Janelle Fuchs, RD CD Registered Dietitian Friday, February 28, 2014

1. Eating Disorders:Understanding Treatment, Improving Relationships with Food, and Promoting Positive Body Image Janelle Fuchs, RD CD Registered Dietitian Friday, February 28, 2014

2. Objectives • Understand factors associated with eating disorder development and maintenance • Recognize medical and cognitive effects of eating disorders • Describe ways health professionals and school personnel can effectively work together to best meet the needs of students and families • Identify potential approaches to preventing eating disorders and addressing body image issues and weight concerns

3. Where are we trying to go? Help adolescents… • Eat and be active in tune with the body’s needs • Eat when hungry and stop when satisfied • Eat a variety of foods without a fear of fat • Appreciate the body • Think critically about media • Employ many coping skills

4. ED Onset and Duration

5. Eating Disorders are NOT about FOOD! But…

6. Warning signs with food & exercise • “I already ate” • Early fullness, frequent snacking, • Frequently absent from mealtimes • Sudden change in favorite foods • Hidden stashes of food/wrappers • Conversation constantly revolves around food • Exercising even when ill or injured • Change in sleep patterns • Eating changes with end of athletic season • Standing when sitting is more appropriate • Irritable/angry when exercise routine is interrupted

7. Eating Disorder Psychological Impact of Poor Nutrition • Depression • Dichotomous thinking • Irritability • Poor concentration • Anxiety • Ritualisticbehaviors • Obsession with food • Compulsive behaviors • Withdrawal/isolation

8. Low body weight Excessive body weight Low heart rate Low/high blood pressure Cold sensitivity Loss of menses or reduced testosterone Hair loss Dry skin Muscle wasting Acne Eating Disorder Physical Impact of Poor Nutrition • Insulinresistance / T2DM • Swollen glands in face/jaw • Edema • Memory impairments • Headaches/fatigue • Tooth decay and gum disease • Esophagus erosion,tears • Chemical imbalances • Dry skin, brittle nails • Constipation, GI problems

9. Eating Disorder Developmental Impact of Poor Nutrition • Cognitive delays • Impaired memory and learning • Delayed emotional maturity • Delayed physical maturity: hormonal, amenorrhea, sex drive • Stunted growth • Bone loss / osteoporosis • Compromised organ tissue

10. ED cycle

11. Multi-factorial Nature of Eating Disorders psychology biology Food restriction Genetics Physical changes Puberty/Menopause neurotransmitters Stressors Identity/self-image Personality factors Perfectionism Depression Coping Stressors Identity/self-image Personality factors Perfectionism Depression Coping Food restriction Genetics Physical changes Puberty/Menopause neurotransmitters social/environment Cultural factors Pressure to “fit in” Normalization of dieting Media Cultural factors Pressure to “fit in” Normalization of dieting Media

12. Treatment: Change happens through relationships TYPICAL TREATMENT RELATED QUESTIONS • Where to start • When, how, and to whom to refer • What does treatment entail? • Who is involved? • How is it covered? • How long does it take? • When is it done?

13. The Treatment Team DIETITIAN • Meal planning • Nutrition education • Establishment of weight range • Education regarding physical aspects of ED • Weight monitoring • Strategizing food-related activities • Body image • Teach coping skills THERAPIST • Assess and treat symptoms of related diagnoses (anxiety, depression, Axis II, etc. ) • Monitor and address suicidal thoughts and self injurious behavior • Explore etiology and maintaining factors of eating disorder • Body image • Teach coping skills PHYSICIAN • Medical monitoring and treatment of medical conditions related to ED • Medication monitoring • Weight monitoring • Education regarding physical aspects of ED

14. Role of ED Dietitian • Provide specific and/or general nutrition information • Medical consequences of eating disorder behaviors • Develop a meal plan • Determine ideal or goal weight range/BMI • Discuss portion sizes • Focus on hunger and satiety cues • Strategize ideas for meals and snacks • Incorporating challenging foods • Make changes to the meal plan • Planning for special events (parties, wedding, starting a new job, school, relationship, etc.) • Assess dietary limitations (vegetarian, lactose intolerance, etc.) • Activity assessment and recommendations

15. What is s/he working on? • Examining beliefs about food & body • Recognizing connections between food intake, behavior patterns, and health • Troubleshooting triggering food scenarios • Navigating resistance • Decreasing black/white thinking, increasing flexibility • Practicing challenge foods

16. The Treatment Team DIETITIAN THERAPIST PHYSICIAN THE FAMILY “The AED stands firmly against any etiologic model of eating disorders in which family influences are seen as the primary cause of anorexia nervosa or bulimia nervosa, and condemns generalizing statements that imply families are to blame for their child’s illness.” La Grange, Lock et al IJED 2009

17. The Treatment Team DIETITIAN THERAPIST PHYSICIAN THE FAMILY FBT –Family Based Therapy Observing family meal dynamics Coach for parents around meals and education of nutrition needs for adolescent Broken record advocate for adolescents nutrition needs

18. The Adolescent in Treatment at school • Adolescent may need support at meals at school • private place to eat • eat with friends • eat in nurse’s/counselor’s office • parents may need to be present regularly • Adolescent may need to be weighed periodically • Agreed upon weight protocol (ex. empty bladder, in gown, etc.) • Need collaboration with athletic coaches • Student may need some academic accommodations • Tutor • Assignments to complete • Time to make up missed work

19. The Adolescent in Treatment at home • Needs consistent support at family meals at home • Weight restoration • Significant commitment in FBT • Nutrition is #1 priority • Needs food available to meet MP goals • Clear boundaries • Specific times to address ED behaviors • Pay attention to other areas of adolescent’s life • Scales removed from home • Natural consequences for under-nutrition • Avoid commenting on food, body • Modeling healthy eating/ body image

20. The Adolescent in Treatment • Don’t expect perfection. Plan for “lapses”, “relapses”, and resistance • Normal ups and downs in recovery process • Write specific plans for lapse/relapse scenarios ahead of time. • They can’t just stop. ED’s are not a choice.

21. How to talk about the food • Ask permission • Be curious • Express a desire for understanding • Be willing to hear many possible responses • Address concerns at non-eating times • Allow space for struggles • Acknowledge “its not about the food”

22. Vignette • 17 y/o female, AN • o/p treatment after residential • Family conflicts • Manipulating MP in anticipation of desserts in IOP • How to address? • 16 y/o male, BN • Within IBW, gaining weight • Wavering trust in MP • Considers re-joining cross country team

23. Do People Recover? • Recovery is a process, a journey • Studies show that at least 50% of people recover fully and go on to live eating disorder free lives • Approximately 25% get better, but still use symptoms • About 20% remain entrenched in the disorder and need long-term treatment • 5% die from complications of the eating disorder

24. What does recovery look like with food and weight for adolescents? • Freedom to choose to eat or not to eat based on physical cues and availability of food vs. anxiety, fear or compulsion • Ability to enjoy social interactions involving food • Ability to participate in active play/sports for the purpose of enjoyment vs. weight control • Ability to use multiple coping skills to manage stress • Tolerating normal fluctuations in body weight and gains appropriate to growth

25. Normal Eating • Normal eating is trusting your body to make up for your mistakes in eating. Normal eating takes up some of your time and attention, but keeps its place as only one important area of your life.– Ellyn Satter

26. Talking about Eating Disorders • Focus on eating disorder consequences, not details • Dispel myths, ex. “everyone with an eating disorder is skinny and doesn’t eat” • Provide resources for positive body image and eating disorder information • Promote healthy body image and behaviors that support healthy body image • Emphasize moderation/balance in food, weight, and health • Discuss cultural messages around food as well as appearance • Stress media literacy

27. Challenge messages about food & weight: Dieting, Intuitive Eating, and Balance • Discourage dieting and extreme weight control methods • Dieting typically fails people; lost weight is regained • Unhealthful weight control behaviors can be dangerous, do not impact weight positively, and can lead to weight gain later • Encourage Intuitive Eating • Teach/encourage trust in body’s knowledge of hunger and fullness • Avoid labeling foods as “good foods”/”bad foods” and judgment of self based on eating • Encourage balanced living • Teach stress management • Focus on development of self aside from appearance/weight • Provide supports for self-care

28. Recognizing our Biases • Her meal plan looks so big. How can that be healthy? • She isn’t underweight anymore so she must be okay. • He would be so much happier if he could just lose the weight. • How can his parents send dessert in his lunch when they know he has an eating disorder? • She’s eating fries.. I thought she was working with a dietitian.. Is she really supposed to be eating that? • She has BED. Shouldn’t she be losing weight, not gaining? • Her parents are overweight too. They can’t help her. • Would I eat differently today if I thought it wouldn’t impact my weight?

29. Health at Every Size • Diets don’t work! • The best way to improve health is to honor your body • Good health can best be realized independent from considerations of size. It supports people—of all sizes—in addressing health directly by adopting healthy behaviors www.haescommunity.org/

30. Media Literacy • Media around weight, shape, food, and appearance is huge • Teach the power of the media, but also the power of the consumer • Introduce popular cultural material as examples-or have students bring examples • Encourage assertiveness and thoughtful consumption of media

34. Challenge media messages about attractiveness and thinness • Support media literacy • Educate! Pictures are altered before printing • Educate about mixed and misleading messages sent by media • Challenge internalization • Media messages can be sensational and degrading • Critical viewing of media can help prevent internalization of message • Speak when spending • Media is created for products that are sold • Use personal resources to decrease sales one person at a time • Increase positive messages • Address weight related teasing

35. Talking to an individual you suspect is struggling • Gather data • Complete assessments, screening questions • Watch, listen, ask questions, talk to support people • Communicate concerns • “It seems like you are not eating lunch very often, but are in the library instead” • “Your teammates are concerned with the amount of exercise you doing above and beyond the team workouts.” • Elicit feedback • “Can you tell me more about these things?” • “What do you think about the things I’ve mentioned?” • Have information on resources available • “I think it would be helpful for you to get some more assistance with these issues. Who do you think we should talk to about this? • “I’m happy to help you and your family with making an appointment with a psychologist and/or a dietitian.” • “The Emily Program is a resource that you may be interested in. I have this brochure about their services. Would you be willing to look at it with me? • Repeat as necessary

36. THE WORST LONELINESS IS NOT TO BE COMFORTABLE WITH YOURSELF. -MARK TWAIN

37. Contact Information Janelle Fuchs, RD CD Phone: 206-283-2220 www.emilyprogram.com