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Grand Rounds (week 6) Eating Disorders

bmi table: http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.pdf

Hilary Kinavey and Dana Sturtevant speaking
adjunct profs at Lewis & Clark
their biz: Be Nourished
easy to be disconnected from your body in our culture
noticed there was no psych care after wt loss surgery
Dana = nutritional therapist,
teaches yoga for body acceptance and is motivational interviewing trainer
noticed pattern that pts lose weight and gain it back in 6mo
distinction: size // weight // shape
their practice: focus on self care--->weight loss is a SE
spectrum between normal and disordered eating: dieting is not normal

quote about losing faith in body, obsession with health
"more women die from eating disorders than from mental illness"
excess exercise dt negative body image
normal to dislike body, raised to expect our bodies to be altered
weight loss after pregnancy as a major endeavor
16yo girls "feel fat", more afraid of fat than cancer, use substances like cigs for wt control
meth also used
4% of excessive dieters are binge eating
shame is largest obstacle to accessing treatment
difficult to get real story
what are the motivations behind a pts desire to make health behavior changes?

eating disorders
meets dsm criteria
attitude about weight and body size causes distress, jeapordizes health, happiness, safety

anorexia
refusal to maintain minimally normal body wt
loss of 3 consecutive periods is part of definition
so men can't officially be anorexic

bulemia
regular intake of large amounts of food followed by compensatory behavior
incl exercise, laxatives, purging

binge eating disorder
binge: word used liberally in our culture
frequent episodes of eating unusually large quantities of food in short time
sense of urgency, out of control feeling

EDNOS
eating disorder not otherwise specified
some combo of other disorders but not all criteria are met
pts morph from one pathology to another, this is common
psychopathology doesn't change that much from one dx to another

orthorexia
obsessed with eating right
not a dsm dx but meets EDNOS criteria
recently coined term
more psych than physical danger
seen among populations who know too much about nutrition
men and women equally described, other dx more female oriented
ex: not willing to eat carrots unless pulled from garden less than 5 mins ago
perfectionism, preoccupation, obsessive thinking
weight mb normal, just can't stop thinking about food

veganism
gluten free
pescatarian
grain free
low fat

food deprivation or scarcity has an impact on us
shouldn't be eating this but I am so what does this say about me?
intervention: increase client's access to food, bring it with us, eat when hungry

study: what % of waking hours pt thinks about food
normal 20%
dieters 20-65%
bulemia 70-90%
anorexia 70-110% (dreaming)

thinking about weight makes it hard to act on health
what are our real needs, what are we hungry for?

study on effects of food deprivation
1940's college age men of sound mind and body
never dieted, normal weight, healthy relationship with food
let them feed liberally for sev mo then put on cal restrx diet for 3mo
1800cals
within short time reported preoccupation with food:
collecting recipes, studying cookbooks, craving certain foods, played with food
ritualism, small bites, an M&M in 4 bites, stall or gulp?
lost interest in sex
after 3mo when could go back to normal eating:
took a year to normalize and trust that food would be available all the time
may take longer for women who have not eaten normally for very long periods

bariatric surgery pts
report little interest in food during honeymoon phase, little hunger, force themselves to eat
report collecting recipes and looking at food magazines, food network

dieting
fads, restriction
predictable sequence of events during diet
eating indiscretions: supposed to be eating some way and blow it
-->emotional rxn, self criticism, blame, shame, guilt, failure
pts may eat in response to such feelings, need another way out, so form a plan
plan: resume, restrict, long run, some plan to get out of negative feelings
problem with plans: aren't flexible enough to answer life's unpredictability
pts don't blame plan, blame selves instead, deconstructs self esteem
can be revolutionary for pts to simply become conscious of this pattern

eating disorders-->inability to participate in life
can't go out to dinner with friends without planning, control
loss of spontaneity, impromptu invites cause panic
hard time letting go of eating indiscretions
polarized thinking about food: kills you or heals you

many women seek tx when they birth a daughter
mom hates body, doesn't want daughter to suffer same

ocd tendencies, perfectionism, all or nothing approaches
the biggest loser: watch this
weighing often
severe restriction of calories
ask pts with high body wts to stop doing all this

WARNING SIGNS
excessive behaviors
gum chewing
caffeine intake
drinking other stuff
body checking, feeling body, fidgeting, finding bones, rolls, comparing to others
mirror time, esp naked
hx of dieting or weight cycling
use of diet pills, laxatives, diuretics, cleanses
emotional eating
eating a lot of heavily processed food
what the hell phenomenon--pts overeat to say goodbye to stuff they want to stop
eating alone with different behavior
tx: guilt free eating, unconditional permission to eat and enjoy food
eating atmosphere: chaos, stress?
diet rebel can't be told what to eat
tx: talk about board of directors in head: all different voices influencing choices
anxiety, worry make us do worse
French are least concerned about diet and have low obesity and little eating disorders

APPROACHES TO PTS
ask how much they think about food
what planning do they do?
eat when hungry or at specific times?
how is quality of life impacted by relationship with food?
how much do they think about weight?
how anxious are you about your weight, or about food?
have you become more consumed with thoughts of your weight in last 3 mo?
how much of identity wrapped up in success with food?
do you experience pleasure from food?
can you enjoy food?
satisfaction
skip foods you once enjoyed?
influence who you hang out with?
what do you mean when you say binge?
relationships
difficult to eat away from home?
eat in isolation?
guilt when stray?
reaction to what we eat is imp
can you be flexible about eating?
when you eat as you are supposed to is it satisfying? why?

normal eating
ellen satyr expert defines it as: going to table hungry, eating until satisfied
michael pollan point: satisfaction vs fullness, other cultures eat to 70% fullness
enough vs maxed
choose food you like and get enough of it
give thought to food selection so you get nutrition, but not so wary as to not enjoy
permission to eat sometimes just because it feels good or for emotional reasons
3 meals a day, or 4, 5, or munching along the way
leaving some cookies on the plate or eating them now
overeating and undereating sometimes
trusting your body
takes some time and attention as one imp area of life
flexible, varies in response to life

TREATMENT
takes a team: physician, dietician, counselor
hardest part: convincing them that they need help
complex conditions, hard to treat
stabilize medical problems
monitor vitals, labs esp potassium
healing relationship with food first, healthing eating plan later
health at every size is foundation of be nourished work
every body is a good body, no one size/shape is perfect
cosmetic vs metabolic fitness
heal body image: hard to take care of a body you hate
learn hunger and fullness cues, trusting hunger cues
mindfulness practices (mb difficult for anorexics early on, may have to distract)
work on neutralizing/legalizing food
eventually work on gentle nutrition, don't do this too early
progress not perfection, taste and pleasure are part of criteria
find joyful ways to move, not focussed on calories burned, return to childhood play
recognize flexibility of normal eating, unconditional permission to eat and to enjoy

look at self as provider
what is my motivation?
clients will make assumptions about me based on my body
be clear about how I define health and illness, what I think about body size and wt loss
what is goal or interaction?
can I practice body acceptance and self care, be good role model?

end of lecture
questions/comments:

weight neutrality = health at every size
judgements about health based on what you can see may be quite incorrect
waiting rooms, bp cuffs, gowns, best be prepared for all size people
they do a whole talk on health at every size

resources?
their website: benourished.org has books & weblinks
INtuitive Eating = fave book
Health at Every size = good book
national eating disorder association online
feast online

encourage us to screen for eating disorders
have you ever had what you'd describe as disordered eating?
have you ever binge/purged?
have you ever dieted? yoyo? wt cycling?
have you ever used wt loss drugs? fen fen and heart dz risk
be in a place of curiousity and neutrality

are you seeing a therapist?
get a release to talk to other providers

"as a culture we don't like people who are big"

Comments

( 2 comments — Leave a comment )
ex_geekygab
May. 14th, 2011 01:47 am (UTC)
Dear God, I think I'm orthorexic, then. Yikes. :-\ But knowing is half the battle, so thank you for sharing this.
liveonearth
May. 15th, 2011 03:10 am (UTC)
orthorexics anonymous
Join the club. =-]
( 2 comments — Leave a comment )

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