NUTRITION COUNSELING IN THE TREATMENT OF EATING DISORDERS

Transcription

1 NUTRITION COUNSELING IN THE TREATMENT OF EATING DISORDERS Marcia Herrin, EdD, MPH, RDN, LD, FAED Private Practice Dietitian Clinical Assistant Professor of Pediatrics, Dartmouth Geisel School of Medicine Hanover, New Hampshire, USA (north of Boston) for complimentary copy of slides.

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3 Sponsors Sponsors Dubai Health Authority Dubai International Nutrition Congress Academy of Eating Disorders aedweb.org

4 This Photo by Unknown Author is licensed under CC BY-NC-ND WHAT IS NEW? WHAT IS IMPORTANT?

5 Anorexia nervosa (AN) The Eating Disorders Bulimia nervosa (BN)

6 The Eating Disorders Anorexia nervosa (AN) Significant low body weight Weight below what is normal VS BMI<15% of ideal weight Atypical anorexia nervosa Weight is within or above normal range Amenorrhea Binge-eating/purging type

7 The Eating Disorders Binge Eating Disorder (BED) Recognized in DSM-5, but not ICD-10 Avoidant/Restrictive Food Intake Disorder (ARFID) Extreme picky eating leading to failure to meet nutritional and energy needs (faltering growth) Difficulty eating in social settings May include fear of vomiting, choking May rely on carbohydrates, nutritional supplements More prevalent in males, autism spectrum disorder

8 The Eating Disorders Anorexia nervosa (AN) Atypical anorexia nervosa Bulimia nervosa (BN) Binge Eating Disorder (BED) Avoidant Restrictive Food Intake Disorder (ARFID)

9 SCOFF Questionnaire *Aoun, A., 2015.

10 Goals of Nutrition Counseling in the Treatment of Eating Disorders Restore and maintain healthy body weight Normalize habits and beliefs Eating and food Exercise Body size and shape

11 Recovery Defined as Healthy State Physical Recovery Attainment of Biologically Appropriate Weight Behavioral Recovery Absence of disordered eating behaviors Eating regularly, meeting nutrient needs, responsive to hunger and fullness Psychological Recovery Improved self-esteem and psychosocial function Weight does not have an undue effect on self-evaluation Abstinence from the pursuit of weight loss

12 Biologically Appropriate Weight Maintained with ease; supports normal growth, function & mental health Normalization of eating patterns Return of menses/pubertal resumption Linear growth if expected Normalization of thoughts/cognitions Prevention of short-term and long-term medical complications

13 Features of a Healthy Weight BMI % Growth Curve Weight deficit Expected weight gain Pre-morbid weight

14 State of the Evidence NO PUBLISHED RESEARCH on Nutrition Treatments for Eating Disorders

15 Evidence-Based Dietetic Practice is based on Evidence-Based Treatments Family-based Treatment (FBT) Children and adolescents Cognitive Behavioral Treatment (CBT) Behavior change techniques Dialectical Behavioral Treatment (DBT) Mindfulness Acceptance and Commitment Therapy (ACT) Body image issues Motivational Interviewing (MI) Engaging patient

16 Tools & Strategies Managing Food Managing Weight Managing Binge Eating Managing Purging Managing Exercise Supervision

17 Managing Food Food Plans Regular eating 3 meals + snacks Variety of foods Fun foods Feared foods Varying prescriptiveness depending on the patients/parents Recent intake guides development of initial food plan Avoid fear foods initially expectation that they will be added in the future Nutrition Counseling in the Treatment of Eating Disorders, Herrin & Larkin, 2013 Dr Graeme O Connor PhD RD MBDA, Specialist Paediatric Dietitian at Great Ormond Street Hospital

18 Food Plans (Food Is Medicine): Should be set by providing practical guidance to NORMALIZE (EDs) patients food intake. Effective food plans should achieve three ends: Nutrients needs are met (for AN & ARFID weight restored) Providing an organized food approach to food consumption Desensitize feared, binged or purged food

19 guide to planning healthy meals (Normal serving size usually is one cup or twice the size indicated on food labels) Food Plan Regular meals and snacks Food plans 3 meals 0-3 snacks Parents oversee feeding of children & adolescents Until child/adolescent demonstrates competency Breakfast Calcium Complex Carbohydrates Fruit or Vegetable Protein (optional) Fat (optional) Snack Lunch Calcium Complex Carbohydrates Fruit or Vegetable Protein Fat "Fun Food" Snack Dinner Calcium Complex Carbohydrates Fruit or Vegetable Protein Fat "Fun Food" Snack

20 Managing Weight If patient is losing weight, increase calories Add 500 kcals/day for 2-7 days, check weight, add again. If patient is gaining weight, thank God. 0.5kg-1kg/week Work on other intake issues: quality, variety, food fears. Nutrition Counseling in the Treatment of Eating Disorders, Herrin & Larkin, 2013

21 Using Growth Curves BMI percentile growth curves are clinically beneficial Incorporate weight deficit to be recovered and expected weight gain associated with normal growth

22 Weight Checks Blind weight checks Residential and inpatient treatment Collaborative Weighing (Fairburn, 2008) Decrease anxiety about weight Decrease weight checks outside of treatment Improved understanding of weight, food and exercise interactions Improved confidence in maintaining weight

23 Managing Weight The scale is how you body speaks to me Weights taken facing forward Make changes to usual intake Weight gain Add 300 kcals if weight unchanged Add 500 kcals if weight declines Weight loss ½ kilo/month I want you to lose weight on the highest calories possible

24 Managing Binge Eating Adequate calories and nutrients Err on side of generosity 2,000 to 2,500 calories/day All food groups Carbohydrates!! Sugar!! Fat!! I can t help you work on bingeing until you stop restricting. I can t help you work on weight loss until you stop bingeing.

25 Managing Purging Psycho-education Stomach rupture Swallowing a toothbrush Russell s sign Chipmunk cheeks Bad teeth Weight gain

26 Managing Purging News Flash Stomach rupture Swallowing a toothbrush Purging Does NOT Get Rid of Calories Russell s sign Chipmunk cheeks Bad teeth Weight gain

27 The Facts 1,200 calories are retained after purging whether the binge was relatively small (1,200 calories) or large (3,500 calories) At least a minimum amount of nutrients are absorbed Diuretic abuse has no known effect on caloric or nutrient absorption Laxatives decreased caloric absorption by only 12%. Nutrient losses are minimal

28 Purging References Kaye, W., Weltzin, T., Hsu, L., McConaha, C., & Bolton, B. (1993). Amount of calories retained after binge eating and vomiting. American Journal of Psychiatry, 150(6), Bo-Linn, G. W., Santa Ana, C. A., Morawski, S. G., & Fordtran, J. S. (1983). Purging and calorie absorption in bulimic patients and normal women. Annals of Internal Medicine, 99,

29 Self-Monitoring of Food Intake, Bingeing, Purging Patterns Triggers Powerful Real time Accountability Be curious Play Detective Paper versions Recovery Record Rise Up

30 Managing Exercise in AN Must be medically stable Some weights too risky Does not interfere with weight gain Must be complying with food plan that sustains activity (Calogero & Perdrotty, 2004) Minimum weight maintained for at least a month* *Pike, K. M., Carter, J. C., & Olmsted, M. P. (2010). Cognitive behavioral therapy for anorexia nervosa. In C. Grilo, & J. E. Mitchell (Eds.), The treatment of eating disorders: A clinical handbook (pp ). New York: Guilford Press.

31 Assessing for Excessive or Compulsive Exercise Do you exercise more than once a day? Do you exercise for more than an hour? Do you exercise more than your coach demands? Do you exercise when you are injured or in pain? Can you take a day off? Can you take two days off?

32 Exercise Prescription Do not exercise more than once a day Do not exercise for more than an hour Do not exercise more than your coach says Do not exercise when you are injured or in pain Take 2 rest days/week

33 Managing Exercise in Other Eating Disorders Supportive of patient s current approach to exercise Telling people to exercise does not work Focus first on food behaviors Provide handouts that prove Exercise is Weight Neutral Children, adolescents, & college students usually get plenty of exercise without adding exercise for exercise s sake

34 Exercise in Futility* * Khazan, O., theatlantic.com/magazine/archive/20 16/04/exercise-in-futility/471492/

35 * *

36 Supervision British Dietetic Association (BDA) Mental Health Specialist Group (MHSG) Position Statement, 2017 Access to regular and good quality clinical practice supervision from an experienced eating disorders dietitian and other MDT members is important. Enables reflection on clinical practice and time to consider emotional and relationship issues, which may arise during consultations. Practice supervision can be available in a number of different ways, including one to one, group, face to face, or on the telephone (BDA MHSG 2017) 2. For supervision outside the dietetic profession it is essential that the supervisor has a clear understanding of both professional and clinical dietetic issues as practice supervision can include caseload management and professional management.

37 My Tools Cognitive Behavior Therapy and Eating Disorders, 2008, Fairburn (CBT) Eating Disorders in Children and Adolescents: A Clinical Handbook 2011, Le Grange, James Lock (FBT) Treatment Manual for Anorexia Nervosa, Second Edition: A Family-Based Approach 2012, Lock, Le Grange (FBT) Eating Disorders in Sport, 2010, Thompson, Sherman Treatment of Eating Disorders: Bridging the research-practice gap, 2010, Maine, McGilley

38 My Tools Eating Disorders: A guide to medical care and complications, 2018, 2 nd ed., Mehler, Andersen DBT Skills Training Manual, Second Edition, 2014, Linehan (DBT) Dialectical Behavior Therapy for Binge Eating and Bulimia 2009, Safer, Telch (DBT) Motivational Interviewing in Health Care: Helping Patients Change Behavior, 2007, Rollnick, Miller (MI) Acceptance and Commitment Therapy for Eating Disorders: A Process-Focused Guide to Treating Anorexia and Bulimia, 2011, Sandoz, Wilson (ACT) The Anorexia Workbook: How to Accept Yourself, Heal Your Suffering, and Reclaim Your Life, 2004, Heffner, Eifert (ACT)

39 My Favorites The Parent's Guide to Eating Disorders, 2007, Herrin, Matsumoto Nutrition Counseling in the Treatment of Eating Disorders, 2013, Herrin, Larkin

40 REFERENCES MOST CITED BY EATING DISORDER DIETITIANS 2018

41 Resources for Dietitians Nutrition Counseling in the Treatment of Eating Disorders, 2 nd Ed, Herrin & Larkin, 2013 Pocket Guide to Eating Disorders, 2 nd Ed, Setnick, 2016 Family Therapy for Adolescents and Weight Disorders, Loeb, Le Grange, Lock, 2015 Treatment Manual for Anorexia Nervosa, 2 nd Ed, Lock, Le Grange, 2012 Eating Disorders in Children and Adolescents, Le Grange, Lock, 2011

42 Resources for Dietitians Eating Disorders: A Guide to Medical Care and Complications, Mehler, Andersen, 2 nd ed., 2018 Clinician's Guide to Collaborative Caring in Eating Disorders London, Treasure, 2010 Dialectical Behavior Therapy for Binge Eating and Bulimia, Safer, Telch, Chen, 2009 Cognitive Behavior Therapy and Eating Disorders, Fairburn, 2008 Acceptance and Commitment Therapy for Eating Disorders, Sandoz, Wilson, Dufrene, 2010

43 Resources for Dietitians Brain Over Binge, Hansen, 2015 Overcoming Binge Eating, 2 nd Ed, Fairburn, 2013 Goodbye Ed, Hello Me, Schaefer, 2009 The Anorexia Workbook, Heffner, Eifert, 2004 Life Without Ed, Schaefer, Rutledge, 2003

44 Resources for Parents Survive FBT, Ganci, 2016 Help Your Teenager Beat an Eating Disorder, 2 nd Ed, Le Grange, Lock, 2015 Helping Your Child with Extreme Picky Eating, Rowell, 2015 Parent s Guide to Eating Disorders, 2 nd Ed, Herrin, Matsumoto, 2008 Your Child s Weight: Helping without Harming, Satter, 2005

45 Complete References on Request