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Eating Disorder In Teens M Jacob 2008 Mda Test

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Promising approaches in the treatment of eating disorders.

Promising approaches in the treatment of eating disorders.
This presentation was done at the Michigan Dietetics Association meeting to an audience of registered dietitians.

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Eating Disorder In Teens M Jacob 2008 Mda Test Eating Disorder In Teens M Jacob 2008 Mda Test Presentation Transcript

  • Eating Disorders in Teens and Young Adults: Promising Approaches
      • Melanie Jacob, RD
      • [email_address]
      • Nutrition Therapy, LLC
      • MDA 2008
  • Eating Disorders
    • Video clips that portray eating disorders
    • Samples:
    • http://www.campaignforrealbeauty.com/home.asp
    • http://www.youtube.com/watch?v=dL7WPylAd5E
  •  
  • Origin of an Eating Disorder
    • Genetics- gun: predisposed to low self esteem, depression/anxiety/perfectionism/compulsive. Brain chemistry makes them more prone to food problems.
    • Culture / Environment-ammunition : health class that teaches about fat in the diet. Sport that identifies with weight or shape. Media.
    • Stress-pulls the trigger : adolescents going through puberty, loss, grief, older sibling moves away.
  • Warning Signs of Eating Disorders
    • Diet behaviors
    • Sudden decision to become vegetarian
    • Weight Loss
    • Refusing to eat with the family
    • Denial of hunger
    • Skipping meals
    • Cold intolerance and layered dressing
    • Social withdrawal
    • Obsessive talking about food, counting calories
    • Increased picky eating or only eating healthy foods
    • Cooking for others but not eating
    • Food rituals and compulsions
    • Parents note - large amounts of food is missing
    • Anxiety about weight
  • Eating Disorders NOS common features
    • Emphasis of weight and shape for self worth
    • Pursuit of thinness through dieting or destructive weight loss techniques
    • Abnormal patterns around eating
    • Abnormal set of beliefs about food, weight or shape
    • Degree of social, emotional, behavioral disfunction.
  • Nutrition Care Process
    • Skills
    • Assessment
    • Intervention
    • Monitoring
  • Skills and Training Recommended for Nutrition Therapist
    • Specialized training in the field of Eating disorders
    • Supervision with a clinical psychologist trained with ED
    • Experience working with a treatment team
    • Maturity and good counseling skills
    • Resolved personal issues with food and body weight
  • A Picture of Denial
    • “I am fine”
    • “I can make my own decisions”
    • “I can get better on my own. I can follow the meal plan on my own.”
    • “Its none of your business”
    • Not eating is the most important thing in the teens life
  • Looking below the surface
    • Eating disorders can be disguised as...
    • GI problems
    • Endocrine issues
    • Fertility problems
    • Vegetarian or picky eating
    • Competitive Athletes
    • Poor growth
    • Unintentional weight loss or gain
  • Look at the Physical Symptoms!!!! Lab values are usually normal
  • Symptoms of Starvation
    • Low heart rate < 60 bpm
      • 3 c's: cold, crabby constipated
    • Delayed gastric emptying
      • Decreased lipase
    • Low blood pressure
      • Orthostatic changes
    • Skin and hair changes
      • Lanugo: fine downy hair
    • Cognitive distortions
      • Weight, shape and food
    • Preoccupation with food
    • Food rituals
  • Medical Consequences Bulimia ‏
      • VOMITING
    • Parotid gland enlargement
    • Erosion of tooth enamel
    • Tears in esophagus
    • Chronic sore throat
    • Esophagitis
    • Stomach cramps
    • Digestive problems
    • Anemia
    • Electrolyte imbalance
    • Hemorrhages, ecchymoses
    • Russell’s sign
    • DIURETIC ABUSE
    • Potassium imbalance
    • Fatigue
    • Kidney damage
    • Fluid loss, dehydration
    • Lightheadedness
    • Electrolyte imbalance
    • LAXATIVE ABUSE
    • Abdominal complaints
      • Cramping
      • Constipation
    • Malabsorption of fat, protein
    • & calcium
    • Electrolyte imbalance
  • Nutrition Care Process
    • Skills
    • Assessment
    • Intervention
    • Monitoring
  • Assessment – Parents & teen
    • General overview – Parents and teen
      • Assess relationship
      • Confidentiality – release signed
      • Why are you here?
      • Medical history/medications
      • Family history
      • Family Routines and commitments
      • Weight history
      • Menstrual history
      • Physical symptoms
  • Assessment-Physical Activity
    • Exercise patterns
      • What sports/gym
      • How long
      • Frequency
      • Family expectations
    • Heart Rate monitoring
      • Beats per minute
    In “shape” or malnourished???
  • Assessment - ED behaviors
    • ED Behaviors - past and current
      • Counting – calories, fat or carbs…how much
      • Fasting or skipping meals
      • Diet pills…when’s the last time?
      • Laxatives…how many?
      • Vomiting…have you tried it…how many times/week…details like how and where
      • Exercise compulsion…can you miss a day
      • Anything else...diuretics, Ipecac,
      • Websites, magazines
  • Assessment – Body Image
    • Body Image
      • Defined
      • Self perceived
      • Others think
      • ED Thoughts
    • Friends
      • Best friends?
      • Boy friend?
      • Groups of friends?
      • School lunch routine?
      • Conflicts?
    • “ How do you see yourself in your minds eye?”
  • Assessment - Nutrition
    • 3 day food records
      • calories
      • balance
    • Food rules
    • Timing and routines
    • Binges/trigger foods
    • Fluids/ Caffeine
    • Supplements
  • Nutrition Care Process
    • Skills
    • Assessment
    • Intervention
    • Monitoring
  • Determining Ideal Body Weight
    • Complete weight and ED history
    • Obtain growth records from MD
    • Assess menstrual history
    • NCHS growth charts
    • Normal growth curve
    • Use a 5 pound weight range with adjustments for normal adolescent growth
    • Impression: 15 yo with 20 pound weight loss in 4 months at 83% of IBW. BMI for age 16.8 <10 th %tile.
    Case: Was 115# At 95# IBW 113-118 #
  • Determining Caloric Requirements
    • Normal BMR 1200 to 1400 kcal
    • Activities of daily living +30% + 400 kcal
    • Adolescent development +30% + 400 kcal
    • Sports – vary + 250 – 500 kcal
    • Weight gain + 250 – 500 kcal
    • Hyper-metabolic rate
    Malnutrition 2600 to over 3500 Normal weight & Purging 2000 to 2400 cals
  • Nutrition Intervention - AN
    • Use food records and recalls to assess current caloric level. Start where they are at then add
    • Scheduled three meals, three snacks daily
    • Set calcium goal from food and supplements
    • D/C use of calorie free, fat free, sugar free
    • Advance calories/exchanges every 3-7 days
    • Use preferences and “safe” foods initially
    • Nutritional supplements
  • Nutrition Intervention-purging
    • Meal ideas given- use safe foods
    • Goal may be to decrease vomiting frequency, work with therapist pace.
    • Food journaling to learn triggers.
      • Food-Emotional-Situational
    • Adequate nutrition to prevent restrictive feelings
    • Increase fluids and fiber
    • Equal distribution throughout the day
  • Exercise Recommendations
    • May need to limit cardio if HR is <60 bpm
    • OK strength training
    • Yoga and stretching
    • Work with MD on incremental increases
      • Weight gain trend needed
    • Watch for purging to change from vomiting to exercise
    • Exercise for enjoyment, stress management, socialization, health
  • Nutrition strategies and protocols Clinical & Counseling topics
    • Meal planning
    • Metabolic rate
    • Re-feeding syndrome
    • Effects of purging on the body & metabolism
    • Role of exercise in recovery
    • Importance of dietary fat
      • Weight changes
      • Set point theory
      • Hunger and fullness
      • Food fears
      • Social eating
      • Negative body image
      • Cognitive behavioral techniques
  • CBT cognitive behavioral therapy
    • Challenge beliefs with accurate interpretations
    • “ I can only eat as many calories that I burn with my exercise routine”
    • “ I won’t be able to stop gaining weight if I start”
    • “ I know if I eat anything with fat I will get fat”
    • “ When I used to eat cheese I was fat, therefore I must avoid it now so I won’t gain weight.”
    • “ I am special if I am thin”
  • Weight Gain expectations
    • Malnutrition/Anorexia
    • Hospital/Residential
      • 2 to 3 pounds
      • per week
    • Outpatient
      • ½ to 1 pound
      • 1 - 2 pound per week
        • Boys
        • Family based
      • Bulimia
    • Initially expect weight gain about 5 pounds
    • Swings up and down however will normalize
    Discourage use of the scale! Blind weight checks
  • Nutrition Care Process
    • Skills
    • Assessment
    • Intervention
    • Monitoring
    On Going Communication Medica l Dietitian Therapist
  • Moving away from a meal plan
    • Hunger and fullness work
    • Phase out nutritional liquid supplements
    • Normal eating
    • Teach trust in letting go
    • Social eating
    • Supportive maintenance
  • Normal Eating
    • Eating when you are hungry
    • Eating until satisfied
    • Eating what you truly want
    • Eating a variety
    • Flexible, enjoyable & balanced
    • Not avoiding foods out of fear or social situation
    • Does not draw attention to yourself
    • Eating takes its place as only one part of your day
  • New Strategies in Eating Disorder Treatment Family-based approach The role of the parents in re-feeding in adolescents and young adults with eating disorders James Lock, MD, PhD Daniel Le Grange, PhD “ Maudsley” Laura Collins mother/writer
  • Overview- Family based approach
    • Cognitive distortions are common from malnutrition and often prohibit the adolescent to eat.
    • Parents are empowered and viewed as the most valuable resource in re-feeding and normalizing eating.
    • They are not blamed for the eating disorder. Parents are equipped to provide the support and given the tools to support recovery.
  • Family Based Approach
    • The goal is to restore weight and return to normal growth and development.
    • Phase I – Weight restoration
    • Phase II The child takes more control over eating again.
      • 95% of target weight
    • Phase III - Establish healthy adolescent identity and autonomy.
      • This occurs when the adolescent is maintaining weight in target range
  • Phase I: Weight Restoration
    • When given a meal plan parents are to:
      • Provide/ prepare/ plate out food
      • Patients job is to eat the food or supplement
      • Parents sit in a supportive fashion to monitor
      • intakes. (Sympathetic yet verbally persistent).
      • Siblings are also supportive to the patient.
      • Assure compliance to food plan and direct all consequences of not eating.
      • Provide consistent exposure and food
      • challenges to help normalize eating.
  • Dietitians role in Weight restoration
    • Food is medicine – Meal plan from RD
    • Education to parents
    • Assist in increase or change of meal plan
    • Meal planning & family meal time guidance
    • Blind weight checks
    • Reassessment
    • Team communication
  • Michigan Program
    • Hough Family Center for Adolescent Eating Disorders (Beaumont Hospital – Pediatrics) ‏
      • Drop of patient admission
      • Increased recovery rates
      • Decrease in out of state admissions
    • Early detection & early intervention
      • Assemble a treatment team
      • Parent coaching group
      • Adolescent skills group
      • Multidisciplinary communication
  • Multi-disciplinary team approach
    • Kathy Mammel, MD Chief of Adolescent Medicine, William Beaumont Hospital
    • Stephanie Milstein, PhD Therapist and Facilitator
    • Parent of recovering teen
    • Mother who used family based approach and daughter recovering from an eating disorder
    Video taken at EDAW at Beaumont Hospital 3/2008
  •  
  • Development up to present
    • Previously parents were often kept out of treatment.
    • Parents bring important resources and need to see ED's as serious medical and psych-iatric illnesses.
    • Maudsley demonstrates that when parents know what they are up against they provide more support and are more effective.
    • It is not your fault. Don't waste time on the why?
  • Advice to Parents
    • Make this your top priority
    • Be available
    • Establish a regular eating pattern
    • Help your child eat more
    • Limit exercise and use rewards when there is progress.
    • No eating disorder debates
    • Know when to back off
    • Take care of yourself
  • Externalizing the illness
    • “ ED” is like an invader, alien or parasite
    Providers Patient Parents ED Patient ED
  •  
  • Potential Alternatives
    • Short hospitalizations to stabilize medically
    • Outpatient intensives
    • Day treatment programs
    • Residential treatment programs
      • $1000 /day
      • 30 to 90 days
      • Often do not maintain the weight gains when they return home.
  • Additional Resources
    • National Eating Disorders Association (NEDA) ‏
      • www.nationaleatingdisorders.org
    • Maudsley Parents
      • www.maudsleyparents.org
    • Gurze catelogue
      • www.gurze.com
    • aroundthedinnertable.org
      • Online forum for parents