ADOLESCENCE

1. ADOLESCENCE & MAJOR EATING DISORDERS by Prof. Hidle Updated Spring 2010

2. Suggested Videos • “Dying to be Thin” – WILL BE SHOWN DURING LAB TIME! • “Adolescent” • “The Enigma of Anorexia Nervosa”

3. Adolescence - overview • Include children ages 12-18(21) years • History taking should include the adolescent’s parent(s) as well as the teen alone, as he/she may be reluctant to discuss certain topics with a parent present. • Respect the adolescent’s need for privacy during physical exam

4. Vital Signs • BP: Systolic 100-120; Diastolic 50-70 • Temp.: 98-98.6 F • Pulse: 60-68 BPM, regular • RR: 16-20, regular • Of note, c/o fatigue may result from inadequate O2 because the heart continues to grow slowly until 17-18 years of age. • Hct higher in males due to increased growth.

5. Growth: Physical Exam • Adolescence is the 2nd major period of acceleration in growth. • Females begin a growth spurt 2 years earlier than males. • Females grow 2.5-5” and gain 8-10 Ibs • Males grow 3-6” and gain 12-14 Ibs • Significant growth in skeletal size, muscle mass, adipose tissue, and skin.

6. Characteristics • Poor posture and decreased coordination • Males tend to be more clumsy than females • Sleep requirement: 8-9 hours/night (females require extra rest prior to menstruation) • Skin is supple, firm, with an increase in size and activity of sebacceous glands, and fully developed eccrine sweat glands • Both males and females are prone to acne

7. Sweat glands are more active in males than females • Secondary sex characteristics begin to develop • By adolescence, individuals usually have formed their sexual identity • Female: average age of menarche is 12-13 years • Male maturation is exhibited by voice changes, appearance of increased body hair, and broadened shoulders

8. Psychosocial considerations • Mood swings are common • Peers – great importance! • Striving for independence, but still need for security of parental love and restrictions. • Developing relationships with peers help reinforce parental values. • When hospitalized, teens often feel loss of independence and identity. Also fear of body image changes, rejection, and loss of emotional control.

9. Nutrition • Females 11-14 years of age need approximately 2200 Kcal/day; 15-18 years of age, 2100 Kcal/day • Males 11-14 years of age need approximately 2700 Kcal/day; 15-18 years of age, 2800 Kcal/day. • Protein: 45-56 Grams/day (15% of total Kcal) in both males and females to support muscle growth

10. Increased need for iron and calcium (1200 mgs/day) – especially needed for bone growth • All of the adult 32 teeth have erupted by late adolescence • Fluid requirement = ~2000 cc/day • Adolescence tends to snack and skip meals = unhealthy eating habits

11. Safety • Causes of death in this age-group: 1) MVA (motor vehicle accidents) 2) Homicide 3) Suicide

12. EATING DISORDERS Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder

13. Anorexia Nervosa • People who intentionally starve themselves • Usually begins in young people around the time of puberty • Extreme weight loss (>15% below the person’s normal body weight)

14. May look emaciated, but are convinced they are overweight (“the mirror lies”) • May require hospitalization to prevent starvation • Food and weight becomes obsessions • Compulsiveness may involve strange eating rituals or refusal to eat in front of others

15. For example, the person may collect recipes and prepare feasts for family and friends, but not partake in the meals themselves • May adhere to strict exercise routines • Loss of menstrual periods is common • Men with anorexia often become impotent

17. Medical Complications - Anorexia • Starvation can damage vital organs such as the heart and brain • To protect itself, the body shifts into “slow gear”: • 1) Monthly menstrual periods stop • 2) RR, HR and BP drop • 3) Thyroid function slows

18. Nails and hair become brittle, the skin dries, yellows, and becomes covered with soft hair (lanugo) • Excessive thirst and frequent urination may occur (s/s UTI) • Dehydration contributes to constipation • Reduced body fat leads to lowered body temperature and the ability to withstand cold

21. Mild anemia, swollen joints, reduced muscle mass, and light-headedness may occur • If anorexia becomes severe, the client may lose calcium from the bones, making them brittle and prone to breakage • Dysrhythmia and heart failure

22. In severe situations, the brain shrinks, causing personality changes. However, this can be reversed when normal weight is reestablished • In National Institute of Mental Health (NIMH) supported research, scientists have found that many patients with anorexia also suffer from other psychiatric illnesses.

23. While the majority have co-occurring clinical depression, others suffer from anxiety, personality, or substance abuse disorders, and many are at risk for suicide • Obsessive-compulsive disorders (OCD), an illness characterized by repetitive thoughts and behaviors, can also accompany anorexia • Individuals with anorexia are typically compliant in personality but may have sudden outbursts of hostility/anger or become socially withdrawn

26. Bulimia Nervosa • Consume large amounts of food • Rid their bodies of the excess calories by vomiting, abusing laxatives or diuretics, taking enemas, or exercising obsessively • A combination of all of the above may be used = purging • Due to the “binge and purge” cycle, the individual usually maintains a normal or slightly above normal body weight

27. Due to their often normal body weight, a person with bulimia may successfully hide their problem from family, friends and medical personnel for years. • Binging/purging can range from once or twice a week to several times a day • Dieting heavily between episodes of binging/purging is common • Eventually, ~50% of those with anorexia will develop bulimia

28. Bulimia typically begins during adolescence (as with anorexia) • Most common in women but also found in men • Person is ashamed of their strange habits and may delay seeking medical help until their 30s-40s • By that time, their eating behavior is deeply ingrained and more difficult to change

31. Medical Complications - Bulimia • Body can be severely damaged, even with a “normal” body weight • Vomiting: acid in the vomit wears down the outer layer of the teeth and can cause scarring on the backs of hands when fingers are pushed down the throat to induce vomiting • Esophagus becomes inflamed • Lymphadenopathy: Glands near the cheeks become swollen

32. Binging: In severe cases, the stomach can rupture • Purging: May lead to heart failure due to loss of vital minerals (i.e. potassium) • Irregular menstrual periods • Decreased interest in sex

33. Some individuals with bulimia struggle with addictions; drug abuse, alcohol abuse, and/or compulsive stealing • May suffer from clinical depression, anxiety, OCD, and other psychiatric illness • High risk for suicidal behavior due to their binge/purge eating combined with the psychiatric conditions above

35. Binge Eating Disorder • Resembles Bulimia Nervosa • Episodes of uncontrolled eating or binging • However, differs from Bulimia in that the individual does NOT purge their body of excess food • A feeling of “loosing control” when eating • Eat large quantities of food and do not stop until they are uncomfortably full

36. Difficulty loosing weight and keeping it off, more so than do people with other serious weight problems • Usually obese with a history of weight fluctuations • Found in ~2% of the general population • Women > men • Occurs in ~30% of people participating in medically supervised weight control programs

38. Medical Complications – Binge Eating • Prone to serious medical problems associated with obesity: • High cholesterol • Hypertension • Diabetes • Higher risk for gallbladder disease, heart disease, and some types of cancer • A/T NIMH research, binge eaters have high rates of co-occurring psychiatric illnesses, especially depression

39. Treatment • Any eating disorder is most successfully treated when diagnosed EARLY! • Unfortunately, many individuals with eating disorders may deny having a problem even when approached about suspicious behaviors/symptoms • For example, individuals with anorexia may not receive medical or psychological attention until they have already become dangerously thin and malnourished

40. Eating disorders in males may be overlooked because anorexia and bulimia are relatively rare in boys and men • The importance of treatment early on cannot be emphasized enough • The longer abnormal eating behaviors persist, the more difficult it is to overcome the disorder and its effects on the body • Long-term treatment may be required • Supportive family/friends is important

41. Steps in treatment – with suspected eating disorder • Physical exam: to rule out other illnesses • If an eating disorder is diagnosed, determine whether the patient is immediate medical danger and requires hospitalization or can be treated outpatient • Hospitalization: if excessive and rapid weight loss took place; serious metabolic disturbances; clinical depression or risk of suicide; severe binge eating and purging, or psychosis

42. Complex interaction of emotional and physiological problems with most eating disorders, requiring a comprehensive treatment plan. Treatment team should include: • Internist • Nutritionist • Individual psychotherapist • Psycho-pharmacologist

43. Psychological aspect • Some form of psychotherapy is usually needed • A psychiatrist, psychologist or other mental health professional meets with the patient individually and provides ongoing emotional support • The goal is for the patient to understand and cope with the illness • Group therapy has been especially effective for individuals with bulimia

44. The effectiveness of combining psychotherapy and medications has been research by NIMH • Researchers found that both intensive group therapy and antidepressant medications benefitting patients suffering from bulimia • The combination treatment was particularly effective in preventing relapse once medications were discontinued • For patient with binge eating disorder, cognitive-behavioral therapy and antidepressant medications may also be useful • For anorexia, antidepressant medications may be effective when combined with other forms of treatment

45. Team Effort • Mental health professionals need to combine treatment with those of other health professionals in order to obtain the best treatment. • MD/NP – treat any medical complications • Nutritionist – advise on diet and eating regimen • Psychologist/psychiatrist – treat the mental/emotional aspect

46. The challenge of treating eating disorders is made more difficult by the metabolic changes • To maintain stable weight, individuals with anorexia may actually have to consume more calories than some of similar weight and age without an eating disorder • In contrast, a person with bulimia may gain excess weight if they consume the number of calories required to maintain normal weight in others of similar size and age

47. Support Groups and Information • Group therapy: Part of therapy which has shown to be very successful • Internet: Even informational sources and connecting with others through the web regarding eating disorders

48. Common Symptoms of Eating Disorders • Common S/S of Eating Disorders *Anorexia *Bulimia Binge Eating • Excessive weight loss in relatively short period X • Continuation of dieting although bone-thin X • Dissatisfaction with appearance; belief that • body is fat, even though severely underweight X • Loss of monthly menstrual periods X X • Unusual interest in food and development of • strange eating rituals X X • Eating in secret X X X • Obsession with exercise X X • Serious depression X X X • Binging; consumption of large amounts of food X X • Vomiting or use of drugs to stimulate vomiting, • bowel movements, and urination X • Binging but no noticeable weight gain X • Disappearance into bathroom for long periods • of time to induce vomiting X • Abuse of drugs or alcohol X X • ** Some individuals suffer from anorexia and bulimia and have symptoms of both

49. THE END!