managing the journey from chaotic eating to healthy eating

Transcription

1 Taming the Hungry Bear managing the journey from chaotic eating to healthy eating Kate Williams H d f N i i d Di i Head of Nutrition and Dietetics South London and Maudsley NHS Foundation Trust

2 1953 UK food rationing Limited amount and variety of imported food Food relatively expensive (>30% of income) Limited shop opening hours Almost no convenience food, food was laboriously cooked from fresh ingredients, with limited labour saving domestic equipment

3 2013 Effectively infinite amount and variety of food availableailable Food is cheap (average 15% of income) Shops open 24 hours Convenience food is almost effort-free and quick Advertising is ubiquitous

4 In my lifetime... we have moved from Many external controls on food intake Dull food that required a lot of effort to obtain and prepare Eating in household groups to Reliance largely on internal control of food intake An exciting variety of food, constantly and easily available Much more likely to eat alone Some people p cope better than others

5 Not coping Binge Eating Disorder 1. Recurring episodes of eating significantly more food, in a short period of time, than most people would eat under similar il circumstances 2. Marked feelings of lack of control Possibly also: 1. Eating more rapidly than normal 2. Eating when not physically hungry 3. Eating in secret 4. Feeling disgusted, d depressed d or guilty about overeating

6 The recovery journey for those who do not cope so well... Support to understand ambivalence and engage with change Contextualise body weight reduction as one element and not the sole focus for change Contextualise disordered eating disordered eating to reduce self-blame, self-criticism and hopelessness Develop an understanding of the process and pace of change Develop and maintain motivation to change

7 Ready for action Develop an understanding of normal healthy eating (as opposed to dieting) Identify the individual s id personal concerns and challenges Agree overall aims Implement change towards the aims by using SMART goals Develop strategies for relapse prevention

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9 Specific issues Separate binge eating management from weight management (though you can do both at the same time) Identify and understand the internal drivers of binge eating Identify and understand the environmental facilitators of binge eating Identify and understand the capacity to control eating Plan and implement strategies to reduce the drivers, manage the environment and strengthen and use control strategies

10 Drivers and Facilitators 1. Biological Genetic Restriction and dieting Appetite dysregulation Food addiction 2. Psychological Depression Emotional dysregulation Impulsivity 3. Environmental Ubiquity of food images Availability of food Affordability of food Hyper-rewarding food

11 Biological Aspects

12 Managing Genetic Factors Family history of obesity and personal history of obesity from early life suggest genetic predisposition to obesity, and possibly poor appetite regulation Understanding that genes do not determine outcome, but are one influence among many, and that environment and lifestyle factors can prevent or modify gene expression

13 Binge-Starve Cycle Feel hungry and miserable BINGE Diet Feel fat and miserable

14 Binge-Binge Cycle Feel fat and miserable BINGE

15 Managing the Cycle Eating diary can identify the pattern if it is still present, good history if not Establish adequate, regular eating using safe foods to achieve a healthy mixture. This may need very frequent small snacks at first. Low GI foods may help, check fluid intake also. Find strategies to begin eating, and bring it to a halt if this is difficult. The diary is a useful tool. Mindfulness may be helpful. If underweight, restore healthy weight If normal weight or overweight, stop dieting and aim to stabilise weight Re-introduce difficult foods in a safe way Be aware of the timescale, this is a slow process

16 Date Time Food/Drink (give an idea of amount) meal/ snack/ binge Situation/thoughts/feelings

17 Appetite Regulation Short-term, meal-to-meal Mediated by neural and short half-life hormone (including PYY and ghrelin) messaging g Long-term Mediated by longer half-life hormones (including insulin and leptin) Psychological Learned behaviour and previous experience Pleasure and reward/disgust and shame Use of food as an emotional regulator Social cues and benchmarks

18 Disruption of Appetite Regulation Binge eaters habitually override satiation signals, and sometimes hunger They eat alone, often in secret The normal alternation ti of ghrelin and PYY is disrupted in eating disorders (Lawson et al, 2011) and in obesity (English et al, 2002) Leptin (Monteleone et al, 2000), insulin and stomach capacity (Geliebter et al, 2004) are disrupted in binge eating disorder and bulimia nervosa. Vomiting makes this more extreme When physiological appetite regulation is weak, people respond more to emotional and external cues

19 Improving Natural Appetite Regulation Regular meals and snacks, spread evenly over the day (and night if the person sleeps badly). Eat by the clock, as physiological i l signals may be misleading Eat with others who are healthy eaters Healthy mixture of dull foods Low GI foods help to stabilise blood glucose and insulin Avoid binge triggers at first Eliminate vomiting Patience

20 Food Addiction Highly palatable food is easily available Specific food craving can be induced by repeatedly consuming the same food when hungry (Polivy et al, 2005) There are changes in the dopamine reward system in obese humans, and in animal models (Avena, 2010; Bello and Hajnal, 2010) Stress increases reward-seeking and entrenches the addiction There is increasing evidence that very sweet or fatty food may be more likely to produce this effect (Ifland et al, 2009) Some of this evidence is from animal models, so beware...

21 Managing Food Addiction Understanding helps make sense of experience Abstinence does not make sense applied to food Addiction does not mean hopeless Establish regular, healthy meals that are not excessively palatable (or unpleasant) Avoid trigger foods at first Seek and use alternative sources of pleasure and ways to deal with stress Stop vomiting Re-introduce difficult foods in a safe way

22 Psychological Aspects

23 Medication and Therapy Depression Emotional dysregulation Impulsivity CBT, IPT and DBT are all effective Anti-depressant medication may be helpful Mindfulness may be helpful

24 Environmental Aspects

25 Understand the difficulties of the Environment In natural human environments (hunter-gatherer th or un-mechanised subsistence farming) acquisition iti of food is labour intensive i food supply is limited sweet, fatty and salty foods are difficult to obtain In modern city environments, things are different. Current UK spending on food is 15% of income, compared to 33% in 1960 Sweet, fatty and salty foods and drinks are easily available, marketed heavily (even as diet foods), are cheap, and often need little or no preparation

26 Managing the Environment routine shopping and eating Plan eating, and non-eating activities Shop for food at planned times, at first this may need to be frequent Reduce impulse buying - shop with a list, shop online. Consider paying with cash, and limit the amount taken Consider carefully what food, and how much, should be kept at home. Avoid shops that may be difficult Use family support This needs time, thought and effort, especially at first. Challenge beliefs that it should be easy.

27 Identifying Triggers and Difficult Situations Use a food diary to increase awareness and identify situations that need to be managed. Plan how to build in coping. Reduce exposure to triggers, for example don t buy magazines that present food images, don t keep trigger foods at home Plan eating, at home and elsewhere. This needs time thought and effort especially at first This needs time, thought and effort, especially at first. Challenge beliefs that it should be easy.

28 Supporting control Understanding that binge eating management is separate from weight management Support motivation to change Develop effective strategies t to manage challenges and to develop confidence Develop a clear vision i of normal, healthy eating as an aim for the individual Adjust unrealistic expectations ti Improve ability to take a long term view Use support effectively Improve psychological wellbeing (treat depression)

29 Relapse Prevention Distinguish lapse, relapse and collapse Identify high h risk situations ti (using the diary) and plan for them Be alert for signs of relapse and use recovery strategies quickly, e.g. seeking support, using a diary

30 Does any of this help? Up to a point

31 Group Programme for Obese Female Binge Eaters Programme of 6 group sessions plus 2-3follow up individual meetings 35 subjects, met DSM-IV for BED All overweight or obese, mean BMI = 42

32 Outcomes after 12 months + 19 (54%) no longer met criteria for BED 10 (28%) continued to binge eat 6 lost to follow up of the 19 who stopped/reduced bingeing, 10 lost at least 5% of baseline body weight at 12 month follow-up of the 10 who continued to binge, all continued to gain weight

33 Individual Programme for BED Discharged Psychiatrist/psychologist assessment Dietitian s assessment + up to 4 follow up meetings + selfhelp manual Taming the Hungry Bear +/- psychotherapy 19 subjects meeting DSM 5 for BED, 11 women, 5 men 14 overweight or obese 14 overweight or obese 2 normal weight 3 no follow up

34 Outcomes at discharge Mean binge/comfort eating (SLAMDOT score max = 3): Baseline: 2.9 Post-treatment: were binge free 14 were obese, 2 normal weight 4lost> 10 kg 4 lost 3-10 kg 6 no change (including 2 at normal weight) 2 gained weight