2/1/17. Disclosure Statement ADDRESSING OBESITY SAFELY: THE NEW AAP POLICY ON OBESITY AND EATING DISORDERS. DSM-5 for Anorexia and Bulimia Nervosa

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1 ADDRESSING OBESITY SAFELY: THE NEW AAP POLICY ON OBESITY AND EATING DISORDERS Christine Wood, MD, FAAP Pediatrician, Coast Pediatrics Carmel Valley Past Co-Chair San Diego County Childhood Obesity Initiative Institute for Healthy Childhood Weight Steering Committee (IHCW SC) Medical Consultant for Center for Discovery Residential Eating Disorder Treatment Center Disclosure Statement I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. Healthy èèèèèèèèèèèèè Problematic Weight control practice: Physical activity (PA) behaviors: Body image: Eating behaviors: Weight status: Healthy eating Dieting Unhealthy weight control behaviors Moderate PA Body acceptance Regular eating patterns Healthy body weight Minimal or excessive PA Mild body dissatisfaction Erratic eating behaviors Mildly over- or underweight Lack of, or obsessive PA Moderate body dissatisfaction Binge eating Overweight or underweight Anorexia or bulimia Anorexia athletica Severe body dissatisfaction Binge eating disorder Severe overweight or underweight DSM-5 for Anorexia and Bulimia Nervosa Changes in DSM-5 will likely affect prevalence rates, since criterion are less stringent than DSM-IV For AN have eliminated the 85% of Ideal Body Weight and amenorrhea as criteria (still includes pathologic fear of weight gain and inaccurate perception of body weight, size, shape, excess dieting) For BN less stringent on frequency of bingeing and inappropriate compensatory behaviors (self-induced vomiting, periods of starvation, compulsive exercise or use of laxatives, diuretics, diet pills) from twice a week for 3 months to once a week for 3 months. From I m Like So Fat by Dianne Neumark-Stzainer, PhD 1

DSM-5 New Additions Binge-Eating Disorder (BED) officially recognized as recurrent bingeing at least once a week for 3 months without compensatory behaviors Avoidant/Restrictive Food Intake Disorder

growth, but without weight or shape concerns Prevalence is around 3-5% of children Boys might have higher risk Stats and Facts 20% of youth have mental disorders, but many are not receiving care 3%

eating disorder Eating disorders affect all ages and ethnic groups Arch of Gen Psych. March 7, 2011 New Trends in Stats and Facts Lifetime risk in US females: 0.9% anorexia 1.5% bulimia 2.

2 DSM-5 New Additions Binge-Eating Disorder (BED) officially recognized as recurrent bingeing at least once a week for 3 months without compensatory behaviors Avoidant/Restrictive Food Intake Disorder (ARFID) Disturbance in eating characterized by persistent failure to meet appropriate nutritional and/or energy needs that leads to weight loss, failure to achieve expected weight gain or faltering growth, but without weight or shape concerns Prevalence is around 3-5% of children Boys might have higher risk Stats and Facts 20% of youth have mental disorders, but many are not receiving care 3% of US teens have an ED, but most do not receive treatment Majority of those with ED met criteria for at least one other psychiatric disorder 16% of transgender college students report having an eating disorder Eating disorders affect all ages and ethnic groups Arch of Gen Psych. March 7, 2011 New Trends in Stats and Facts Lifetime risk in US females: 0.9% anorexia 1.5% bulimia 2.8% binge-eating disorder New DSM-5, less stringent, so likely Hispanics highest rates bulimia increase in numbers For females between yrs with anorexia, mortality rate is 12x higher than death rate of ALL other causes of death; 20% of deaths are by suicide ANAD Eating Disorder statistics, accessed Jan 30, Psycho-Developmental Factors Family Functioning Style Drive for thinness Achievement-oriented Enmeshment Lack of conflict resolution Over-protectiveness High Risk Personality Whites highest rates of anorexia Pediatrics. 2010;126(6): Bright (top 5% of class) Lack coping skills Doesn t like change Needs control, attention Fear of growing up Media Hollywood movies and TV Magazines Websites (Pro-Ana) Lifestyle Family preoccupied with healthy eating and exercise Dieting parents From , hospitalizations for ED increased most sharply 119% for children younger than 12 years of age Socio-Cultural Factors Anxious Perfectionist Obsessive People pleaser Conflict avoidant Approval seeking Increasing prevalence among males: 5-10% of all adolescent ED are males Increasing prevalence among minority groups Family values on thinness Peers Drive for thinness (eg, under 100 club ) Dieting peers 2

Social-Cultural Factors Personal Trauma, abuse Special event (prom, college, special event) Sports pressure Statements by others Bullying Family dynamics Psychological Complications Eating disorders

3 Social-Cultural Factors Personal Trauma, abuse Special event (prom, college, special event) Sports pressure Statements by others Bullying Family dynamics Psychological Complications Eating disorders are coping mechanisms that have adaptive functions Co-morbid conditions often exist Anxiety, Depression, OCD, Substance Abuse Percent with comorbidities Anorexia: 56.2% Bulimia: 94.5% Binge Eating Disorder: 78.9% Need to treat all the underlying issues in order for the person to recover fully Childhood Obesity In for children and adolescents aged 2-19 yrs in the US: The prevalence of obesity has remained fairly stable at about 17% and affects about 12.7 million children and adolescents Obesity prevalence was 8.9% among 2-5-year-olds Obesity prevalence was 17.5% among 6-11-year-olds Obesity prevalence was 20.5% among year-olds Prevalence of Obesity Among Adults and Youth: US, CDC National Center for Health Statistics (NCHS) data brief Childhood Stress Measured year olds and found those exposed to stress were more likely to be heavier 4 years later Demographic: Poverty, single parent status, maternal high school drop out Physical: Residential crowding (people/room), noise level, housing problems Psychosocial: family turmoil, child separation from family, exposure to violence Childhood stress with poverty and family tension can make it difficult for children and teens to self-regulate and lead to increase fat and sugar consumption Pediatrics. 2012;129(1):e68-e73 ACE and Adult Health Outcomes Increased number of adverse events in childhood Psychological, physical, sexual abuse Violence against mother Living with household members who were substance abusers, mentally ill or suicidal Imprisoned household members With 4+ categories of ACE 4-12 fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt 2-4 fold increase in smoking, poor self-rated health, STDs fold increase in physical inactivity and severe obesity Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults, Felitti, Vincent J et al. American Journal of Preventive Medicine, Volume 14, Issue 4,

Recommended Community Strategies to Prevent Obesity Obesity Society.

5, 2014 Promote availability of affordable healthy food and beverages Support healthy food and beverage choices Encourage breastfeeding Encourage physical activity or

2009/Vol. 58No. RR-7 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5807a1.

4 Recommended Community Strategies to Prevent Obesity Obesity Society. Americans view on obesity is changing: Fewer adults see it as a personal problem of bad choice Science Daily, Nov. 5, 2014 Promote availability of affordable healthy food and beverages Support healthy food and beverage choices Encourage breastfeeding Encourage physical activity or limit sedentary activity among children and youth Create safe communities that support physical activity Encourage communities to organize for change MMWR July 24, 2009/Vol. 58No. RR-7 COMMON INFLUENCES ON OBESITY AND EATING DISORDERS Factors That Align with Obesity and Dieting Family Meals Weight Talk Weight Teasing Body Image Of American elementary school girls who read magazines, 69% say that pictures influence their concept of ideal body shape 47% say the pictures make them want to lose weight The development of the ideal body image perceptions in the US. Nutrition Today. 45(3); Ad for Steve Madden shoes 4

Dieting Becomes the Means to Obtain the Thin Ideal Where Has This Lead Us?

et al, 1991 Smolak, 1996 Prospective study of 9-14-year-olds followed for 2 years, dieting was associated with greater weight gain and increased rates of binge eating in both boys and girls.

2003;112(4):900 Source: National Association, 2005. www.nationaleatingdisorders.

5 Dieting Becomes the Means to Obtain the Thin Ideal Where Has This Lead Us? Poor body image through the ages 1st to 3rd graders 42% want to be thinner1 10 year olds 81% afraid of being fat2 American women 80% are dissatisfied with their appearance Collins, 1991 Mellin et al, 1991 Smolak, 1996 Prospective study of 9-14-year-olds followed for 2 years, dieting was associated with greater weight gain and increased rates of binge eating in both boys and girls. Several studies show dieting is counterproductive to weight management efforts. Relation between dieting and weight change am ong preadolescents and adolescent. Pediatrics. 2003;112(4):900 Source: National Association, Dieting Becomes the Means to Obtain the Thin Ideal Prospective study of 14 to 15 year olds followed for 3 years, dieting was the most important predictor of developing an ED. Those who severely restricted energy intake and skipped meals were 18 times more likely to develop an ED than those who did not diet. Those that dieted at a moderate level had a fivefold increased risk. And even among girls who are clearly not overweight, over 1/3 report they have dieted. Body image, eating disorders and obesity in youth: Assessment, prevention and treatment (2 nd ed) Washington DC American Psychological Associations. Onset of adolescent eating disorders: population based cohort study over 3 years. BM J. 1999;318(7186): Factors That Align with Obesity and Dieting The Case for Family Meals Family Meals Weight Talk Weight Teasing Body Image Frequent family meals lowered risk in teens: Smoking, drinking and drugs Disordered eating Depression Overweight And they had better grades and ate healthier Family Dinner Meal and Adolescent Development. J Adolesc Health Sep;39(3):

Family Meals Frequency of family meals improves diet quality with increased consumption of fruits, vegetables, grains and calcium-rich foods.

2 In girls, family meals perceived to be enjoyable were protective from extreme weight control behaviors.

2008;162(1):17-22 2 Family dinner and disordered eating behaviors in a large cohort of adolescents. Eat Disord. 2010;18(1):10-24 Why Does it Work?

of childhood obesity and the use of unhealthy weight control behaviors Preventing obesity and eating disorders in adolescents: what can health care providers do? J Adolesc Health.

6 Family Meals Frequency of family meals improves diet quality with increased consumption of fruits, vegetables, grains and calcium-rich foods. 1 Prospective study of 13,000 pre-teens and teens found that eating family dinners most or every day for the prior year was protective against purging behaviors, binge eating and frequent dieting. 2 In girls, family meals perceived to be enjoyable were protective from extreme weight control behaviors. 1 Family meal patterns associations with sociodemographic characteristics and improved dietary intake among adolescents. Arch Pediatr Adolesc Med. 2008;162(1): Family dinner and disordered eating behaviors in a large cohort of adolescents. Eat Disord. 2010;18(1):10-24 Why Does it Work? Families consume healthier foods than if teens choose on their own Family meals provide interaction Parents can monitor eating issues A supportive home environment can greatly reduce the contribution of childhood obesity and the use of unhealthy weight control behaviors Preventing obesity and eating disorders in adolescents: what can health care providers do? J Adolesc Health. 2009;44(3); Meaningful Conversation 66% of Americans regularly watch TV while eating dinner Average parent spends 38.5 min per week in meaningful conversation with their child Henry J. Kaiser Foundation, "Generation M 2 : Media in the Lives of 8-18 Year Olds," January Creating Mindful Family Meals Set a goal No TV, phones, texting Involve kids in planning Eat slowly Involve all senses Avoid portion distortion Keep meals pleasant Set the mood Factors That Align with Obesity and Dieting Family Meals Weight Talk Weight Teasing Body Image 6

Weight Talk What is Weight Talk? Comments from family members about their own weight or comments to a child by parents about the child s weight.

1 Interview with patients in recovery from eating disorders found that weight talk impacted them negatively. Focus on healthful eating behaviors, not weight control behaviors was more beneficial.

2015:38(1):122-135 2 Parent conversations about healthful eating and weight: associates with adolescent disordered eating behaviors. JAMA Pediatr. 2013;167(8):746-753.

2% of middle adolescent females 37% of early adolescent males, 29% of middle adolescent males Family weight teasing predicts overweight status, binge-eating, and extreme weight control behaviors in

Weight-related teasing from adolescence to young adulthood. Obesity. 2013;21(9):E428-E434.

7 Weight Talk What is Weight Talk? Comments from family members about their own weight or comments to a child by parents about the child s weight. Several studies found parental weight talk, whether encouraging their child to diet or talking about their own dieting is linked to both overweight and eating disorders. 1 Interview with patients in recovery from eating disorders found that weight talk impacted them negatively. Focus on healthful eating behaviors, not weight control behaviors was more beneficial. 2 1 Parent-adolescent conversations about eating, physical activity and weight. J Behav Med. 2015:38(1): Parent conversations about healthful eating and weight: associates with adolescent disordered eating behaviors. JAMA Pediatr. 2013;167(8): Weight Teasing In overweight adolescents, weight teasing is found in 40% of early adolescent females, 28.2% of middle adolescent females 37% of early adolescent males, 29% of middle adolescent males Family weight teasing predicts overweight status, binge-eating, and extreme weight control behaviors in girls and overweight in boys Hurtful weight-related comments from family members and significant others were associated with use of unhealthy weight control behavior and binge eating. Weight-related teasing from adolescence to young adulthood. Obesity. 2013;21(9):E428-E434. Teasing and Bullying % of teens report being teased about their weight by their peers Girls Boys Underweight 48% 41% Average-weight 21% 14% Moderately overweight 31% 26% Overweight 63% 58% Weight teasing among adolescents. Int J of Obesity. 2002;26: Factors That Align with Obesity and Dieting Family Meals Weight Talk Weight Teasing Body Image Body Image Half of teen girls and a quarter of teen boys are dissatisfied with their bodies and these numbers higher in overweight teens. This is a risk factor for both eating disorders and disordered eating. More dieting, unhealthy weight control behaviors, binge eating. Health Professionals Role In Prevention Of Childhood Obesity and Arch Pediatr Adolesc Med. 2002;156(2):

Working with Nutrition as a Health Professional AVOID NUTRITIONAL Learn about Motivational Interviewing (AAP app Change Talk ) Don t label foods as good and bad Encourage following natural cues for

themselves or others Identify stress and offer stress reduction techniques Understand Weight Bias Avoid language that places blame Emphasize lifestyle change and health improvement Emphasize

Yale Rudd Center for Food Policy > Weight Bias & Stigma > Tools for Health Care Providers www.yaleruddcenter.

obese children feel blamed and dismissed Integrated Approach Randomized controlled trials of obesity prevention program show a reduction in use of purging, diet pill use and a decrease in in concerns

8 Working with Nutrition as a Health Professional AVOID NUTRITIONAL Learn about Motivational Interviewing (AAP app Change Talk ) Don t label foods as good and bad Encourage following natural cues for self-regulating foods Teach how to critically view media and explain to parents the issues Teach parents not to talk about diets or put inappropriate pressure about food, weight or body image on themselves or others Identify stress and offer stress reduction techniques Understand Weight Bias Avoid language that places blame Emphasize lifestyle change and health improvement Emphasize achievable behavior goals, rather than weight WEIGHT IS NOT A BEHAVIOR AND SO NOT A TARGET FOR BEHAVIOR CHANGE! Yale Rudd Center for Food Policy > Weight Bias & Stigma > Tools for Health Care Providers Reactions of Adult Patients and Parents Upset by comments about their weight from doctors Feel berated and disrespected by providers Report that their weight is blamed for all problems Parents of obese children feel blamed and dismissed Integrated Approach Randomized controlled trials of obesity prevention program show a reduction in use of purging, diet pill use and a decrease in in concerns about weight1 An integrated approach to the prevention of obesity and EDs focuses less on weight and more on healthy familybased lifestyle modification Encourage families to include more family meals, homeprepared meals and fewer discussions about weight and dieting2 1 Anderson and Wadden 2004, Edmunds, 2005 The impact of school-based obesity prevention trial on disordered weigh-control behaviors in early adolescent girls. Arch Pediatr Adolesc Med. 2005:159(3): Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity. Pediatrics. 2007;120(suppl4):S164-S192 8

The Balancing Act Health professionals can help families and

activity and avoid unhealthy emphasis on weight and dieting In

and body image with the competing challenge of increasing

9 The Balancing Act Health professionals can help families and children apply principles of proper nutrition and physical activity and avoid unhealthy emphasis on weight and dieting In the community, we need a shift in approaches to weight, dieting and body image with the competing challenge of increasing prevalence of obesity Be the change you wish to see in the world. ~ Gandhi 9

EATING DISORDERS By Briana Vittorini

EATING DISORDERS By Briana Vittorini OVERVIEW What is an eating disorder? Important facts The SHOCKING truth The most common forms Beliefs about eating disorders Prevalence vs. Funding OVERVIEW Specific