Workshop 1 Sarah Fuller. Welcome. Veganism in Eating Disorders. Dietitians?

Transcription

1 Workshop 1 Sarah Fuller Welcome Veganism in Eating Disorders What should Insert we consider text here as Dietitians?

2 Socially acceptable dietary restrictions in eating disorders Sarah Fuller Advanced Specialist Eating Disorders Dietitian, Bedfordshire CAMH Eating Disorders Team and Rhodes Wood Hospital

3 What do we mean by socially acceptable dietary restrictions? Food restriction via: Veganism Orthorexia Clean eating Gluten free

4 Could restrictions lead to eating disorder? Key questions to ask Are they restricting their diet or finding suitable balanced alternatives? Restriction of fear foods and an increase in safe foods Are you allowed treats? Social foods E.g. muffins, brownies, cheesecake or chocolate cake Are ethical choices seen in non-food aspects of life e.g. clothes, makeup, toiletries, use of free time? Thoughts around managing natural errors in following the food guidelines oops, now I know that I won t do it again, I m human so I made a mistake v s oh no! what have I eaten, that was poison/toxic or I may gain weight as a result Social effects of eating can you eat in front of others without knowing the calorie content of the meal/snack, can you eat in front of others, in restaurants etc? Social media: thinspiration/fitspiration or diet sites. We know that frequent users of social media are x 3 more likely to develop a mental health problem

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6 Veganism The Vegan Society defines Veganism as a way of living which seeks to exclude, as far as is possible and practicable, all forms of exploitation of, and cruelty to, animals for food, clothing or any other purpose it can therefore be seen as an ethical movement rather than a diet.

7 The rise of veganism 2016, Vegan Society + market research surveyed 10,000 people aged 15 years in UK: At least 1.05% of the population aged 15 and over (at least 542,000 people in Britain) are now following a vegan diet - a significant increase since the last estimate of 150,000 ten years ago. Appears to be driven by young people making more ethical and compassionate choices. Close to half of all vegans are in the age category (42%) compared to just 14% who are over 65. Majority of vegans live in urban or suburban areas (88%) vs rural areas (12%) London, has 22% of all vegans in Britain! Almost twice as many vegans identify as female (63%) than male (37%)

8 Veganism in eating disorders Whilst there is lots of research into vegetarianism and eating disorders there is very little into veganism and EDs About to be published flash survey services responded - reflecting 1126 patients ADULTS = 66 vegans in 641 sample 10.2% Hospitalised = 48/468 = 10.2% Day Hospital = 18/173 = 10.4% CAMH = 66/485 = 13.6% Hospitalised = 46/281 = 16.3% Day Hospital = 20/204 = 9.8%

9 Veganism related to an eating disorder? Key questions to ask Does your family follow a vegan diet? What does your family think about your choice to become vegan? What was the initial reason behind your initial decision and drive to achieve veganism? Environmental sustainability, disease prevention, animal welfare verses to cook separate meals from family, weight loss or body image? A goal of weight loss or change in body shape = red flag Does your religion advocate a specific diet? most religions endorse necessity over prohibition i.e. young people can be exempt from dietary restrictions or fasting for the sake of their physical and mental health. Is there any growing restriction within the diet? i.e. did this start off as healthy eating then vegetarianism or restrictions of food groups. Are there any self-diagnosed or not medically confirmed restrictions in the diet e.g. lactose free or gluten free?

10 Points of nutritional vulnerability in a vegan diet 2018 Vegan diets: review of nutritional benefits and risks Expert report of the Federal Commission for Nutrition (FCN), Switzerland generally cover the macronutrients Protein Average intake is adequate BUT high variability, some are deficient Micronutrients Vitamin B12 Iodine Zinc EPA and DHA fatty acids BUT 10-50% don t take supplements

11 Points of nutritional vulnerability in a vegan diet 5 a day Poor consistency in achieving this Only those with well planned diets meet this Groups with higher requirements have a higher risk of nutritional deficiencies Pregnancy Breastfeeding Infancy Childhood Older age Those with chronic illnesses esp ED s

12 Possible signs of an unhealthy vegan diet Over restriction can include: The elimination or minimisation of fats and oils Excluding foods containing sugars or social foods Eating less than 20 foods Avoiding alcohol and eating out socially Further restriction to organic produce or specific brands Physical health compromise or the refusal to maintain a healthy weight

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14 Orthorexia Orthorexia is the fixation on righteous eating when healthy eating guidelines are taken to extremes, and the correct foods will cleanse the body and this association with food becomes the primary sense of self esteem Orthorexia Nervosa is not currently recognized as a clinical diagnosis in the DSM-5? Sits under ARFID ( fear of consequences of eating) Orthorexia is a term coined by Steven Bratman, MD in He used the term to help his patients entertain the possibility that this healthy eating may not be as beneficial as they presumed Key difference between orthorexia and AN or BN is those with AN or BN obsess about calories and weight while orthorexics obsess about healthy eating (not about being thin and losing weight). No purging behaviours are seen.

15 Orthorexia Initially starting with eating more healthy and cutting out a food or food group always results in reported improved wellbeing - until the effect plateaus Often based in health fears e.g. I'm going to get cancer/heart disease and very black and white thinking may lead to you cant eat red meat as it gives you cancer etc Every day is a chance to eat right, be good, rise above others in dietary prowess, and self-punish if temptation wins (usually through stricter eating, fasts and exercise). Self-esteem becomes wrapped up in the purity of orthorexics diet and they sometimes feel superior to others, especially in regard to food intake. Tends to get more and more restrictive over time- less and less safe foods - increased control

16 Orthorexia Nutritional concerns Cutting out food groups e.g. dairy (calcium and phosphate) or carbohydrates Avoidance of fats especially saturated fats Inadequate protein can lead to muscle atrophy Self imposed dietary restrictions e.g. gluten free or lactose free

17 Orthorexia Supported by ++ internet reinforcement via health bloggers and conflicting messages on internet Strongly linked with the fitness industry

18 Orthorexia Consider the following questions. The more questions answered yes to, the more likely you are dealing with orthorexia. Do you wish that occasionally you could just eat and not worry about food quality? Do you ever wish you could spend less time on food and more time living your life? Does it seem beyond your ability to eat a meal prepared with love by someone else one single meal and not try to control what is served? Are you constantly looking for ways foods are unhealthy for you? Do love, joy, play and creativity take a back seat to following the perfect diet? Do you feel guilt or self-loathing when you stray from your diet? Do you feel in control when you stick to the correct diet? Have you put yourself on a nutritional pedestal and wonder how others can possibly eat the foods they eat?

19 Clean eating

20 Clean eating Clean eating is about eating whole foods, that are minimally processed, making them as close to their natural form as possible. There is a heavy focus on fruits, veggies, wholegrains, animal and plant based proteins, nuts, seeds and oils. Trend fuelled by wellness bloggers #cleaneating Not evidence based breaking news No added sugars except natural sugars Agave sugar is still sugar Brown sugar actually has more calories per tsp than white sugar Coconut oil is mostly saturated fat Kale got a PR company but watercress and spinach have a more favourable nutritional value If green tea really helped people loose weight the NHS would be prescribing it It s important to fast regularly to cleanse toxins from your body nope you have a liver, kidney and spleen for that Lots of rules to follow - lists of good/clean and bad/un-clean Often promotes expensive supplements or Organic foods

21 Gluten free diets Patients diagnosed with Coeliac Disease, or other chronic medical conditions, are more likely to be diagnosed with an ED due to necessary increased focus on dietary changes and monitoring. A gluten free diet is the only treatment option for Coeliac Disease and this is an auto-immune reaction to one of the components of gluten (usually gliadin). Coeliac UK estimates that 1:100 people in the UK suffer Within the UK & USA sales of Gluten free products are increasing by >10% year on year as there is a perceived benefit to health BUT gluten free products Contain more fat / sugars than their counterparts Don t contain wholegrains which have proven health benefits Are not routinely fortified

22 Gluten free diets Zanini, B., et al. (2015): "Randomised clinical study: gluten challenge induces symptom recurrence in only a minority of patients who meet clinical criteria for non-coeliac gluten sensitivity Conclusion: Double-blind gluten challenge induces symptom recurrence in just one-third of patients fulfilling the clinical diagnostic criteria for non-coeliac gluten sensitivity. American Heart Association (2017): Low gluten diets may be associated with higher risk of type 2 diabetes Conclusion: 30 year follow up showed that participants who ate less gluten also ate less cereal fibre, known to be a protective factor for Type 2 DM development Lebwohl B., et al (2017): Long term gluten consumption in adults without celiac disease and risk of coronary heart disease: prospective cohort study Conclusion: Long term dietary intake of gluten was not associated with risk of coronary heart disease. However, the avoidance of gluten may result in reduced consumption of beneficial whole grains, which may affect cardiovascular risk. The promotion of glutenfree diets among people without celiac disease should not be encouraged.

23 Gluten free diets BUT... There is a rise in patients presenting with Non Coeliac Gluten Sensitivity The science on gluten sensitivity is evolving and we're learning new information on the condition regularly. ~1% of the population may have NCGS New research suggests that gluten alone may not be responsible for the symptoms produced by the condition currently called gluten sensitivity. Instead, it is showing that perhaps FODMAP s may be the cause of the symptoms instead. Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols, which are short chain carbohydrates and sugar alcohols that are poorly absorbed by the body, resulting in abdominal pain and bloating similar symptoms to Coeliac Disease but without the intestinal damage Wheat, barley and rye gluten-containing grains are all high in FODMAP s

24 When to refer to Dietetics Poor variety e.g. ~<7 main meal choices, < 3 lunch choices, and limited snack choices. Elimination of food groups without appropriate alternatives Dietitian would assess the diet for nutritional adequacy focusing on key vulnerable areas: Calcium, Iodine, Iron, Selenium, Vitamin B2, Vitamin B12, Vitamin D and Zinc