearance, weight category sports, and endurance sports. early detection is of importance to maintain and improve performance and prevent long-term health consequences. Screening for ReD-S can be undertaken as part of an annual periodic Health exam-ination and when an athlete presents with Disordered eating (De) / eating Disorders (eD), weight loss, lack of normal growth and development, endocrine dysfunction, recurrent injuries and illnesses, decreased performance / performance variability or mood changes.

RED-S Risk Assessment Model for sport participation

this model can be incorporated into the periodic Health examination. Depending on the findings on history and physical examination, the athlete is classified into one of the 3 following categories: "Red Light": High risk, "Yellow Light": moderate risk, "green Light": low Risk.

Comparison of Structured Behavioral Intervention to Commercial Program

• 12 month study consisting of 2 groups:• Vtrim - online therapist-led behavioral weight loss program• eDiets - commercial weight loss program • 6 Month Intervention Phase:• Vtrim - modification of eating and exercise habits through use of behavioral strategies and self-management skills; self-reported weight each week• eDiets - access to eDiets.com; prescribed calorie goal, self-reported weekly weights and automated feedback messages sent; meal plan with recipes, grocery lists, exercise encouraged. • Contact with staff:• Vtrim - 26 weekly on-line meetings led by trained therapist; weekly feedback from therapist on completed assignments and food journal entries• eDiets - professional-facilitated on-line meetings (self-help) but no direct accountability to a therapist • 6 Month Maintanence Phase:• Vtrim - same behavioral program emphasized; meetings held bi-weekly. Therapist feedback given only on meeting weeek. • eDiets - continued access to commercial web site • Attrition not significant by treatment group• Vtrim - 18% at 6 months; 35% at 12 months• eDiets - 19% at 6 months; 23% at 12 months Phase 1 (0-6 months) • Intense behavioral online program (6.8+ 7.8kg ) • eDiet program (3.3 + 5.8 kg) (p=0.005) Phase 2 (12 months)• Intense behavioral program (5.1+ 7.1 kg)• eDiets (2.6 +5.3 kg) (p=0.034)

Study 4: Methods

• 148 Hispanic and Black low-income families in Houston, Texas • 3 evening meal observations on each family• Measures- Caregiver's Feeding Styles Questionnaire (CFSQ; parent-report)- Global coding of the emotional climate (observed live coding)- Behavioral coding which corresponds to the CFSQ items (observed live coding)- Videotapes of each meal on split screen

etiology eds

• 25-30% of bulimics have prior history of AN• AN and BN are cross-transmitted in families• Twin studies suggest 50-80% genetic contribution to liability - similar to bipolar• Majority of patients exhibit childhood perfectionism, OCD patterns, anxiety• These characteristics persist after recovery. • Puberty represents change that challenges rigidity, exacerbates serotonin dysregulation• Reduced dietary intake modulates serotonin and alleviates dysphoric mood• Malnutrition and weight loss, however, exaggerates dysphoric mood• Functional MRIs implicate interaction of pathways regulating appetite and emotion

Bone Turnover and Bed Rest

• 28 adolescents (13-21 years of age); admitted on bed rest x 5d with weight restoration• Osteocalcin (bone formation) increased • Bone-specific alkaline phosphatase (bone formation) declined for younger subjects• Urine N-telopeptides (bone resorption) nadir on d3; returned to baseline by d5• Acutely, bone resorption and formation were suppressed; by discharge, resorption increased• Limited physical activity is associated with an imbalance of bone turnover

Initial Meal Planning Guidelines for All Eating Disorder Types

• 4 - 6 eating opportunities per day• Meals and snacks - same size acceptable if so desired• Work with client's preferred schedule• No more than 4 hours between eating opportunities to prevent:- Hypoglycemia- Extreme hunger- Poor judgment- Temptation to binge • Small portion size to provide comfortable volume- Avoid foods that cause a desire to purge• Source of protein and CHO should be included with every meal and snack• If fluids have been used to reduce calories or induce purging, avoid beverages at meals and take them between meals instead• Work with patient preferences- Don't include foods known to be triggers for bingeing, purging, self-harm, or extreme regret- Incorporate new foods slowly • Decrease caffeinated and calorie-free foods and drinks• Encourage patient and family to accept the meal plan• Acceptable to become "obsessed" with the meal plan for the time being• Use any meal plan model that works- Exchange lists, point systems, etc.

Study 2: Methods

• 718 Hispanic, Black, and White low-income families with preschoolers in Texas and Alabama• Information on feeding styles, demographics, and other psychosocial variables were elicited from parents• Dietary intake of child (while with parent)- 3 dietary recalls reported by parent (NDS)- food intake (average servings consumed after 3 pm) • Anthropometrics measured on parent and child

Prognosis

• 75% of adolescents with anorexia nervosa treated by AM specialists had excellent/much improved outcome 4 years after diagnosis; 25% symptomatic• Poorer outcomes: later onset, longer duration, lower minimal weight, failed prior treatment, disturbed premorbid personality, difficult family relationships, premorbid obesity, bulimia, vomiting, laxative use

School and Community-Based Interventions with Children and Adolescents

• A number of reviews shown this type of intervention to have modest success in decreasing risk factors and increasing protective factors- Schools: usually the focus is on the students- Teachers need to be targeted--daily interaction with students, and important to emphasize to avoid discussion about own dieting behaviors and making comments about students needing to lose weight• School as a whole: comprehensive - Piran implemented a program at a residential ballet school using whole-school approach• This high participatory model of students and feminist principles was very effective at ballet school

Personal History: Food Behaviors

• A personal history/experience with disordered eating is not necessary to be an effective practitioner- It is important that any issues that the practitioner's may have be resolved before being exposed to the rigors of treating EDs• Do I practice non-restrained eating?• Does it take me significantly more or less time to eat a meal than most other people? Does it change when I am eating along?• Do I receive pleasure from the food that I eat, enjoying its texture, aroma, color, and taste? • Are others uncomfortable eating around me?• Can I talk about food all day long and then go home and eating normally, without food preoccupation?

Pro-Anorexia Websites

• AN is a lonely and isolating experience- makes the internet an ideal venue for offering support and advice- Pro-ED community views AN and BN as a lifestyle rather than a potentially dangerous disorder• Mainly females aged 13 - 25 yr view the sites- Many require users to register- Can get advice on how to have AN "safely," how to hide an ED, tips on using emetics, etc.• In 2001 Yahoo and MSN shut down access to many pro-ED sites- The sites simply moves to other servers, somewhat driven underground • Typical Components- A disclaimer- Autobiographical information about the website designer- The "Ana Creed" and the "Thin Commandments"- "Tips and Tricks"- "Thinspirations" photo gallery of thin models and celebrities, severely emaciated women, and morbidly obese women• Examples: Kate Moss, Mary Kate Olsen, Nicole Richie- Quotations- Links to other pro-anorexia websites • "Tips and Tricks"- Dieting and Calorie Restriction (28%) is the most common theme• "Throw away or spray something on foods you may be tempted to eat"- Distractions (14%)• "When you are hungry, spin around until you feel sick"- Deception - General 6%• "Putting bandages over your knuckles when purging will help prevent scarring"• "Make a meal when everyone is out and throw it all away. Say you ate it"• "When you go to the doctor, drink water before, wear bigger shoes, put coins in your bra to increase your weight"- Thinspiration - 5.7%• "Create a pro-anorexia scrap book with pictures and quotes"- Other ways to burn calories• "When you are sitting, shake your leg or tap your pencil. Every calorie counts"

Digital and Media Literacy Competencies

• Access: Make responsible media choices and apply critical thinking skills to find and share appropriate, relevant and reliable information to guide knowledge, beliefs and actions.• Analyze: Know how to decode and make sense of information and examine the content to ascertain purpose, point of view, accuracy and currency.• Evaluate: Determine value and quality of the content for you and others while considering potential effects of messages.

Physiologic Changes Dermatologic System

• Acrocyanosis• Hypercarotenemia• Brittle hair and nails• Lanugo• Hair loss• Russell's sign (callouses over the knuckles)• Pitting edema

Study 3: Results Feeding styles and self-served portions

• Across experimental conditions, children whose mothers were indulgent in their feeding style served themselves greater entrée portions• Children of indulgent mothers also ate more of the entree

Physiologic Changes Gastrointestinal System (cont.)

• Acute Pancreatitis• Superior mesenteric artery syndrome• Gallstones

Errors in Thinking and Attitudes that Perpetuate Eating Disorders

• All-or-none reasoning• Personalization• Over generalization• Magical or superstitious thinking• Catastrophizing and magnification• Perfectionistic thinking

Summary

• Although primarily a psychological disease, the medical complications of eating disorders may be serious and long term- Cognitive- Bones- Stature- Mental health• It is critical to diagnosis an eating disorder as early in the disease course as possible • An interdisciplinary approach is critical in the intensive work toward recovery- Nutrition- Psychology - Psychopharmacology- Medical doctor- Other support staff including social work

Endocrine

• Amenorrhea- Low estradiol, luteinizing hormone, follicle-stimulating hormone- On of the clinical features of AN- In BN, there is more of a "pattern of irregular menstruation"• Hypercortisolism- Seen most commonly in AN- In BN many have normal level• Thyroid function- T4: thyroxine levels are normal- T3: triiodothyronine levels are decreased (malnutrition-induced decrease)- Normal thyroid stimulating hormone (TSH)

Treatment for Eating Disorders

• An interdisciplinary team approach is ideal• Medical care by providers trained in eating disorders • Nutritional support• Psychological component with family involvement when appropriate• Team work prevents splitting -• Treatment takes many months to years• Treatment empathetic, not punitive

Pro-Eating Disorder Websites: Users' Opinions

• An internet-based study in the United Kingdom- Eating Attitude Test (EAT-26) developed and posted- Also used a 24-item questionnaire to assess:• How they learned about websites; how often the websites were visited; motivation to visit; any change in attitude toward body; any change in self-esteem; and does visiting maintain your restricting, fasting, purging, etc.• Many reported visiting when in negative mood- There was a trend of worsening body image as a result• Lifestyle - an existential state pervading every aspect of life and one's identity• Genuine social support- 24% reported some form of social difficulty

Additional Meal Planning for AN

• Anding: 1000 kcals/d• Estimate current caloric intake and set daily goal 200-300kcal higher- 60% Carbohydrate, 20% Protein and 20% Fat - if possible- But: many can tolerate this initially, so 10 to 15% Fat is acceptable• Divide calories into 6 eating opportunities per day- Discourage meal skipping and "catching up" or saving calories for a later meal- Structure meal plans (ie: 3 large meals, 3 snacks daily)• Solid food may not provide adequate caloric intake- Liquid supplementation may be necessary

Anorexia Athletics

• Anorexia athletica described as being an intense fear of gaining weight or becoming fat despite being underweight- Weight loss of least 5% of expected body weight- Usually accomplished by reducing total energy intake- Often with extensive or compulsive exercising• Individuals frequently engage in binge eating as well and use of purging- Self-induced vomiting, laxatives or diuretic abuse

Antipsychotics and Tranquilizers

• Antipsychotics- Maybe useful during weight restoration phase - Also when there is obsession, anxiety, limited insight, and psychotic-like thinking- Chlorpormazine (Thorazine) is the oldest typical antipsychotic in the US• Has largely replaced electroconvulsive therapy, psychosurgery and insulin shock therapy and helped propel deinstitutionalization of people with severe mental illness• Major tranquilizers- Olanzapine, Chlorpromazine and Loxapine for use in AN when disorder is severe and entrenched• Nearly psychotic

Psychological/Behavioral Characteristics: Athletic Anorexia

• Anxiety, both related and unrelated to sport performance• Avoidance of eating and eating situation• Claims feeling fat despite being thin• Compulsiveness and rigidity - especially on eating & exercise• Depression, social withdrawal from teammates• Excessive or obligatory exercise beyond needed• Exercising while injured despite prohibitions• Insomnia• Obesessiveness and preoccupation with weight and eating while at low weight; resistant to weight gain• Excessive weighing behavior

Aesthetic Sports

• Artistic gymnastics- Performance viewed as facilitated by thin or small body size and shape- Rosen and colleagues found most gymnasts were dieting for performance and appearance• noted using vomiting, laxatives, diuretics, fluid restriction or diet pills• Diving - Revealing swimsuits stressor• Figure skating- Pressures regarding thinness even greater when skaters are in teams for synchronized figure skating

Bert

• Bert: Example of male who developed Anorexia• Also had a body self image disorder - body dysmorphia - with a core psychopathology of over evaluation of shape• Muscle dsymorphia more typically is seen when a male sees themselves as very small when they actually are muscular- Bert was getting thinner (not more muscular) - but this was acceptable• Body dysmorphia and Muscle dysmorphia may happen in athletes in certain sports.

Psychological/Behavioral Characteristics: Athletic Bulimia

• Binge eating• Agitation when bingeing is interrupted• Depression• Dieting that is unnecessary for health or sport performance• Evidence of vomiting unrelated to illness• Excessive exercise • Excessive use of the restroom; "disappearing" after eating• History of sexual abuse• Self-critical, especially concerning body, weight, sport performance• Secretive eating• Stealing (especially food)• Substance abuse• Use of laxative, diuretics, of both unsanctioned

Types of Topics Covered by Groups

• Biological nature of eating disorders• Effect of starvation on cognition and behavior with children- Example: as with the Minnesota study, starvation breaking food into small pieces• Starvation is rationing food and not done in defiance of the parents (e.g., a biological response)• Work on decreasing Expressed Emotions- Increased emotions to poor outcomes- Seeing starvation significantly increases the parents' anxiety and tendency to protect their child

Brief Review: Key Risk Factors for Development of Eating Disorders

• Body dissatisfaction• Weight concerns• Internalization of the thin ideal• Dieting behaviors• Media influences • Peer teasing• Unhealthy weight control behaviors• Sexual abuse• Gender - females are at higher risk

Non Lean Sports

• Body size and body image also appear to be important in nonlean sports such as swimming• Swimmers - many reported to misperceive their body weight- Especially girls likely to perceived themselves as overweight and larger than actual weights- Research suggests swimmers' weight concerns more related to societal influences than sport demands• More recently, greater emphasis place on lowered body fat- Revealing swimsuits can be a stressor

Body Shaping Drugs in Young Female Sport Participants

• Body-shaping drugs are substances that are used to suppress appetite, decrease weight , or promote leanness or muscularity- Anabolic steroids - Central nervous system stimulants - amphetamines and amphetamine-like substances- Drugs prescribed for the treatment of attention-deficit/hyperactivity disorders (Adderall, Dexadrine, and Ritalin)- Nicotine- Ephedrine

Aesthetic Sports and Eating Disorders

• Both lean and appearance• Judged - does appearance and judging further increase the risk of an eating disorder?• Revealing attire- Shape and amount of skin exposed• Sportswoman in judged sports have higher incidence of dieting than those in referred sports- On study found those in diving, gymnastics, and cheerleading show a greater drive for thinness and trend for eating disorders

Physiologic Changes Cardiovascular System

• Bradycardia• Orthostatic hypotension• Arrhythmias• Electrocardiogram changes• Ipecac cardiomyopathy• Mitral valve prolapse• Congestive heart failure• Pericardial effusion

Special Considerations for Sports Participation

• Bulimia nervosa more likely in sports that emphasize weight or leanness• Certain individuals likely develop an eating disorder even without sport participation- Sports is simply another risk factor• Bulimia nervosa more likely to occur in late adolescence and early adulthood- Time when many young athletes become more serious about their sport- May be looking for an "edge" (e.g., decreased body weight or body fat) to enhance performance

Cognitive Behavioral Therapy (CBT)

• CBT is proven very effective for bulimia nervosa and binge eating disorder- Remember BN is associated with a great deal of shame and people may avoid treatment because of that shame associated with their ED• CBT requires:- Well trained and experienced therapist(s)- Mental health professional with advanced degree- Specialized training in CBT- Twenty sessions (~ 50 min each) over 4 - 5 months• Financial burden placed on the patient and/or the patient's family can be very large

Internet-Based College Program

• California State University at Northridge - Eating Disorders Web Site for students - JADE - is a peer education program dedicated to awareness and prevention of eating disorders.• Student peer educators receive extensive training in recognizing and articulating causes, symptoms, treatment and referral sources as they prepare to present this information to classes, clubs and organizations on the Cal State Northridge campus• Students teach how to help their friends and encourage body image acceptance. JADE educator - trained in leadership development, public speaking and communication skills, and receive three units for each semester of participation.- http://www.csun.edu/counseling/jade- Includes a screening survey for eating disorders

Physical/Medical: Symptoms Athlete with Bulimia

• Callus on back of hand from inducing vomiting (Russell's Sign)• Dehydration, especially in absence of training or competition• Dental and gum problems• Edema, complaints of bloating, or both• Electrolyte abnormalities• Frequent or extreme weight fluctuations• Gastrointestinal problems• Loss of weight despite eating large volumes• Menstrual irregularity• Muscle cramps, weakness, or both• Swollen parotid glands

Other Lean Demand Activities

• Cheerleading: may be at risk for body image and eating problems due to weight issues- Related to performance - tumbling and stunting (being tossed and lifted)- Appearance and revealing uniforms- Occurring at all ages tends to increase risk • Dance - similar to cheerleading in terms of its risk- Aesthetic/appearance with revealing costumes - Some forms (i.e. ballet), dancers are lifted

Food Parenting Literature

• Child overweight has been linked with environmental factors including how parents interact with children around food (food parenting practices)• Highly controlling/directive food parenting practices have been consistently associated with overweight and weight gain in children across multiple studies• Highly control in food parenting undermines children's ability to focus on internal cues of hunger and fullness

Internet to Reach Adolescents and Young Adults

• Children & adolescents spend average 5.5 hrs/d using media• Adolescents use Internet more than any other age group- 93% youth age 12-17 are online and primary activities are watching videos (57%), social networking (65%), making purchases (38%), seeking health information (28%)- Kaiser Family Foundation report (Rideout, 2010) 8 - 18 yr spend average 90 minute/day on Internet - 2019 report: American 8-to-12-year-olds spent 4 hours and 44 minutes on screen media each day. Teens average 7 hours and 22 minutes — not including time spent using screens for school or homework.• Internet programs are accessible to large groups, cost-effective, much less labor intensive than face-to-face• Multisensory experience - conveys information more vividly and memorably than single-medium presentations

IPT vs CBT for Bulimia

• Cognitive behavioral therapy (CBT) - Therapist and patient collaborate to challenge dysfunctional thoughts and behaviors- Thought stopping and stimulus control- Self monitoring and practicing techniques- Treatment of choice for Bulimia• IPT generally thought to be less effective than CBT- Shown to be effective in adolescents with depression- Comparable to CBT in adults, slightly slower results• Limited efficacy demonstrated with AN, but elements are used in Family therapy that prove to be effective- Consider CBT and then IPT

Computerized and Internet-Based Self Care

• Computers and the internet may be used as an alternative to manual-based self care- May have some advantages: more interactive, can be individually tailored• Effectiveness of an unsupported/unguided CD-ROM entitled "Overcoming Bulimia"- CBT intervention (8 modules using motivation and education)- Followed by 5 - 15 therapist sessions depending on how much purging behavior was reduced (less than 50% means more therapy sessions)- Patients can wait up to 3 months on waiting list for 15 therapist sessions• Hypotheses: - #1 People receiving CD-ROM would show greater symptomatic improvement- # 2 At 7 months, both groups have similar outcomes

Cognitive Behavioral Therapy for Anorexia Nervosa (CBT-AN)

• Core belief in AN is associated with desire to control eating and weight- Self-worth is represented in the size and shape of the body• Features- "Specialness"- Competitiveness- Positive identification with Anorexia• Duration of therapy is recommended to be 1 - 2 years for those who achieve outpatient weight restoration- Therapy is recommended for 1 year for patients who enter therapy at a reasonable weight after inpatient hospital discharge • Develop and sustain motivation to change- Thoughtful, nonconfrontational use of information to help patient reassess perceived risks and benefits of symptoms- Endorsement of an experimental approach- each step is viewed as an opportunity to gather information rather than a commitment to change- Explore the functional effects of patients' choices rather than challenge their rationality or validity- Working through patients' personal values to convince them that AN violates key principles that are fundamental to their sense of identity• Manage eating and weight- Goal weight gain and rate of gain are individualized- Weight is assessed at each session• Modify beliefs about weight and food• Modify views of self • Stage 1: - Assess and address the illness- Increase the patients' motivation for change- Develop target weights, and eating patterns• Stage 2:- Challenge dysfunctional beliefs about food, eating, weight, self-concepts, etc.• Stage 3:- Increase the patients' awareness of potential triggers for relapse - Take appropriate preventive action

Multi-Family Groups (MFG) vs. Typical Family Based Therapy (FBT)

• Cost effective• Learning by role-modeling by other parents• May reduce the shame and guilt by noting that other families are going through the same dynamics• Support of adolescents among themselves during FBT

Digital and Media Literacy Competencies - continued

• Create: Produce your own messages with awareness of purpose, audience, creative techniques, and potential effects (i.e. text message IM, email, twitter, blog, web site, social network, photo, image, video, sound cartoon flyer, interview letter, etc.)• Reflect: Apply social responsibility and ethical principles to your identity, personal experience, and communication behavior.• Act: Take social action individually or collaboratively to share knowledge, solve problems, and participate in your community locally, nationally and internationally.

Surfing for Thinness

• Cross sectional study conducted at Stanford (1997-2004)- 698 families (age 10 -22 yr) diagnosed with eating disorder- 182 individuals participated (76 patients; 106 parents)• Parents (52.8%) aware of pro-eating disorder websites- 27.6% discussed with child- 62.5% unaware of pro-recovery sites• Patients (41%) visited pro-recovery and (35.5%) visited eating disorder websites- 25% visited both• Conclusions: Pro-ED website usage is prevalent among patients; parents overall had little knowledge of EDs and child's disordered behavior

Prevention Study Types

• Cross-sectional associations- Associations of variables at the same point in time• Longitudinal associations- Provide information about temporality (i.e. which came first)• Intervention studies- Help determine if manipulation of one variable(s) can lead to changes in another variable(s) • A literature review looked at studies of ED prevention and interventions in a University campus setting (1987-2007)- Limited by small sample size; majority were female undergraduates• Six major categories:- Didactic information only- Psycho-educational programs- Cognitive behavioral therapy (CBT) - Computer-based- Media literacy intervention- Dissonance-based • Education programs in 1980s and 1990s used a one-shot, single teaching session • A meta-analysis of ED prevention programs yielded encouraging findings- Published and unpublished articles; 1980-2006• Assessed effectiveness of ED prevention programs - Established risk factors for eating pathology- Potential moderators of intervention effects• 51% of eating disorder prevention programs reduced eating disorder risk factors- Body mass, thin-ideal internalization, body dissatisfaction, dieting, negative affect• 29% reduced current or future eating pathology

Leading Scientists in Eating Disorder Research and Treatment

• Cynthia Bulik - University of North Carolina - Watch Dr. Bulik in the video link posted this week where she discusses mid-life development of eating disorders - Below is one of Dr. Bulik's important ongoing research projects • Anorexia Nervosa Genetics Initiative:• https://www.med.unc.edu/psych/eatingdisorders/research/completed-research-studies/anorexia-nervosa-genetics-initiative-angi/• Dr. Walter Kaye : Researcher and Director of University of California at San Diego Eating Disorders Program- Review the short video on Brain Imaging and Eating Disorders post this week- Review the information on brain imaging and Eating disorders by Walt Kaye, MD

DBI - Anorexia Nervosa

• DBI for reducing thin-ideal internalization- Young women internalized thin-ideal (Western culture) could argue against this concept- Theoretically, psychological discomfort-or dissonance- could be resolved by reducing the endorsement of the thin-ideal• Model shares similarities with CBT for bulimia- Over-evaluation of weight/shape leads to dieting which increases the risk for binge eating- Binge episodes magnify shape and weight concerns, which encourages further dieting and more extreme compensatory behaviors

Outpatient/Day Hospital Treatment of AN and BN

• Day Hospital programs are typically more intensive and cost effective than inpatient programs- Best for the MODERATELY ill who have not responded well to other therapy- 4-, 5- and 7-days a week options• Goals- Normalize eating and follow balanced meal plan- Eliminate purging and over-exercising- Help gain weight if below healthy weight- Address issues and stress core psychopathology• Contraindications- Significant depression, active substance abuse, suicidal risk • Group therapy- A group culture can develop• Cause the new member to feel pressure to try to recover from their ED• Help build a sense of commitment- Groups can also teach members how to become better at purging, etc. since members often share their techniques• Cognitive behavioral therapy• Interpersonal psychotherapy• Family therapy • Pharmocotheapy

Renal

• Decreased glomerular filtration rate• Decreased urine concentrating capacity• Pyuria• Proteinuria• Hematuria• Dehydration or excessive hydration• Nocturnal Enuresis

Extent of menstrual cycle dysfunction

• Depends on a number of factors:- Degree of energy restriction- Body's reserve of energy- Initial hormonal status before energy restriction

Diet History

• Diet history- Fear- Safe- Binge- Purge foods• Use of appetite-suppressing agents- Caffeine, gum, candy cigarettes, sodas• Assessment of excess intake of alcohol, fortified foods and supplements

First and Foremost...

• Do not rehydrate using IV bolus hydration• If IV hydration is unavoidable, gently rehydrate without boluses• Always provide nutrition orally whenever possible; avoid NG or parenteral feeding

Questions?

• Do you smoke cigarettes?• How often/for how long do you exercise?• When was your last menstrual period?• Have your periods been irregular?• Are you cold when others in the room seem comfortable?• Have you had any bone fractures?

Helpful History Questions

• Do you think you are too thin, too heavy, or just right?• Have you had difficulty maintaining your weight recently?• Have you ever felt you had to vomit or diet to keep your weight stable?• Have you ever used laxatives, diuretics, diet pills or Ipecac?• Do you drink a lot of caffeine?

Examples of Questions for Binge Eating Behaviors

• Do you worry you will get out of control around food?• What foods are your weakness? Do you avoid them?• Are you usually really hungry when you start to eat?• Do you ever stop before you feel full?• Is your eating different when you are alone?

Cognitive Behavioral Therapy

• Does not investigate the "why"• Time-limited, manualized approach• Challenge dysfunctional thoughts• Techniques include thought-stopping and stimulus control• Patient must self-monitor and practice techniques when not in session • Treatment of choice for BN• Ego-syntonic nature of AN makes CBT less effective• Only 2 randomized control studies among adolescent ED participants- Both compared CBT to FBT- CBT with more rapid symptom reduction, lower cost and greater acceptability by BN/EDNOS patients in one; no difference in one study of AN

Personal History: My Body Image

• ED individuals are often drawn to the dietetics profession because of their preoccupation with food- Many practitioners use their personal experience with EDs in helping others, this can only come after a challenging journey of personal growth- Regularly talking about food, body image and weight; being asked how much you weigh, how many calories you consume, why you choose certain foods can be stressful for the nutrition professional and create an over-awareness of food and the bodyBefore becoming a practitioner it is important to ask:• Am I comfortable with my body the way it is now? Do I like my body?• Do I think of all of my various body parts in a positive way? • Do I accept a variety of body sizes and shapes as being (potentially) healthy, depending on one's physical fitness and nutritional intake?• How do I feel about my own weight?• How do I feel when I see a very large person? A very thin person?

Distance Running

• Early study in 1986 reported more than half of distance runners used at least on pathogenic weight control method (vomiting, laxative, diuretics, diet pills, etc.).• Other research found 13% of the elite runners had a history of anorexia nervosa, 27% had a BMI < 17, and 9% reported bingeing and purging• Regarding female athlete triad symptoms in 99 collegiate athletes in 8 sports - runners had:- the highest % of menstrual dysfunction (44%)- lowest total body, lumbar spine, and pelvis bone mineral density (Mudd et al, 2007)

Meal Planning Guidelines for BN and BED

• Eating < 6 times per day may be adequate - Structured food plans do not work as well but can provide support during meal preparation- Regular eating times should be encouraged• Guilt and/or purging may occur even with small or "normal" amounts• Calm environment• Provide supervision and do not allow access to the bathroom up to an hour after eating• Initially, meals should not include foods the patient is unwilling or unable to keep down

Eating Disorders in Diabetes Mellitus

• Eating Disorders as defined by the DSM-IV have been found in as much as 10% of teenage girls with type 1 diabetes (T1DM) compared to 4% of those without T1DM• Diabetes treatment often leads to increased BMI in adolescent girls which causes more body dissatisfaction- May result in restrained eating (risk factor for BN)- Girls who develop diabetes in puberty may be most at risk for disturbed eating behaviors due to the weight gain that occurs along with puberty • Disordered eating behavior leads to diabetic retinopathy occurrence that is three-times higher than the general population- Binge eating and insulin omission lead to increased blood sugar levels and more episodes of ketoacidosis

Differential Diagnosis

• Eating Disorder• Inflammatory bowel disease• Achalasia• Primary endocrine disorder Diabetes mellitus Addison's disease• Depression or other psychiatric disease• Malignancy including CNS tumor• Pregnancy

Energy Availability and the Female Athlete Triad

• Energy availability is defined as dietary energy intake minus exercise energy expenditure• Energy spectrum from "optimal energy availability to low energy availability with/without an eating disorder"(ACSM, 2007)• Low energy availability (LEA) - physically active female ingests insufficient calories to fuel physical activity and support normal bodily process- Pituitary "turns off" the reproductive system inadequate estrogen- LEA disrupts luteninizing hormone pulsatility• 2007 ACSM replaced amenorrhea with menstrual function

Review Descriptions of Family Dysfunctional Types

• Enmeshed Family: Over involvement, may have emotional detached parent - other seeks another relationship (child is the replacement), codependency, child often perfectionist, child has over sense of responsibilities • Disconnected: Bonding does not occur; parent(s) depressed, mental illness, long separations; weight loss can cause crisis and bring broken family together ("glue")• Chaotic Family: Parental behavior unpredictable and /or abusive; often alcohol or drug or psychological problem in a parent leading to inconsistent behavior; child becomes "people pleaser".

Approach with Children

• Establish regular eating patterns• Incorporate "safe" foods initially• Manage anxiety, low mood and potential negative feelings around menarche• Set realistic expectations• Discuss plans for a "lapse" (an occasional going off treatment) and an actual "relapse" • Identify triggers and strategies to address these factors that lead to lapses and relapses

Nutrition Therapists for Eating Disorders

• Evaluate your personal struggle- Your experience can benefit your compassion, but it does not count as a credential. Be certain that you have addressed and resolved these issues• Pursue additional education- Nutrition is not enough; ED professionals will also need education in the areas of psychology and counseling• Be prepared to be part of an ED treatment team• Become familiar with psychiatric terms and medications • Become familiar with the Ancel Keys Starvation Study- This study underscores the contribution to dietary restriction makes to the development of EDs and disordered eating • Read, read, read- Read a variety of newsletters, journals and books to further your education in the field of EDs• Network- Begin networking with non-dietetics professionals in your area who have experience treating EDs (therapists, licensed clinical social workers [LCSW], physicians)• Join professional associations- The Academy for Eating Disorders, National Eating Disorders Association, etc.• Seek supervision- Strongly consider receiving supervision from an expert, such as SCAN Symposium, Renfrew Center Fdn., AED and local functions• Attend conferences• Understand diagnoses thoroughly- Know diagnostic criteria for AN, BN, BED, EDNOS but never pigeon hole your clients• Treat the whole person

Academy of Nutrition and Dietetics: ED Standards of Practice 2020

• Examples of Outcomes for Standard 2: Nutrition Diagnosis • Each RDN - competent, proficient, expert:- Diagnoses nutrition problems based on evaluation of assessment data and identified supporting concepts (ie., etiology, signs, and symptoms)- Prioritizes the nutrition problems (s)/diagnosis (es)- Communicates to patients/clients/family- Documents diagnosis - Re-evaluates• Not clear - depending on setting - who is the professional who actually makes the Eating Disorder diagnosis - the past practice always was the physician/psychiatrist

Signs and Symptoms Excessive Exercise

• Exercise primary means of copying• Exercise occurs despite injury and overuse injuries• Withdrawal effects when withheld• Stress fractures• Menstrual irregularity or decreased testosterone in men• Loss of bone density• Decreased immunity; frequent colds• Inflexibility of exercise schedule (will not not exercise)• Decrease in sport performance• Overtraining syndrome (staleness)

Family Based Treatment vs. CBT for Children with AN

• Family based treatment (FBT) shown to be effective for AN (prior assigned paper)• Children are more emotionally attached to family than adults• High stress levels for families caring for the adolescent - The child may appear to be or is even literally starving to death• FBT maybe more difficult for the child with the inclusion of the parents and siblings in treatment- Discomfort feelings vs. the support of family

Family-based Therapy for AN (FBT-AN)

• Family-based therapy is increasingly popular ("Maudsley Method") for AN- Family expected to come to most therapy sessions- potentially problematic as parents may have to take time off work to supervise meals• Recommended for younger patients with shorter duration of illness• Maudsley Model = Intense family involvement - Phase 1 - weight gain through refeeding with high family involvement (rewards system)- Phase 2 - transfer control back to patient- Phase 3 - individual therapy for the patient• Variations in methods have been tried with similar results; parental involvement may be the key • Dr. Milddleman's Concerns with this method:- Food intake and weight gain prior to cognitive shifts may lead to increased purging- No change in distorted eating behaviors- High level of parental expressed emotion may hinder efficacy- Issues of control may be exacerbated- Parental eating patterns may make this method inappropriate• FBT outcomes have not been as successful in BN as in AN• Appears to be effective in early-onset, short-history cases of AN

Family-based Therapy for AN

• Family-based therapy is increasingly popular ("Maudsley Method") for AN• Recommended for younger patients, shorter duration of illness• Maudsley Model = Intense family involvement - Phase 1 - weight gain through refeeding with high family involvement (rewards system)- Phase 2 - transfer control back to patient- Phase 3 - individual therapy for the patient• Variations in method with similar results; parental involvement may be key • Concerns with this method:- Food intake and weight gain prior to cognitive shifts may lead to purging- No change in distorted eating behaviors- High level of parental expressed emotion may hinder efficacy- Issues of control may be exacerbated- Parental eating patterns may make this method inappropriate

Study 1: Convergent Validity Feeding styles, food parenting practices, and general parenting

• Feeding styles and food parenting practices• Authoritative - higher monitoring• Authoritarian - higher restriction and pressure to eat• Indulgent - lower restriction• Uninvolved - lower monitoring• Feeding styles and general parenting • Authoritative - higher nurturance and reasoning • Authoritarian - lower nurturance and reasoning• Indulgent - higher nurturance and less physical punishment• Uninvolved - lower nurturance, organization and follow through with discipline

Feeding Styles vs. Food Parenting Practices

• Feeding styles- depict the overall climate of the feeding relationship - set the tone for food parenting practices • Food parenting practices- are specific ways that parents direct their children's eating behaviors• Feeding styles reflect the larger context within which food parenting practices are expressed

Bone Density - Males

• Few studies among males• Castro et al.; Spanish study• Two factors associated with low bone density:- Duration of illness, calcium intake, physical activity of >3 hours/week- Testosterone trended toward significance• Regression analysis reveals independent predictor is duration of illness• Misra et al. found that testosterone and lean mass predicted BMD among males

Refeeding Syndrome

• Fluid and electrolyte dysregulation- Sever hypophosphatemia, hypokalemia, hypomagnesemia- Abnormal glucose metabolism- Deficiencies in vitamins and trace elements• Metabolic disturbances when starved patients or severely malnourished patients are fed too much, too soon• During refeeding, insulin levels increase with introduction of carbohydrates- Results in increased glycogen, fat and protein synthesis- Requires phosphates, magnesium and potassium (already low and the stores rapidly are depleted)• Refeeding increases the basal metabolic rate• Cardiac arrhythmias are the most common cause of death

4 Cornerstones for Parent Promoting Healthy Weight/Positive Body Image-continued

• Focus less on weight; instead focus on behaviors and overall health- Encourage the teen to adopt healthy behaviors without focusing on weight loss- Help the teen develop an identity that goes beyond physical appearance- Establish a no-tolerance policy for weight teasing in the home• Provide a supportive environment with lots of talking and even more listening- Be there to listen and provide support when the teen discusses weight concerns- When the teen talks about fat, find out what is really going on- Keep lines of communication open, no matter what- Provide unconditional love, not base on weight, and let the child know

Implications of DBI

• General (universal) versus high-risk (selected) samples- Programs offered to selected groups produced similar effects- Implies that DBI may be appropriate for a variety of populations• Targeted school-based programs may fail if the participants efforts to resist unhealthy dieting are thwarted by peers- Sororities: tend to reject programs that target only high-risk individuals because they would like a program that also fosters stronger group cohesion- Athletic departments also reject a targeted approach because they do not want to single out high-risk teams• DBI proves to be most positive when universal and selected

Self-Regulation Program for Maintenance of Weight Loss

• Goal - to prevent weight regain over 18 months• Eligibility for 18 month study:• Lost 10% of body weight during prior 2 years (authenticated by MD or weight-loss counselor) -• Randomized to 1 of 3 groups:• Control • Face-face intervention• Internet intervention -• Composition of face-to-face and internet intervention • Identical in content- self-regulation theory• Compare current weight with entry weight• Taught to adjust eating & exercise behaviors • Provide self-reinforcement -• Contact with staff:• Control - quarterly newsletters, no interaction with staff• Face-to-face - Weekly group meetings first month, monthly group meetings next 17 months. Led by study personnel -• Contact with staff:• Internet - provided with laptop; access to web site where weekly lessons posted, reported weekly weight and physical activity minutes. Weekly chat rooms first month phased to monthly chat rooms led by study personnel. • Frequency of attendance to group sessions or chat rooms decreased from baseline to 18 months• Face-to-face - 78.7% to 41.5%• Internet - 65.7% to 34.2% • Weight regain at 18 months:• Control group - 4.9 kg• Internet - 4.7 kg• Face-to-face - 2.5 kg• Intensity of behavioral treatment in face to face groups resulted in less weight gain compared to control

Comparison of Strategies for Sustaining Weight Loss

• Goal of 30 month Phase 2: Maintenance of Phase 1 weight loss or loss of additional weight• Three groups randomly assigned:• Self-directed comparison• Interactive technology-based• Personal-contact • Composition of interactive-tech & personal-contact intervention • self-monitoring• continual contacts• accountability• motivational interviewing• dietary & physical activity recommendations identical • Contact with staff for 30 months:• Interactive-technology - only if failed to log on to web site after 2 e-mail prompts• Personal-contact - monthly telephone contact for 5-15 minutes and every 4th month a 45 min face to face counseling session • Frequency of visits to the web site:Interactive technology - average of once/week and had 1 web site contact for 77% of 30 (23/30) monthsPersonal contact - 91% of monthly calls • Weight regain at 30 months• Self-dircted group - 5.5 kg• Interactive technology - 5.2 kg• Personal contact - 4 kg

While the patient waits .......

• Good evidence that antidepressant medications has an "anti-bulimic" effect in BN and BED- The effect of medication is rapidly expressed (within 2 weeks) and may not be sustained- Rarely produces complete resolution• Medication options:- SSRI antidepressants effectiveness for AN appears to vary with the phase of treatment• In weight-restored patients up to 60 mg/day may decrease chance of relapse and lead to better weight maintainence- Fluoxetine does not appear to have significant benefits during weight restoration• Higher doses have been shown to impair appetite and cause weight loss in normal weight and obese patients; this has not been reported in AN

Main Elements of Cognitive Behavior Therapy for Bulimia

• Good therapeutic relationship• Self-monitoring• Education about the cognitive model• Regular weekly weighing• Education body weight, adverse effects of dieting, purging consequences• Regular eating patterns• Self control strategies• Problem solving• Cognitive restructuring • Methods to increase acceptance of body

The main elements of CBT-BN are:

• Good therapeutic relationship• Self-monitoring• Education• Regular weekly weighing• Regular pattern of eating• Self-control and problem-solving• Cognitive restructuring - eating, body shape, weight -• Drop out rate at treatment centers is approximately 15 - 20%• CBT substantially reduces binge eating and purging- 80% reduction in frequency- 40-50% CESSATION• Effects of CBT are maintained over 6 - 12 months• CBT may be more effective when combined with antidepressant therapy- Further help reduce anxiety and depressive symptoms

Physiologic Changes Endocrine System

• Growth delay and short stature• Delayed puberty• Amenorrhea• Low T3 syndrome• Partial diabetes insipidus• Hypercortisolism• Down-regulation of the growth hormone receptors

common complaints

• Hair loss• Abdominal pain• Constipation• Weakness and fainting• Coarse, yellow skin• Short stature and/or delayed puberty• Muscle cramps• Chest pain

Further Studies

• Head imaging study if high suspicion of malignancy (lower threshold among males with anorexia nervosa)• Bone density study - often reveals pathology when other tests are within normal limits

Initial Target Weight

• Healthy weight- Use a weight range versus a fixed number- May take time for an agreement for a target weight• Bulimia- Discussion should include an explanation that the client's present weight is a purging weight NOT a true weight- Once purging stops, short-term rehydration of up to 5 pounds is highly likely and normal• Rate of weight gain- Average of 1 to 2 pounds per week is the goal- Most initially retain 3-5 pounds of water; up to 10 pounds is also abusing laxatives - Extra water weight can last 4-8 weeks

Food Parenting Literature cont

• Highly controlling/directive food parenting practices - extensive external control over children's eating- examples include restrictive behaviors and if-then statements• Less controlling/non-directive food parenting practices- methods used by parents that allow for child autonomy- examples include using reasoning and choice

Food Parenting Literature 2

• Highly controlling/directive food parenting practices- Restriction (restriction of child's access to snack foods)- Pressure to eat (tendency to pressure child to eat more or eat all the food on the plate)• Samples- Middle income White families• Conceptualization- No focus on less controlling/non-directive food parenting practices- No focus on more nurturing food parenting practices

History of Eating Disorder

• History- Weight and body perceptions in elementary school- Diet or compulsive eating around puberty- Parental involvement with food control• Parents- Compulsive about food- Dieting or exercise• Age body dissatisfaction developed• Eating disorder behaviors- Purging, alcohol/drugs, smoking, compulsive exercise

Family Therapy: Maudsley

• Individual versus whole family therapy- Maudsley Hospital in London• Parent takes on the responsibility to get the child to eat- Research suggests that family therapy has significantly better outcomes compared to individual therapy upon discharge from the feeding program, especially in those younger than 19 y- At least one parents should be present at each meal/snack; if the child has BN they should remain for at least 1 hour after• Three phases- First: therapist observes; counsels family; and models feeding - Second: transfer of responsibility for eating choices from parent to child- Third: patient and therapist address issues pertaining to adolescence and effects on eating - "phase-out"

Care Continuum

• Inpatient, or 24-hour care in hospital - Includes either medical or psychiatric facility• Costs $1,400 -$1,800 + per day- Typically and hopefully a short-term stay to treat medical conditions including medical malnutrition• Residential- May be able to better simulate daily living activity when return home- Patients may still exhibit restrictive eating or purging behaviors but they may not necessarily lead to medical instability- Insurance may not cover these behaviors as the level of care may be much smaller• Partial hospitalization or day treatment • Intensive outpatient programs• Transition or recovery houses- Provide group therapy and/or recovery meetings

Certification to Practice Eating Disorders

• International Association of Eating Disorders Professionals (IAEDP): http://www.iaedp.com/- Certification course and examination• Rigorous education requirements; requirement for qualifying work experience; must pass a written exam covering the ED field; must complete continuing education hours- Professionals who demonstrate clinical expertise through education, experience and a rigorous examination are eligible for certification• Certified Eating Disorders Specialist in mental health (CEDS)• Certified Eating Disorders Specialist in Nutrition (CEDSN)• IAEDP seminars, workshops, newsletter, professional advancement opportunities

Structure of the Maudsley Program (Multi-Family Therapy)

• Introductory - overview prior to workshop• 4 Day intensive workshop- Parents bring in food and lunches child expect to have- Planned activities to explore food management difficulties• Managing mealtime: "food is medicine and the meal plan is a prescription of how you take the medicine"• Joint meals:- Provide context for parent to help child start eating healthier- Interrupt fixed patterns that are maintaining the eating disorder• One day follow up workshops for 9 months

What can be done while the patient waits?

• It may take a few months to actually begin treatment as it takes some time to properly diagnose and then find the best treatment option/facility• In the mean time, the patient can be urged to explore other options:- Self help books or CD-ROMs• Help teach the patient about the psychological education central to CBT• Can be utilized with or without the help of a mental health professional- "Guided" self-help using CBT• Non-specialist "facilitator"• Reasonable effective for bulimia nervosa• Eight 30 minute sessions over 3 - 4 months- Guided may be used to determine if "stepped care" is neededNOTE: it is unlikely that self-help treatment for AN would be effective as a sole treatment if the individual is very underweight; most of the self-help research to date has focused only on BN and BED

Joyce

• Joyce: Fear of body shape changes associated with going through puberty. • This as a general finding of other adolescent females around puberty; remember biomodial distribution- A few of you did NOT answer the second part of this question - to compare her situation with other female adolescents of similar age

Nutritional Assessment

• Labs- Compensation for malnutrition: albumin, hemoglobin, hematocrit typically normal- C-3 complement levels (factor in immune cascade) - protein status- Serum ferritin, transferrin, plasma iron - assess iron stores• Exercise- Assess daily activity- Hyperkinesis

Internet-Base Interventions for Eating Disorders in Adults

• Lack of geographic boundaries, enabling widespread dissemination of treatment• Cost-effective • Greater user control, flexibility and anonymity• Interventions often use Cognitive Behavior Therapy (CBT)- Self-help intervention by book, with tasks and homework- Some structure treatment programs• CBT: can help reduce symptoms related to eating disorders for bulimia nervosa and binge eating• Few number of internet-based interventions for anorexia due to the weight loss that can be life threatening

Mood Stabilizers

• Lithium carbonate- Not effective in treatment of BN • May lead to undesirable weight gains due to rapid volume changes• Topriamate (Topamax)- Not an effective mood stabilized but may be useful for BN and binge eating disorder

Physical Signs of Eating Disorders Dermatological

• Loss of scalp hair - telogen effluvium (telogens are resting stage of hair follicle) • Dry skin - xerosis• Brittle nails• Lanugo hair• Hypercarotenemia• Russell's sign -Acrodermatitis: An inadequate supply or Zinc contributes to this disorder (also malabsorption and low zinc stores).

Antidepressants

• Major indication of depression with bingeing and purging- Selective serotonin reuptake inhibitors (SSRI) preferred• Less cardio-toxicity and neurotoxicity• Effective with co-existent obsessive-compulsive disorder• Fluoxetine (Prozac) in weight restored patients (up to 60 mg/d) may decrease relapse, better weight maintenance- No real benefit in patients during weight restoration- Higher dosages have been shown to impair appetite and cause weight loss in normal weight and obese patients; this has not been reported with lower doses in AN• MAO Inhibitors- Carry a risk of hypertensive crisis in patients with BN- Must follow a low-tyramine/tyramine-free diet • Use of tricyclics in malnourished patients may put them at greater risk of: - Hypotension- Increased cardiac conduction times- Arrhythmia (especially purging)• Bupropion (Wellbutrin)- an atypical antidepressant- Associated with increased seizures with BN- Acts as a norepinephrine and dopamine reuptake inhibitor and nicotine antagonist• Mirtazapine (Remeron)- antidepressant associated with weight gain - associated with neutropenia- In OCD, PTSD a loss of appetite or anorexia and subsequent unintentional weight loss has been observed

Thin Commandments

• Many of the more uncompromising pro-Ana websites contain the doctrine "Ana creed" or the Thin Commandments- These are generally rules or beliefs about living an anorexic lifestyle• Thin Commandments1. If you aren't thin, you aren't attractive.2. Being thin is more important than being healthy.3. You must buy clothes, cut your hair, take laxatives, starve yourself, do anything to make yourself look thinner.4. Thou shall not eat without feeling guilty.5. Thou shall not eat fattening foods without punishing oneself afterwards. 6. Thou shall count calories and restrict intake accordingly.7. What the scale says is the most important thing.8. Losing weight is good/gaining weight is bad.9. You can never be too thin.10. Being thin and not eating are signs of true will power and success.

Health Consequences of Secondary Amenorrhea

• May afflict as many as 66% of female athletes- depends on sport and criteria to define amenorrhea• Infertility problems• Decreased bone mineral density• Increased risk of stress fractures - 24% in athletes with no periods or irregular periods compared with 9% of athletes with regular periods• Increased risk of premature osteoporosis

Health Consequences of Anovulation/ Oligomenorrhea

• May be a precursor to secondary amenorrhea• Infertility problems• Decreased bone mineral density• Increased risk of stress fractures and musculoskeletal injuries• Increased risk of premature osteoporosis

Motivation for Change with Children

• May need to be actually malnourished- Parents, friends, professionals become concerned with significant weight loss which leads to undertaking treatment• Approach with children- Use timelines- Pro/con comparisons of the eating disorder illness- Writing essays can be effective• Collaboration with the youth is very important- Need to jointly develop treatment plans

Long term damage? amenorrhea

• May restore some but not all of bone mineral density lost during amenorrhea- Depends on extent of amenorrhea

Why Media Literacy?

• Media literacy skills can help educate, engage, and empower youth• Identify ED risks in the digital media culture• Counteract messages that normalize unrealistic body image and unhealthy food and fitness choices• Advocated healthy ideal cultural standards for appearance, body size and shape

Media Literacy: Anti-Eating Disorder Strategies for Youth

• Media messages are constructed:- Which medium is used to create the message?- Who wrote, edited, designed, produced and distributed the message?- Did you create the message? Or is the source someone you know or admire?- How credible is the source?- Who is the intended target audience?• Each medium uses its won creative techniques, interactive features, and software to construct the messages- What techniques are used to create the message?- What features are used to get he audience's attention?- If models or celebrities are features, do they really look like that?

Media Literacy

• Media messages have embedded values, points of view, and lifestyles- What does the message really say about body image and health habits?- What body shape and size does it suggest are desirable?- Is the information accurate and true? Fact or opinion?• People understand the same message in different ways base on their individual skills, beliefs, and experiences- What do people take away from the message?- How might a person with weight or food issues interpret the message?- How might certain beliefs, attitudes or prejudices about weight, diet and exercise affect a person's understanding of the message?- How might people interpret the message differently based on their age, gender identity, sexual orientation, education, race, ethnicity, religion, political ideology, ability, appearance , or prior experiences? • Media messages can influence beliefs, attitudes, values, behaviors, and the democratic process- What does the message mean to you?- Does the message reinforce or conflict with your beliefs and attitudes about healthy body image?- How does the message make you feel about yourself and your body?- How might it affect how you related to other people and they relate to you?- What actions should be taken to promote healthy body image?

Initial Interview and Assessment

• Medical history- Menstruation• Eating disorder evaluation• Establish goal: help them to have least possible body fat consistent with good health- Provide the scientific rationale behind the recommendations• End of interview: weight and height measured- Binge eating• Medications and supplements/meal replacements

Ultimate Treatment Goals for All Eating Disorders

• Medical/physical stability and physical health restoration• "Normalized" (non-restrictive) eating- Variety, balance- Nutritional adequacy- Comfort with food• "Normalized" (not excessive) and safe physical activities • Absence of purging behaviors• Healthy coping mechanisms for triggers• Improved mental health• Supportive social structure in place to prevent relapses during stress

Mortality

• Meta-analysis 1920-80 (not adolescent-specific) - mortality is 0.56% per year• 10-fold increase compared to age-matched controls• Cause of death:- Complications of the ED - 54%- Suicide - 27%• Most studies assess the most severe cases referred to hospitals; no data for adolescents

4 Cornerstones for Parent Promoting Healthy Weight and Positive Body Image

• Model healthy behavior for children- Avoid dieting, or at least unhealthy dieting behaviors- Avoid making weight-related comments as much as possible- Engage in regular physical activity that you enjoy• Provide an environment that makes it easy for children to make healthy choices- Make healthy food choices readily available- Establish family meal norms that work for the family- Make physical activity the norm in the family and limit TV- Support teen's efforts to get involved in physical activity

Other Signs of an Eating Disorder

• Moodiness and irritability • Low self-esteem• Perfectionism• Social withdrawal and intolerance of others• Overly sensitive to criticism• Extreme concern about appearance

Male Athlete Triad?

• Most studies have involved males in endurance sports- Primarily runner studies suggesting that endurance training can decrease testosterone levels- May be clinically insignificant - testosterone usually within normal limits• A clear relationship between lower testosterone levels and impact on bone mineral density not established• Males do develop eating disorders- Low testosterone often medical consequence- Some research suggests male anorexics may have a more severe form of osteoporosis than females• Muscle Dysmorphia - discussed previously

Primary Prevention

• Much of the work in the area of prevention began in the 1990s• Policies and programs designed to lower incidence of EDs- Reduced exposure risk- Increased exposure to factors that protect• Community-based cross sectional studies identify factors- Weight concerns- Eating disorder symptoms

Eating Disorder Treatment Services

• Multidisciplinary- A team approach has been proven to be the most effective treatment for EDs• Medical, psychological, nutritional, possibly social workers for families• Treatment should follow the 2006 American Psychiatric Association guidelines• Evidence-based care• Cost Effective

Treatment Programs

• Multidisciplinary• Follow published treatment guidelines - American Psychiatric Associations Practice Guidelines for Treatment of Patients with Eating Disorders, 2022 - draft form currently, not for publication - Posted in this week's module- Entire guidelines as reference- READ: Summary Statement for Assessment and Determination of Treatment Plan - specifically Cognitive Behavior for Bulimia and Binge Eating Disorders• Evidence-based care• Cost effective

Technology in the Delivery of Targeted Prevention for Eating Disorders

• My Body, My Life: Body Image Program for Adolescent Girls - An Internet-based intervention for adolescent girls who self-identified with body image or eating problems- Intervention or delayed treatment group (control)- Groups of 4 - 8 girls met with therapist online for 90 minutes for 6 weeks• Discussion board was also offered to allow participants to stay in contact- Body dissatisfaction, disordered eating and depressive symptomatology were significantly improved • Improvements maintained at 2 and 6 mo follow-up

Professional Organizations

• National Eating Disorders Association- http://www.nationaleatingdisorders.org/- Programs and Events- Information and resources• General for parents, children, adults• NEDA Educator toolkits- Research efforts- Online newsletter

Sub-study Hypothesis: Specific influencing behaviors encourage long-term compliance

• Non-directive verbal influence strategies (reasoning, choice)• Positive non-verbal influence strategies (engaging body positions, helping child with food)• Positive affect (smiling)

Nutrition Therapist for Eating Disorders

• Nutrition education/medical model nutrition therapy/empowerment model- Weight gain or loss is not viewed as the primary indicator of success- Improved self-esteem and relief from depression become more important parameters of success• Preferred teaching style- Those who aspire to be ED therapists should observe nutrition therapy with an experienced counselor (individual and group)- They should also attend multidisciplinary supervision meetings- Work can be highly emotional and exhausting- Teaching requires more listening and less talking as the practitioner• Team interventions- Requires the practitioner to relinquish personal opinions for the sake of the team unity and the client's recovery

Assessment and Treatment of Sport Eating Disorders

• Nutritional assessment and treatment for sport participants with eating disorders will be addressed in other 5033.50 presentations and modules:- Module 9: Roberta Anding's presentation- Module 10: Medical complications, nutritional assessments- Module 11: Nutrition, cognitive-behavioral treatment, and prevention

Other Medication (AN)

• Olanzapine has been studied (small #) with improved compliance and weight gain- May represent a side effect of the medication• Anxiolytics may be considered for anxiety occurring before meals/eating• American Psychiatric Association: medications are not recommended as sole or primary treatment for AN

DBI - Eating Disorder Programs

• Originally dissonance behavioral intervention consisted of three 1-hour group sessions- Then became an expanded 4 1-hour program for school-based intervention• Didactic presentation minimized- Less effective than interactive techniques• Between-session homework- Expands amount of time engaging in dissonance-inducing activities• Motivational enhancement exercise• Group activates to foster social support and group cohesion

Orthorexia Nervosa

• Orthorexia nervosa has been used to describe pattern of eating that begins with eating "healthier"- Obsessive need to make one's eating "pure"- Can lead to a very restrictive diet much like anorexic patients• Orthorexia was not listed in the DSM-IV and was not included in the DSM-V revision.

Physical Signs of Eating Disorders Metabolic

• Osteopenia- Defined as: low bone mineral density- Detected by bone densitometry- Low estrogen levels are the most important cause of development in AN• Hypercholesterolemia- Frequently occurs in patients with AN who have preserved supply of free fatty acids- Results from accelerated cholesterol metabolism and improves with weight gain• Nutrient deficiencies- Zinc- Vitamins - Trace metals

Modeling Behaviors

• Parents need to model behaviors they want children to perform• Parents of children with eating disorders often are achievement-striving parents- Often parent neglect themselves- Lack of balance between parent's leisure and work• Parent need to learn to care for themselves• Caring for YOU is caring for your child !!

Socialization of Children &Theory of Parenting

• Parents socialize children to comply with necessary parental demands• Parents who socialize by fostering child autonomy and showing respect produce children who are the most competent• Children could contribute to their own development by internalizing values/norms and using those as a guide when parents are not there • Developmental psychologists have demonstrated (over 4 decades) that effective parenting results in children's self-regulation and competence• Variations in parental demandingness and responsiveness (parenting styles) depict an overall emotional climate in which parenting practices are expressed• Parenting styles (an overall attitude toward the child) are different from parenting practices (goal directed attempts to get the child to do something specific)

Nutrition Support Indications: Enteral or Tube Feedings

• Patient refuses any oral caloric intake• Medically unstable due to low weight• Continuing rapid weight loss despite improved intake• Malnutrition causing inability to think clearly/proceed in treatment• Excessive energy needs- Hypermetabolic- Additional may be supplement in night tube feeding

Implications with Children

• Pharmacological studies are difficult with children- There may not be efficacy and safety studies with children• Resistance of parent to place children on medications• Medications usually started at lowest dosage levels• Many psychological symptoms of starvation can be resolved with weight restoration

Preparticipation Examination

• Physical examinations at the beginning of sport season provide opportunity to screen for eating-related difficulties• Position Stand on the Female Athlete Trial by American College of Sports Medicine (ACSM) recommends a screening for triad components at pre-participation- History, physical examination, appropriate lab tests- Example posted:• Pre-physical examination and female triad screening (see the female athlete triad screening questionnaire posted this module)

Multidisciplinary

• Physician specializing in eating disorders• Licensed mental health professional trained in eating disorder therapy• Support groups- Anorexia Nervosa and Associated disorders- American Anorexia and Bulimia Association- Anorexics and Bulimics Anonymous- Overeaters Anonymous

AND Pocket Guide to Eating Disorders 2nd Edition - 2017

• Pocket guide also in electronic version• Labs to assess eating disorders• Nutrition diagnoses• Guides for meals and snacks• Importance of staying within scope of practice

Innovative Approaches to Prevention and Intervention: the Internet

• Potential for use of Internet as a platform to provide psychological interventions- Programs to prevent and treat eating and weight disorders- Many individuals reluctant to seek help for negative body image or eating disorder symptoms due to shame or embarrassment- Can reach more individuals, particularly in geographical areas without adequate access to professionals with expertise

Protective Factors to Decrease Risk

• Prevention program specifically targeting girls• Frequency of family meals found to be cross sectionally and longitudinally protective against extreme weight control behaviors in adolescent girls• Enhancement of media literacy skills- May help to protect against negative media images of thin models and quick-fix diets• Avoidance of family members teasing a person about his or her weight- Also, family members avoiding discussing own personal weight concerns and using dieting/unhealthy weight control behaviors

On-Line Group Interactions

• Pro-ED online support forums and the narratives within are increasingly the focus of research- Provide a place in which users can access support anonymously, which reduces the risks of making direct contact- Allows users to talk freely about problems; to gain sympathy and support; and to gain information- Goals of increased weight loss; Physiological changes; those with EDs view themselves as different• "4 lbs a week! You can do it!"• "My hair is falling out a ton......but I'm getting like hair on my arms?" (lanugo)• "...sometimes I forget I'm not normal around food..."• "Scales are evil! I can't help it I am on the damn thing like 3 times a day..." • Conceal identity- "Just a word of advice, be careful who you tell, once its out there, you can never take it back."- "I think I can trick my rents [parents] into thinking I'm eating when I'm not, even on xmas day."• Pro-Ana behaviors- "I'm too much of a wimp to purge!"- "Purge in the shower! It covers up the sound, smell, and washes out the evidence."

Neurological

• Pseudoatrophy of the brain- Can been visualized using fMRI- AN patients may suffer from enlarged ventricles and external cerebrospinal fluid spaces (pseudoatrophy)• Sleep disturbances• Alteration in the function of the sympathetic nervous system (SNS)- Patients with BN have decreased activity of SNS- Changes in Neuroendocrine metabolism in both AN and BN are likely state-related changes associated with effects of dieting and starvation

Study 1: Qualitative and Quantitative Techniques

• Qualitative- Observational videotapes- Cognitive interviews- De-centering techniques• Quantitative - Factor Analyses- Assessment of convergent and predictive validity

Treatment of the Triad

• Rate of recovery occurs at different rates.

Critical Evaluation of Efficacy of Self-Help Interventions for BN and BED

• Recent review of 26 studies of self-help in BN or BED- Mixed results regarding the utility of self-help interventions• Conclusions:- When waiting to begin treatment or when no other treatment is available, use of self-help is beneficial- Self-help compared to CBT showed similar efficacy- Guided self-help may have more specificity for treatment of BED than BN• Mental health professionals vs. self-help- The addition of a brief session with a mental health professional did not produce noticeable benefits compared to pure self-help

Evidence-based clinical guidelines for Eating Disorders: International

• Recent systematic review compared evidence-base clinical treatment guidelines internationally (n=9)• Individuals with eating disorders often do not receive evidence-based treatments- Majority of ED therapists do not adhere to evidence-based treatment protocols; use combinations of interventions• Anorexia: consistently recommend outpatient treatment first- Hospitalization for: failed out-patient, high risk for medical complications (weight status), behavioral factors, psychiatric comorbidity- Specialized professionals emphasized and team approach- Ranges of for energy intake (30-40 kcal/kg); others lower intakes for refeeding syndrome- Emphasized family base therapy for younger patients • Bulimia Nervosa- Outpatient therapy first line- Cognitive-behavioral therapy as first line psychotherapy, especially in an individual format- Family-base therapy for younger patients- Drugs: SSRI fluoxetine• Binge-eating Disorder (BED)- Only 3 out of 7 recommend outpatient treatment first line for BED- Cognitive-behavioral therapy - Anti-depressant generally recommended- For anti-obesity medications specifically orlistat when BED with obesity

CDC Charts 2 - 20 Years

• Record current weight and height for boy or girl • Plot weight and height on National Center of Health Statistics (NCHS) growth chart - Stature percentiles- Weight percentiles- Determine child's percentiles• Determine 50th percentile weight for height- Use for Ideal body weight- Compare to USDA older tables (TCH) • Determine percent ideal body weight.

Cognitive Changes

• Recovered AN have smaller brain tissue volumes and neuropsychological deficits compared to controls• Low weight and high urinary free cortisol associated with greater structural abnormalities• No correlation between measures of brain volume and cognitive test scores• Those who have resumed menses/on OCPs score better on cognitive tests

Gürze Resources

• Recovery Support- Newsletter, blogs, therapists• Materials for parents and loved ones• Self-help manuals- BN- AN- BED• Workbooks- Body image, spirituality- Kids, Teens and Young Adults- For the Professional• Treatment facilities by state- Also National organizations

Binge Eating Disorder (BED)

• Recurrent binge eating (lack of control) - eating in discrete period an amount of food that is definitely larger than what most people would eat in a similar period of time- A sense of lack of control over eating during the episode• Binge-eating episodes are associated with three (or more) of:- Eating much more rapidly than normal- Eating until feeling uncomfortable full- Eating large amounts of food when not feeling physically hungry- Eating alone because of feeling embarrassed by how much one is eating- Feeling disgusted with oneself, depressed, or very guilty afterwards -• Marked distress• Averages at least one days a week for 3 months• Severity based on average number of binge eating episodes per week- Mild: 1 - 3- Moderate: 4 - 7- Severe: 8- 13- Extreme: 14 or more• Is NOT associated with inappropriate compensating behaviors

Bulimia Nervosa

• Recurrent episodes of binge eating (lack of control)- Eating in a period of 2 hours an amount of food larger than most eat• A sense of lack of control over eating during the episode• Recurrent inappropriate compensatory behavior to avoid weight gain• Binge eating and compensatory behavior occur at least once/week for three months• Self evaluation unduly influenced by body shape and weight• Does not occur exclusively during episodes of AN• Severity based on average number of compensatory behavior episodes per week- Mild 1-3, Moderate 4-7, Severe 8-13, and Extreme 14 or more

Refeeding Syndrome cont

• Reintroduction of carbohydrate increases demand for phosphorylated intermediates of glycolysis (e.g. ATP) • Insulin is released• Phosphorus, potassium, magnesium shift to intracellular space• Fluid imbalance occurs (etiology not clear)• May need to provide thiamine (via multivitamin)

Dissonance-Based Interventions (DBI) for Prevention of Eating Disorders

• Relatively new development of this intervention was prompted by the desire for methods that are effective in changing attitudes and beliefs• Theory- Possession of inconsistent cognition creates psychological discomfort• Motivates people to alter cognitions- Act contrary to original attitudes dissonance• Dissonance is maximized when participants feel that they have voluntarily changed their attitude, otherwise the inconsistent behavior is attributed to the demands of the situation- Shift in attitudes• Reduces the perceived inconsistency between the original and the new attitude

Malnutrition Affects Multiple Systems

• Renal effect/fluids and electrolytes• Cardiovascular • Gastrointestinal • Endocrine• Hematologic• Skeletal• Dermatologic• Neurologic

Physical Signs of Eating Disorders Cardiovascular

• Restriction fluids/oral: low blood pressure- Sinus bradycardia• Fluid restriction or vomiting -> hypovolemia and orthostatic hypotension• Sudden death- Cardiac arrhythmias- Hypokalemia- Ipecac abuse• Mitral value prolapse• Congestive heart failure

Anorexia Nervosa (AN)

• Restriction of energy intake relative to requirements, leading to significantly low body weight in the context of age, sex, developmental trajectory and physical health• Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight • Disturbance of weight or shape- Undue importance of weight or shape, or denial of seriousness of problem• Subtypes:- Restricting Type- Binge-Eating/Purging type• Specify Severity Based on BMI: Mild ≥ 17; Moderate 16-16.99, Severe 15-15.99; Extreme < 15

Summary of Moderator Effects

• Risk status of participants- Selected programs produced larger intervention effects than did universal programs overall• Sex- Intervention effects were significantly larger for programs that focused solely on females versus those that included males• Age- Eating pathology is more likely to emerge between ages 15-19 in adolescent girls; rates much lower during early adolescence• Sessions- Intervention effects were significantly stronger for interactive versus didactic programs- Those delivered by trained interventionists were more effective versus endogenous providers- Brief, single sessions were less effective than multi-session programs- Focusing on body acceptance was more effective

Moderator Effects Examined in Meta Analysis

• Risk status of the participant- Universal prevention programs that target everyone versus selected interventions that target only those at high risk for eating pathology• Sex of participants• Age• Sessions- Interactive vs. didactic (providing information)- "Endogenous" providers vs. dedicated interventionists- Number of sessions (one hour versus multiple)- Program content (general or content-targeted)

Physiologic Changes Neurologic System

• Seizures• Myopathy• Peripheral neuropathy• Cortical atrophy

Peer Influences for Adolescents

• Self esteem strongly influenced by interpersonal relationships• Friend groups tend to have similar concerns about body image• Friends tend to use similar behaviors to manage weight and shape- Behaviors can result in adaption of eating disorder behaviors (e.g., vomiting, laxative abuse, etc.) of the group• Peers can also help to challenge the adolescent's beliefs and help with healthy strategies

Examples of DBI Sessions

• Session 1: Interactive, participant-driven- Cost of the thin-ideal- Discussions of the origins of thin-ideal and how it is perpetuated- Letter to hypothetical girl regarding the costs- Self affirmation exercise at home in mirror• Record positive aspects of themselves (physical, behavioral, emotional, social)• No negative thoughts• Session 2: Review Session 1 material- Discuss writing letter and mirror exercises and reactions- Counter-attitudinal role-play• Each attempts to dissuade the group leaders from pursuing the thin-ideal- Homework• A) provide 3 examples from lives concerning pressures to be thin and challenges to these pressures,• B) Produce a top-10 list of things females can do the resist the thin-ideal • Session 3:- Review sessions 1 & 2 - Patients discuss an example from own life concerning pressure to be thin and how they might react• Role-play is involved- Homework: challenge themselves with behavior experiments relating to own body image concerns (ie: wear shorts if they have been afraid to do so due to dissatisfaction)• Session 4:- Discuss body activism - Subtle way thin-ideal perpetuated (for example, complimenting a friend on weight loss; joining in when friends complain about their body)- How to talk positively about one's body- Exit exercise: Write another letter to a hypothetical young girl to instruct her on how to avoid developing body image concerns- Select a self-affirmation exercise to complete at home (practice saying "thank you" instead of "no, I'm fat" when given a compliment

Indications for Hospitalization

• Severe malnutrition - weight less than 75% of ideal body weight• Dehydration or electrolyte imbalance• Cardiac arrhythmias• Physiologic instabilitysevere bradycardiahypotensionhypothermiasevere orthostatic changes • Arrested growth and development• Failure of outpatient treatment• Acute food refusal• Uncontrolled binging and purging• Acute complications of malnutrition (syncope, seizures, pancreatitis, etc.)• Acute psychiatric emergencies

Short Stature?

• Short stature has long been considered an effect of AN• Stature may be spared in adolescents - If illness is subsequent to growth spurt/peak height velocity- Hypogonadal state may cause delay in bone age, allowing for offset of deficits- Males have later growth spurt, may be more susceptible to short stature

Treatment of AN in Specialty Care Continuum

• Six-month outcome of 71 patients with Anorexia Nervosa- Inpatient treatment ~ 5 weeks- Day-hospital program (DHP) ~ 3 weeks (step-down care)• 63% were restricting and 37% bulimic-anorexic• Mon - Friday; 2 supervised meals and one snack• On discharge- 35% showed excellent outcomes- 24% unsatisfactory outcomes• Older, more chronic AN, weighed less in pt.

Parental/Caregivers in Eating Disorders

• Social Stigma of Eating Disorders - Etiology of the child's eating disorder often attributed to familial psychopathology and dysfunctional parenting• Need to educate parents that eating disorder thinking and behaviors, along with the effects of starvation, impact the child's:- Emotions- Cognition- Social relationships- Increase rigidity of thinking• Goals: Maximize the use of parents in treatment, improve their mental health, and reduce the caregiver's stress

Typical Structure of ED Prevention Programs

• Social factors - brings attention of one of the risk factors- Media and cultural pressures to be thin• Prevention programs emphasizes healthy eating and healthy weights and bring increased awareness of the relationships:- Association of the person own and peers' weight preoccupation- Peer teasing about weight and disordered eating- Co-occurrence of puberty and dating as a period of when eating disorders may occur- Parent's criticism and children's preoccupation on weight can increase risk • Initially - primarily focus of ED prevention programs is the psychoeducation (didactic)- Information about eating disorders- Causes- Healthy weight control practices• Later - focus is on the risk reduction components- Pressures to conform to the thin-ideal- Body dissatisfaction- Dieting - Negative affect- Self-esteem defects- Increasing protective factors

Changing Societal Norms

• Societal level changes needs for significant decreases in prevalence of weight-related problems• Change in advertising world- Dove Champaign for Real Beauty (read below) when first launched 2010- current web site: http:- https://www.dove.com/us/en/stories/about-dove/dove-self-esteem-project.html• National Eating Disorders Association (NEDA)- Media watchdog program - volunteers pay attention to TV, radio, newspaper, magazine and internet ads or programs; send notices of ads or programs worthy of praise or protest to NEDA

Treatment Goal Sheet

• Some type of food record- AN: food record- BN: food, hunger and emotions record• Vitamin and mineral supplementation- Multivitamin with extra Fe, Ca- Additional Ca if no dairy• Decrease compulsive exercise- Initially by 50% with a goal of 30-60 minutes MAX per day

Sport Participation vs. Nonparticipation

• Sport participation can have a positive effect on attitudes and behaviors related to eating or body- Also, can be positive for self-perception of competence and ability• But much research suggests that sport participants tend to have more eating problems- Lean- Aesthetic- Endurance- Weight-dependent

Sport Body Stereotypes

• Sports often expected to display particular body size or shape- Jockeys short, basketball tall- Distance runners thin, Sumo wrestler fat- Female gymnast tiny, football players huge• Sport personnel or sport participants may be less apt to perceived a size or shape as unhealthy if it is the expected one• Symptoms versus "normal"- Amenorrhea - can be considered normal in sport environment- Weight loss - maybe perceived at risk if leanness is valued- Training - harder and longer than teammates - does it increase risk?• Gender bias- Males more dissatisfied with bodies from waist up; females more from waist down- Males, if dissatisfied want to be larger; females - smaller/thinner

Cognitive-Behavioral Therapy for BN(CBT-BN)

• Stage 1:- Three major aims:• Engage by explaining rationale; educate about disorder and correct misconceptions; and regain control over eating and establish a regular pattern of eating• Stage 2:- Emphasis on regular eating but treatment broadens to both cognitive and behavioral aspects- Focus on over evaluation of shape and weight and the various behavioral expressions• Stage 3:- Ensure progress is maintained in the future• Patient must have realistic expectations• Patients must develop a solid plan for dealing with any setbacks

Additional Meal Strategies for All Eating Disorders

• Start the day with a hearty breakfast- Decreases the likelihood of bingeing later in the day- Helps to prevent metabolic slowdown that accompanies restrictive eating• Discourage checking weight after meals• Supervise during and after meals- Support and guidance• Eat with others• Limit caffeinated beverage

Technology in Delivery of Weight Management Programs

• Student Bodies 2 - Internet-based program that addressed weight loss and eating disorder attitudes and behaviors in adolescents- Utilizes a cognitive-behavioral approach specifically designed to help overweight adolescent girls and boys lose weight and improve body image- 16 week intervention included education of healthy nutritional choices, physical activity, behavior modification for managing weight, and cognitive activities to improve body image- First 8 weeks focused on weight loss; later 8 weeks target improving body image

Studies with Feeding Styles

• Study 1 - Development and validation of a measure of feeding styles (parent-report)• Study 2 - Relationship of feeding styles to children's eating behaviors and weight status (parent-report)• Study 3 - Testing of the effect of feeding styles on children's self-served portion sizes and intake (laboratory setting; parent-report)• Study 4 - (In progress) Examining the emotional climate of the dinner meal and development of a bi-directional coding system (observation)

Forms of Group Based Treatments

• Support Groups: - leader not trained- provides support with eating disorder • Group Psycho education: - similar to seminars- information shared related to eating disorders• Family Based: - entire family- education with experiential activities to provide treatment

Physical Signs of Eating Disorders Gastrointestinal

• Swelling of the parotid or submandibular glands• Esophageal problems- Esophagitis- Esophageal rupture- Mallory-Weiss tears (occurs in mucous membrane of esophagus where it meets the stomach)• Acute gastric dilatation - can occur with binge eating• Impaired gastric emptying - bloating, early satiety• Loss of normal peristaltic function (laxative abuse)• Constipation - reduced food and fluid intake, slow colonic time

Other Medication (BN)

• TCA may be effective; not as safe as SSRI• Topiramate may decrease binge-eating; small study among obese participants with large drop-out rate• Ondansetron may reduce binge-eating and vomiting; small study• More study is needed prior to any recommendations

Treatment Facilities for Eating Disorders

• The Meadows Ranch - Arizona- (previously Remuda Ranch) -A holistic inpatient treatment program for women, adolescents and children struggling with AN, BN and related issues• Renfrew - Pennsylvania, Florida, New York, Connecticut, New Jersey, North Carolina, Tennessee, Texas, Maryland, Guatemala- A women's mental health center specializing in AN, BN, BED, trauma, anxiety, depression• Eating Recovery Centers - multiple locations treating AN, ARIF, BN - Inpatient, residential, partial hospitalization, intensive outpatient

Nutritional Diagnosis for Eating Disorders

• The nutrition care process organizes nutrition diagnoses into three different groups: Intake, Clinical and Behavioral-Environmental• Nutritional diagnosis is phrased in problem, etiology and signs and symptoms (PES) format:- [Nutrition diagnosis term (problem) related to [etiology] as evidence by [signs and symptoms]• Examples follow that proved sample Nutrition Diagnoses for the different eating disorder diagnoses• More examples provided in the Eating Disorder Pocket Guide by AND

Pitfalls of Internet Therapy

• Therapist may not be licensed to practice outside of a certain geographical area- May not be insured- Hard to determine their qualifications online- Online counseling may prevent the patient from obtaining the personal therapy touch• E-mail is not always secure- Must consider how emails are stored (similar to any clinical record)?• Confidentiality issues exist• "Netiquette"- How much content should be and can be shared online?

Eating Disorders and Internet

• There is a growing body of research that allows for evidence-based eating disorder research conducted on line- Participants may be recruited on-line utilizing questionnaires• Therapist:- Internet can be used to make appointments, help clients with self-monitoring records, and provide progress reports- Some participants are more willing to share information online than face to face

Strategies to improve female triad

• Throw away the bathroom scale• Don't crash diet if you need to lose weight- Cut back on calories by ~20%• Eat adequate, high quality protein- yogurt, fish, chicken, beans, tofu, nuts• 40 - 60+ grams of fat each day are essential- nuts, peanut butter, salmon, olive oil• Eat red meat 2 - 3 times per week- (vegetarians are 5 times more likely to have menstrual problems!)• Maintain a calcium-rich diet- 3 - 4 servings every day

Why the Patient May Not Want to Give Up the Disorder

• To distract from difficult emotions• A means to power and control• A means to security/safety• An excuse or explanation - for anything• An identity• A (safer) way to be angry• A way to avoid people, intimacy, difficult situations• A may to have other attend to him or her• A way to be special• A way to deal with eating and weight • A way to rebel or self-abuse/punish

Endurance Sports

• Triathlons- 2002 Wethington findings suggested that food restriction, body size distortion and disordered eating attitude were common among female triatheletes- Cycling, swimming, and running - have differing body ideals• Cycling- More than half male cyclists had EAT-26 scores above 20• EAT scores > 20 denotes at least concerns regarding body weight, body share, and eating- 46% of elite male cyclists felt pressure to lose weight and 41% used fasting

Common Triggers

• Try to identify an emotional incident or a period when healthy release of stress was/is not available• Others:- Death or illness, divorce or marriage, birth of child- Rape, miscarriage, abortion, abuse- Threats to safety or security - burglary, terrorism, job loss- Moving to new city (especial school-age child)- Disappointment, social rejection- Comments about weight, size, shape (+ or -) - Mandated weight loss for sport, dance, other

Additional Meal Planning Guidelines for AN

• Use weight changes as a guide for increasing daily calorie goals- Can be more rapid in a highly monitored setting- May be very slow as needed• Provide supervision and support for patient during and after meals until a pattern of normal eating and comfort with eating is established• At meal time: avoid food, weight, and/or eating topics• Allow for "diet", "low calorie", reduced fat, etc. items only after review to determine appropriateness • Identify ritualistic food behaviors-Reheating foods repeatedly during meal-Exercising during a meal-Abnormal mixtures of foods-Excessive cutting and chewing of foods• Discuss ALL rituals at non-meal times to determine purpose and encourage discontinuation

Use of Medications

• Very little data pertaining to adolescents• Fluoxetine most commonly studied:- No effect on eating behaviors or weight maintenance for AN; use for antecedent depression/anxiety/OCD+ or after weight restoration- Decreases vomiting and binge-eating behaviors for BN• 60 mg per day produced greater effects than 20 mg per day, especially among those with depression*

Special Considerations for Sports Participation - continued

• Weight-class sports more at risk for practicing bulimic behaviors, if not developing bulimia nervosa• Many these sports (i.e., boxing, judo, wrestling, etc.) believe that "cutting weight" to complete at a weight class below their natural weight gives an advantage- Heavier and stronger than those in the lower weight class; they try to re-nourish and rehydrated between the weigh-in and the competition- Such weight loss typically involves fluid loss• Using dehydration techniques (e.g., vomiting, misuse of laxatives or diuretics, excessive exercise)- Eating between weigh-in and competition may qualify as binge eating

Additional Weight-Class Sports

• Weightlifting - tend to have higher levels of eating disturbance• Horseracing - jockeys - Many racetracks have special facilities including oversize toilets ("heaving bowls") for vomiting and saunas to maintain weight at low ranges• Rowing - has light weight and heavy weight which may increase the risk- Eating symptoms of binge eating, fasting, weight fluctuations, and weight reduction strategies- Higher scores on eating attitudes and problems

Session Topics of CD-ROM Based CBT for Bulimia Study

• What is bulimia?• Understanding why I have bulimia• How do I change?• The role of thought in bulimia• Assertiveness and a "bigger life"• Problem solving• Living life to the full• Planning for the future

Weight-Class Sports: Higher Risk of Disordered Eating

• Wrestling: male sport most often associated with disordered eating- Use of pathogenic methods to "cut weight"- NCAA implemented several changes to safeguard wrestlers - setting weight classes early in season, timing weigh-ins, banning pathogenic weight loss• Body Building - involving increasing muscle size, definition, symmetry, decreasing body fat- Nutrition and (de)hydration strategies to give muscular and lean cut look• Tend to follow very high protein diets- Males vs. Females

Other Medications and Supplements

• Zinc may increase weight gain (14-28 mg) irrespective of the plasma levels- Causes gastric upset in about 2% of patients which is reduced by taking with food• Hormone replacement therapy- Maybe used to improve bone mineral density• Marginal benefit- Monthly bleeding may cause misunderstanding that body is functioning normally- Estrogen can cause fusion of the epiphyses (growth plates) and should not be administered to girls before growth is completed• No indication for bisphosphonates (ie: Fosamax)- May over-suppress bone turnover

Primary Prevention - continued

ATHENA - Athletes Targeting Healthy Exercise and Nutrition Alternative- Program scripted, coach facilitated and peer led for female middle and high school sport participants- Designed to decrease disordered eating risk and use of body-shaping drugs- Curriculum helps to build skills for controlling mood, counter media influences, and provide information on sports nutrition and strength training- https://youth.gov/content/athletes-targeting-healthy-exercise-nutrition-alternatives-athena#:~:text=ATHENA%20(Athletes%20Targeting%20Healthy%20Exercise,prevention%20program%20for%20male%20athletes

The Anorexia Nervosa Genetics Initiative (ANGI): Overview and Methods

AbstractBackground: Genetic factors contribute to anorexia nervosa (AN); and the first genome-wide significant locus has been identified. We describe methods and procedures for the Anorexia Nervosa Genetics Initiative (ANGI), an international collaboration designed to rapidly recruit 13,000 individuals with AN as well as ancestrally matched controls. We present sample characteristics and the utility of an online eating disorder diagnostic questionnaire suitable for large-scale genetic and population research.Methods: ANGI recruited from the United States (US), Australia/New Zealand (ANZ), Sweden (SE), and Denmark (DK). Recruitment was via national registers (SE, DK); treatment centers (US, ANZ, SE, DK); and social and traditional media (US, ANZ, SE). All cases had a lifetime AN diagnosis based on DSM-IV or ICD-10 criteria (excluding amenorrhea). Recruited controls had no lifetime history of disordered eating behaviors. To assess the positive and negative predictive validity of the online eating disorder questionnaire (ED100K-v1), 109 women also completed the Structured Clinical Interview for DSM-IV (SCID), Module H.Results: Blood samples and clinical information were collected from 13,364 individuals with lifetime AN and from controls. Online diagnostic phenotyping was effective and efficient; the validity of the questionnaire was acceptable.Conclusions: Our multi-pronged recruitment approach was highly effective for rapid recruitment and can be used as a model for efforts by other groups. High online presence of individuals with AN rendered the Internet/social media a remarkably effective recruitment tool in some countries. ANGI has substantially augmented Psychiatric Genomics Consortium AN sample collection. ANGI is a registered clinical trial: clinicaltrials.gov NCT01916538; https://clinicaltrials.gov/ct2/show/NCT01916538?cond=Anorexia+Nervosa&draw=1&rank=3. ResultsGeneral ANGI Descriptive InformationTable 1 provides information regarding the number of cases and controls by site and source. Only those samples that passed quality control to be submitted for genotyping are included.Evaluation of Recruitment SourcesDetails about where participants heard about ANGI in the US are provided in Figure 2. The most successful recruitment avenue for cases was the Internet, including social media, whereas, for controls, it was email followed by the Internet. Advocacy groups and clinicians (including clinical programs and eating disorder centers) were also important for recruiting cases. More than 20% of controls heard about ANGI through ResearchMatch (a not-for-profit online recruitment tool) or UNC (but not via email). Notably, 12% of cases and 13% of controls heard about ANGI from family members.Figure 3 demonstrates the importance of using media outlets for participant recruitment. Although ANGI participation had increased steadily in Australia between the media launches in April 2013 and in March 2015, there was a tremendous spike in interest and study completion after the second launch. In approximately 2 months, the number of individuals who completed the ED100K-v1 questionnaire went from 2,228 to 3,574 individuals. Similarly, Figure 4 illustrates the impact of media launches for ANGI-ANZ(NZ) recruitment.We also explored whether cases from eating disorder treatment centers were significantly more ill than individuals from the community in the US. Cases ascertained through the community reported a significantly younger age at lowest weight [mean(sd)=17.4 (5.7)] than those recruited through eating disorders clinics [mean(sd)=19.5 (9.9); t-value=−2.23, p=.028]. The two groups also differed significantly on lowest illness-related BMI with those from eating disorders clinics [mean(sd)=14.2 (2.1)] having lower lowest illness-related BMIs than those from the community [mean(sd)=15.1 (1.9); t-value=−4.75, p<.0001]. However, the majority of participants in both groups, 82.8% from eating disorder clinics and 63.3% from the community, reported illness-related BMI values consistent with severe and extreme DSM-5 AN severity indices.

Treatment approaches

Regular pattern of eating Recognition of food volumes Avoidance of feast and famine Body weight regulation Fluid weight vs. body weight

PARENT ROLE

Release person weight, shape, appearance agendas; no judgment. Provide balanced meals and snacks. Include dessert and non-diet foods. Prioritize meals over other activities. Eat with family, eat what they are eating.

WEEK 6: Recovery Plan

Review of treatment Recovery plan Address potential barriers "Booster session" planning

Refeeding syndrome

Severe malnutrition Low total body potassium and phosphorus Weakened cardiac system Calorie level, start low and gradually advance Increasing calories causes increases in insulin and rapid nutrient transfer TCH Points System

FEMALE ATHLETE TRIAD SCREENING QUESTIONNAIRE

This tool can be given to female athletes during the pre-season evaluation, known as the pre-participation examination. Positive responses to these questions should trigger concern for the evaluating physician thus identifying the female athlete at risk for the Female Athlete Triad. Upon identification of an 'at-risk' athlete, the physician can investigate further by completing a second level, more in-depth, questionnaire, physical examination and laboratory evaluation found following this screening questionnaire. 1. Do you worry about your weight or body composition? Yes No 2. Do you limit or carefully control the foods that you eat? Yes No 3. Do you try to lose weight to meet weight or image/appearance requirements in your sport? Yes No 4. Does your weight affect the way you feel about yourself? Yes No 5. Do you worry that you have lost control over how much you eat? Yes No 6. Do you make yourself vomit, use diuretics or laxatives after you eat? Yes No 7. Do you currently or have you ever suffered from an eating disorder? Yes No 8. Do you ever eat in secret? Yes No 9. What age was your first menstrual period? Yes No 10. Do you have monthly menstrual cycles? Yes No 11. How many menstrual cycles have you had in the last year? Yes No 12. Have you ever had a stress fracture? Yes No

Who is more likely to develop amenorrhea?

Those who:• Lose weight quickly• Have a low body weight• Have low percent body fat• Exercise very hard• Have had irregular menstrual periods even before training hard• Emotionally stressed• Practice restrictive eating behaviors

Weight Loss on the Internet

To review the use of the internet as a method to deliver online lifestyle interventions including behavior modification techniquesTo establish the effectiveness of lifestyle programs delivered via the internet for weight loss or maintenance

Responsiveness feeding style

the degree to which parents use more responsive strategies when trying to influence children's eating (e.g. praise, positive comments)