Eating Disorders
Eating
Disorders Eating Disorders can cause serious physical problems and, at their most severe, can even be life threatening. Most people with Eating Disorders are females, but males can also have Eating Disorders. An exception is binge-eating disorder, which appears to affect almost as many males as females. Treatments for Eating Disorders usually involve psychotherapy, nutrition education, family counseling, medications and hospitalization. Anorexia signs and symptoms may include:
Bulimia signs and symptoms may include:
Binge-eating disorder signs and symptoms may include:
For more information on Eating
Disorders, please visit the National Eating Disorders
Association (NEDA)
website. What Are Eating
Disorders? Eating disorders affect several million people at any given time, most often women between the ages of 12 and 35. There are three main types of eating disorders: anorexia nervosa, bulimia nervosa and binge eating disorder. People with anorexia nervosa and bulimia nervosa tend to be perfectionists with low self-esteem and are extremely critical of themselves and their bodies. They usually “feel fat” and see themselves as overweight, sometimes even despite life-threatening semi-starvation (or malnutrition). An intense fear of gaining weight and of being fat may become all-pervasive. In early stages of these disorders, patients often deny that they have a problem. In many cases, eating disorders occur together with other psychiatric disorders like anxiety, panic, obsessive compulsive disorder and alcohol and drug abuse problems. New evidence suggests that heredity may play a part in why certain people develop eating disorders, but these disorders also afflict many people who have no prior family history. Without treatment of both the emotional and physical symptoms of these disorders, malnutrition, heart problems and other potentially fatal conditions can result. However, with proper medical care, those with eating disorders can resume suitable eating habits, and return to better emotional and psychological health. Anorexia Nervosa Anorexia nervosa is diagnosed when patients weigh at least 15% less than the normal healthy weight expected for their height. People with anorexia nervosa don't maintain a normal weight because they refuse to eat enough, often exercise obsessively, and sometimes force themselves to vomit or use laxatives to lose weight. Over time, the following symptoms may develop as the body goes into starvation:
Bulimia Nervosa Although they may frequently diet and vigorously exercise, individuals with bulimia nervosa can be slightly underweight, normal weight, overweight or even obese. But they are not as underweight as people with anorexia nervosa. Patients with bulimia nervosa binge eat frequently, and during these times sufferers may eat an astounding amount of food in a short time, often consuming thousands of calories that are high in sugars, carbohydrates and fat. They can eat very rapidly, sometimes gulping down food without even tasting it. Their binges often end only when they are interrupted by another person, or they fall asleep or their stomach hurts from being stretched beyond normal capacity. During an eating binge sufferers feel out of control. After a binge, stomach pains and the fear of weight gain are common reasons that those with bulimia nervosa purge by throwing up or using a laxative. This cycle is usually repeated at least several times a week or, in serious cases, several times a day. Many people don’t know when a family member or friend has bulimia nervosa because people almost always hide their binges. Since they don’t become drastically thin, their behaviors may go unnoticed by those closest to them. But bulimia nervosa does have symptoms that should raise red flags:
Treatment Eating disorders clearly illustrate the close links between emotional and physical health. The first step in treating anorexia nervosa is to assist patients with regaining weight to a healthy level; for patients with bulimia nervosa interrupting the binge-purge cycle is key. For patients with binge eating disorder it is important to help them interrupt and stop binges However, restoring a person to normal weight or temporarily ending the binge-purge cycle does not address the underlying emotional problems that cause or are made worse by the abnormal eating behavior. Psychotherapy helps individuals with eating disorders to understand the thoughts, emotions and behaviors that trigger these disorders. In addition, some medications have also proven to be effective in the treatment process. Because of the serious physical
problems caused by these illnesses, it is important that any
treatment plan for a person with anorexia nervosa, bulimia
nervosa or binge eating disorder include general medical
care, nutritional management and nutritional counseling.
These measures begin to rebuild physical well-being and
healthy eating practices. Preventing Obesity and Eating Disorders in Adolescents
Obesity and eating disorders (EDs) are both prevalent in adolescents. There are concerns that obesity prevention efforts may lead to the development of an ED. Most adolescents who develop an ED did not have obesity previously, but some teenagers, in an attempt to lose weight, may develop an ED. This clinical report addresses the interaction between obesity prevention and EDs in teenagers, provides the pediatrician with evidence-informed tools to identify behaviors that predispose to both obesity and EDs, and provides guidance about obesity and ED prevention messages. The focus should be on a healthy lifestyle rather than on weight. Evidence suggests that obesity prevention and treatment, if conducted correctly, do not predispose to EDs.
Introduction The prevalence of childhood obesity has increased dramatically over the past few decades in the United States and other countries, and obesity during adolescence is associated with significant medical morbidity during adulthood.1 Eating disorders (EDs) are the third most common chronic condition in adolescents, after obesity and asthma.2 Most adolescents who develop an ED did not have obesity previously, but some adolescents may misinterpret what “healthy eating” is and engage in unhealthy behaviors, such as skipping meals or using fad diets in an attempt to “be healthier,” the result of which could be the development of an ED.3 Messages from pediatricians addressing obesity and reviewing constructive ways to manage weight can be safely and supportively incorporated into health care visits. Avoiding certain weight-based language and using motivational interviewing (MI) techniques may improve communication and promote successful outcomes when providing weight-management counseling.4 This clinical report complements existing American Academy of Pediatrics (AAP) reports on EDs5 and obesity prevention.6 The aim is to address the interaction between obesity prevention and EDs in teenagers and to stress that obesity prevention does not promote the development of EDs in adolescents. This report provides the pediatrician with office-based, evidence-informed tools to identify behaviors that predispose to both obesity and EDs and to provide guidance about obesity and ED prevention messages. Increasing Prevalence of Adolescent Obesity Data from the NHANES on adolescent obesity prevalence revealed that, in 2011–2012, 20.5% of 12- to 19-year-olds were obese (BMI =95th percentile according to the 2000 sex-specific BMI-for-age growth charts of the Centers for Disease Control and Prevention).7,8 Combining the definitions of overweight (BMI between the 85th and 95th percentiles) and obesity, according to the NHANES 2011–2012 data, 34.5% of 12- to 19-year-olds were overweight or obese.7,8 Disparities exist in obesity rates among minority youth, with Hispanic, American Indian, and African-American adolescents having the highest prevalence of obesity. Over the past 30 years, the rate of childhood obesity has more than doubled, and the rate of adolescent obesity has quadrupled. However, more recent data over the past 9 years between 2003–2004 and 2011–2012 have revealed no significant changes in obesity prevalence in youth or adults. Although halting the increase in the rate of obesity is a step in the right direction, the prevalence of obesity remains high, and its health care burden and costs remain significant.9 Relationship Between Childhood Obesity and Adult Health Status Most studies have found that children and adolescents who are obese, especially those in the higher range of BMI percentiles, are more likely to be obese as adults.10–12 The health consequences of obesity can manifest during childhood, but the longer a person is obese, the more at risk he or she is for adult health problems. A high adolescent BMI increases adult diabetes and coronary artery disease risks by nearly threefold and fivefold, respectively.13 Type 2 diabetes is one of the most serious complications of childhood obesity. Risks of other common comorbid conditions, such as hypertension, abnormal lipid profiles, nonalcoholic fatty liver disease, gallstones, gastroesophageal reflux, polycystic ovary syndrome, obstructive sleep apnea, asthma, and bone and joint problems, are significantly increased in both obese adolescents and adults who were obese as adolescents.1,14–16 In addition, the psychosocial morbidities associated with childhood obesity, such as depression, poor self-esteem, and poor quality of life, are of significant concern.17–19 Prevalence of EDs in Children and Adolescents and Changes in DSM-5 Diagnostic Criteria The onset of EDs usually is during adolescence, with the highest prevalence in adolescent girls, but EDs increasingly are being recognized in children as young as 5 to 12 years.20–22 Increased prevalence rates also have been noted in males and minority youth.23 The peak age of onset for anorexia nervosa (AN) is early to mid-adolescence, and the peak age of onset for bulimia nervosa (BN) is late adolescence. Although overall incidence rates have been stable, there has been a notable increase in the incidence of AN in 15- to 19-year-old girls.24 In the United States from 1999 to 2006, hospitalizations for EDs increased 119% for children younger than 12 years.25 The lifetime prevalences of AN, BN, and binge eating disorder in adolescent females are 0.3%, 0.9%, and 1.6%, respectively.26 The reported female-to-male ratio is 9:1, but increasing numbers of males with EDs are being recognized, especially among younger age groups.20–22 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for EDs are listed in Table 1.27 The diagnostic criteria for both AN and BN in the DSM-5 are less stringent than in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, so the numbers of reported cases likely will increase. For AN, the 85% expected body weight threshold and the amenorrhea criterion from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, both have been eliminated in the DSM-5. For BN, DSM-5 modifications from the previous edition include reducing the threshold of the frequency of binge eating and inappropriate compensatory behaviors (self-induced vomiting, periods of starvation, compulsive exercising or the use of laxatives, diuretics, or diet pills) from twice a week for 3 months to once a week for 3 months. Binge eating disorder now is officially recognized in the DSM-5 as a distinct disorder characterized by recurrent episodes of bingeing at least once a week for 3 months, but without compensatory behaviors, and is associated with the development of obesity.28 “Atypical AN” describes a subset of patients who lost a significant amount of weight and then returned to normal weight but who continue to have preoccupations with body shape and weight, comparable to patients with “classic” AN. Medical Complications Associated With EDs The medical complications of EDs have been well described elsewhere.5 In general, medical complications are either the result of physiologic adaptations to the effects of malnutrition or a consequence of unhealthy weight-control behaviors. Young people who have lost large amounts of weight or lost weight too rapidly can develop hypothermia, bradycardia, hypotension, and orthostasis even if their current weight is in the normal range.29,30 Rapid weight loss can be associated with acute pancreatitis and gallstone formation. Electrolyte disturbances can occur secondary to self-induced vomiting or the use of laxatives or diuretics or can develop when food is reintroduced after prolonged periods of dietary restriction (the so-called refeeding syndrome). Dietary restriction can lead to primary or secondary amenorrhea in adolescent girls of even normal weight as a result of the suppression of the hypothalamic-pituitary-ovarian axis, which is mediated in part by leptin.31 Prolonged amenorrhea results in a low-estrogen state, which can contribute to osteoporosis.23 The Interaction Between EDs and Obesity Prevention in Adolescents Most adolescents who develop an ED were not previously overweight. However, it is not unusual for an ED to begin with a teenager “trying to eat healthy.”32 Some adolescents and their parents misinterpret obesity prevention messages and begin eliminating foods they consider to be “bad” or “unhealthy.”32 US Food and Drug Administration–mandated nutrition facts on food labels list percent daily values based on a 2000-kcal diet. Moderately active adolescent girls require approximately 2200 kcal/day, and moderately active adolescent boys require 2800 kcal/day for normal growth and development. Teenagers who are athletes require even higher caloric intakes.33 Strict adherence to a 2000-kcal/day diet may lead to an energy deficit and weight loss for many growing teenagers. Adolescents who are overweight may adopt disordered eating behaviors while attempting to lose weight. In cross-sectional studies, adolescents who are overweight have been shown to engage in self-induced vomiting or laxative use more frequently than their normal-weight peers.34,35 Some adolescents who were overweight or obese previously can go on to develop a full ED.3,30,32 In 1 study in adolescents seeking treatment of an ED, 36.7% had a previous weight greater than the 85th percentile for age and sex.3 Initial attempts to lose weight by eating in a healthy manner may progress to severe dietary restriction, skipping of meals, prolonged periods of starvation, or the use of self-induced vomiting, diet pills, or laxatives. Initial attempts to increase physical activity may progress to compulsive and excessive exercise, even to the point at which the teenager awakens at night to exercise or continues excess exercise despite injury. EDs that develop in the context of previous obesity can present with challenges that delay treatment of the ED.32 At first, weight loss is praised and reinforced by family members, friends, and health care providers, but ongoing excessive preoccupation with weight loss can lead to social isolation, irritability, difficulty concentrating, profound fear of gaining the lost weight back, and body image distortion. If the pediatrician only focuses on weight loss without identifying the associated concerning symptoms and signs, an underlying ED may be missed. Evidence-Based Management Strategies Associated With Both Obesity and EDs in Teenagers Cross-sectional and longitudinal observational studies have identified the following certain behaviors associated with both obesity and EDs in adolescents: 1. Dieting. Dieting, defined as caloric restriction with the goal of weight loss, is a risk factor for both obesity and EDs. In a large prospective cohort study in 9- to 14-year-olds (N = 16?882) followed for 2 years, dieting was associated with greater weight gain and increased rates of binge eating in both boys and girls.36 Similarly, in a prospective observational study in 2516 adolescents enrolled in Project Eating Among Teens (Project EAT) followed for 5 years, dieting behaviors were associated with a twofold increased risk of becoming overweight and a 1.5-fold increased risk of binge eating at 5-year follow-up after adjusting for weight status at baseline.37 Stice et al38 showed that girls without obesity who dieted in the ninth grade were 3 times more likely to be overweight in the 12th grade compared with nondieters. These findings and others36,38,39 suggest that dieting is counterproductive to weight-management efforts. Dieting also can predispose to EDs. In a large prospective cohort study in students 14 to 15 years of age followed for 3 years, dieting was the most important predictor of a developing ED. Students who severely restricted their energy intake and skipped meals were 18 times more likely to develop an ED than those who did not diet; those who dieted at a moderate level had a fivefold increased risk.40 2. Family meals. Family meals have been associated with improved dietary intake and provide opportunities for modeling behavior by parents, even though family meals have not been shown to prevent obesity across ethnic groups.41–43 A higher frequency of family meals is associated with improved dietary quality, as evidenced by increased consumption of fruits, vegetables, grains, and calcium-rich foods and fiber and reduced consumption of carbonated beverages.44 Eating family meals together 7 or more times per week resulted in families consuming 1 serving more of fruits and vegetables per day compared with families who had no meals together. These improvements in dietary intake were sustained 5 years later during young adulthood.45 Family meals also have been shown to protect girls from disordered eating behaviors.46–48 Most recently, a prospective study in more than 13?000 preadolescents and adolescents found that eating family dinners most days or every day during the previous year was protective against purging behaviors, binge eating, and frequent dieting. The trend was similar in both females and males, although not statistically significant in males.48 In girls, family meals perceived to be enjoyable were protective from extreme weight-control behaviors.46 Postulates for why family meals are protective include the following: families will consume healthier foods than teenagers would choose on their own; parents can model healthy food choices; family meals provide a time for teenagers and parents to interact; and parents can monitor their child’s eating and address issues earlier when they are aware of their child’s eating behavior.49 3. Weight talk. Weight talk by family members refers to comments made by family members about their own weight or comments made to the child by parents to encourage weight loss. Even well-intended comments can be perceived as hurtful by the child or adolescent. Several studies have found that parental weight talk, whether it involves encouraging their children to diet or talking about their own dieting, is linked to overweight37,50 and EDs.51 Project EAT linked weight talk to higher rates of overweight 5 years later. Loth et al51 interviewed patients in recovery from EDs and found that weight talk affected them negatively. Parents who had conversations about weight had adolescents who were more likely to engage in dieting, unhealthy weight-control behaviors, and binge eating. However, if the focus of the conversation was only on healthful eating behaviors, overweight adolescents were less likely to diet and to use unhealthy weight-control behaviors.52 4. Weight teasing. In overweight adolescents, weight teasing by peers or family members is experienced by 40% of early adolescent females (mean age: 12.8 ± 0.7 years), 28.2% of middle adolescent females (mean age: 15.9 ± 0.8 years), 37% of early adolescent males, and 29% of middle adolescent males.53 Family weight teasing predicts the development of overweight status, binge eating, and extreme weight-control behaviors in girls and overweight status in boys. Adolescent girls who were teased about their weight at baseline were at approximately twice the risk of being overweight 5 years later.37 A 10-year longitudinal study found that the prevalence of weight teasing did not decrease as children matured into young adults, despite the fact that the relationship between bullying and obesity had received a great deal of attention in the news.53 A group of subjects who were studied in their young teenage years were studied again in young adulthood to evaluate the role of hurtful weight-related comments and eating behaviors (n = 1902; mean age: 25 years). For both males and females, hurtful weight-related comments from family members and significant others were associated with the use of unhealthy weight-control behaviors and binge eating in both males and females.54 5. Healthy body image. Approximately half of teenage girls and one-quarter of teenage boys are dissatisfied with their bodies; these numbers are higher in overweight teenagers.55 Body dissatisfaction is a known risk factor for both EDs and disordered eating; higher scores of body dissatisfaction are associated with more dieting and unhealthy weight-control behaviors in both boys and girls, reduced physical activity in girls, and more binge eating in boys.56 Body dissatisfaction and disordered eating occur in minority populations and are not limited to white girls and boys.57 Adolescents who were more satisfied with their bodies were more likely to report parental and peer attitudes that encouraged healthful eating and exercising to be fit, rather than dieting; they were less likely to report personal weight-related concerns and behaviors.58 MI Is Useful in Addressing Weight-Related Issues MI was developed by Miller and Rollnick in 1991 to treat patients with addiction. Although MI has been well studied in adults with addictions and obesity, fewer studies have evaluated the effect of MI on patients with EDs and the use of MI in children and adolescents.59–61 Studies to date on the use of MI for patients with EDs60,61 and for children and adolescents with obesity have been promising.62–65 The most recent book on MI by Miller and Rollnick defines MI as “a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.”66 This counseling approach involves 4 broad processes listed in Table 2.67 A study conducted through the AAP Pediatric Research in Office Settings (PROS) network assessed the effect of MI delivered by pediatricians and found that pediatricians and dietitians who used MI to counsel families with overweight children were successful in reducing children’s BMI percentile by 3.1 more points than a control group in which MI was not used.68 The AAP Web and mobile app called “Change Talk: Childhood Obesity” (http://ihcw.aap.org/resources) uses an interactive virtual practice environment to train pediatricians about the basics of MI. Pediatricians can successfully facilitate their patients’ lifestyle behavior changes. Concerns from pediatricians and parents that obesity counseling can lead to an ED can be addressed by understanding the effectiveness of family-centered MI to promote healthy behaviors. What To Do If an ED Is Suspected The pediatrician often is the first professional consulted by a parent or the school when there is a concern about a possible ED. Height, weight, and BMI should be plotted on the 2000 growth charts available from the Centers for Disease Control and Prevention (www.cdc.gov/growthcharts), and the current data should be compared with as many previous data points as possible. A BMI below the fifth percentile is underweight and may indicate an ED. Other possible indicators of an ED include missed menstrual periods in girls, an unusually rapid decline in BMI, or engaging in disordered eating behaviors by normal-weight and overweight adolescents who are dissatisfied with their body image. Early diagnosis and intervention are associated with improved outcome.69 EDs are best evaluated and managed by a multidisciplinary health care team, with the pediatrician as an important member of that team.70 A thorough physical examination and review of systems can help to identify any underlying medical and psychiatric causes for weight loss. This comprehensive clinical assessment has been described in detail elsewhere.5 High-risk eating and activity behaviors and clinical findings of concern are outlined in Table 3. The pediatrician may feel comfortable performing this evaluation or may prefer to refer the patient to a specialized ED center, if one is available in the local community. A psychological assessment by a mental health professional can assist with the evaluation for comorbid psychiatric illnesses (eg, affective or anxiety disorders). High-Risk Eating and Activity Behaviors and Clinical Findings of Concern In children and adolescents with AN and BN, family-based therapy (FBT), in which the parents control the refeeding process, has been shown to be an effective first-line method of treatment.71,72 With FBT, the pediatrician can assist with monitoring the patient for weight gain and vital sign stability and can communicate with the patient, family, and therapist. Becoming familiar with the general principles of FBT can assist the pediatrician in understanding his or her role in this form of treatment (Table 4).73 An Integrated Approach to Obesity and ED Prevention Focuses on Healthy Family-Based Lifestyle Modification Obesity prevention and treatment, if conducted correctly, does not predispose to EDs. On the contrary, randomized controlled trials of obesity prevention programs have shown a reduction in the use of self-induced vomiting or diet pill use to control weight74 and a decrease in concerns about weight in the intervention groups.75 Family involvement in the treatment of both adolescent obesity and EDs has been determined to be more effective than an adolescent-only focus.73,76 An integrated approach to the prevention of obesity and EDs focuses less on weight and more on healthy family-based lifestyle modification that can be sustained. Pediatricians can encourage parents to be healthy role models and supportively manage the food environment by creating easy accessibility to healthy foods (eg, fruits, vegetables, whole grains, beans and other legumes, and water) and by limiting the availability of sweetened beverages, including those containing artificial sweeteners, and other foods containing refined carbohydrates. Discussions between pediatricians and parents about increasing physical activity and limiting the amount of total entertainment screen time to less than 2 hours/day are important and may lead to changes in family behavior.77 Another area of prevention is avoiding the presence of a television in the teenager’s bedroom, because having a television in the room predicts significantly less physical activity as well as poorer dietary intakes compared with not having a television in the room.78,79 Other evidence-based approaches encourage parents to include more family meals, home-prepared meals, and meals with less distractions as well as fewer discussions about weight and about dieting.6,80 Understanding that poor body image can lead to an ED, parents should avoid comments about body weight and discourage dieting efforts that may inadvertently result in EDs and body dissatisfaction. Role of the Pediatrician in the Prevention of Obesity and EDs in Adolescents Observations that can be concluded from current research summarized in this report to help prevent weight-related problems including both obesity and EDs include the following: 1.Discourage dieting, skipping of meals, or the use of diet pills; instead, encourage and support the implementation of healthy eating and physical activity behaviors that can be maintained on an ongoing basis. The focus should be on healthy living and healthy habits rather than on weight. 2.Promote a positive body image among adolescents. Do not encourage body dissatisfaction or focus on body dissatisfaction as a reason for dieting. 3.Encourage more frequent family meals. 4.Encourage families not to talk about weight but rather to talk about healthy eating and being active to stay healthy. Do more at home to facilitate healthy eating and physical activity. 5.Inquire about a history of mistreatment or bullying in overweight and obese teenagers and address this issue with patients and their families. 6.Carefully monitor weight loss in an adolescent who needs to lose weight to ensure the adolescent does not develop the medical complications of semistarvation. Time constraints in a busy pediatric practice are significant. Weight issues can be a topic of sensitivity and therefore can be time consuming. The evidence-based suggestions in this report can be implemented in relatively brief encounters and can be an excellent first step for teenagers and families to promote a healthy lifestyle. Footnotes
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J Consult Clin Psychol. 2005;73(2):195–202pmid:15796626 40.Patton GC, Selzer R, Coffey C, Carlin JB, Wolfe R Onset of adolescent eating disorders: population based cohort study over 3 years. BMJ. 1999;318(7186):765–768pmid:10082698 41.Fulkerson JA, Neumark-Sztainer D, Hannan PJ, Story M Family meal frequency and weight status among adolescents: cross-sectional and 5-year longitudinal associations. Obesity (Silver Spring). 2008;16(11):2529–2534pmid:18719674 42.Taveras EM, Rifas-Shiman SL, Berkey CS, et al Family dinner and adolescent overweight. Obes Res. 2005;13(5):900–906pmid:15919844 43.Sen B Frequency of family dinner and adolescent body weight status: evidence from the national longitudinal survey of youth, 1997. Obesity (Silver Spring). 2006;14(12):2266–2276pmid:17189555 44.Neumark-Sztainer D, Hannan PJ, Story M, Croll J, Perry C Family meal patterns: associations with sociodemographic characteristics and improved dietary intake among adolescents. 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J Adolesc Health. 2009;44(3):206–213pmid:19237105 50.Berge JM, MacLehose RF, Loth KA, Eisenberg ME, Fulkerson JA, Neumark-Sztainer D Parent-adolescent conversations about eating, physical activity and weight: prevalence across sociodemographic characteristics and associations with adolescent weight and weight-related behaviors. J Behav Med. 2015;38(1):122–135pmid:24997555 51.Loth KA, Neumark-Sztainer D, Croll JK Informing family approaches to eating disorder prevention: perspectives of those who have been there. Int J Eat Disord. 2009;42(2):146–152pmid:18720475 52.Berge JM, Maclehose R, Loth KA, Eisenberg M, Bucchianeri MM, Neumark-Sztainer D Parent conversations about healthful eating and weight: associations with adolescent disordered eating behaviors. JAMA Pediatr. 2013;167(8):746–753pmid:23797808 53.Haines J, Hannan PJ, van den Berg P, Eisenberg ME, Neumark-Sztainer D Weight-related teasing from adolescence to young adulthood: longitudinal and secular trends between 1999 and 2010. 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Eat Behav. 2013;14(4):432–436pmid:24183130 61.Macdonald P, Hibbs R, Corfield F, Treasure J The use of motivational interviewing in eating disorders: a systematic review. Psychiatry Res. 2012;200(1):1–11pmid:22717144 62.Carcone AI, Naar-King S, Brogan KE, et al Provider communication behaviors that predict motivation to change in black adolescents with obesity. J Dev Behav Pediatr. 2013;34(8):599–608pmid:24131883 63.Resnicow K, Davis R, Rollnick S Motivational interviewing for pediatric obesity: conceptual issues and evidence review. J Am Diet Assoc. 2006;106(12):2024–2033pmid:17126634 64.Schwartz RP, Hamre R, Dietz WH, et al Office-based motivational interviewing to prevent childhood obesity: a feasibility study. Arch Pediatr Adolesc Med. 2007;161(5):495–501pmid:17485627 65.Resnicow K, McMaster F, Bocian A, et al Motivational interviewing and dietary counseling for obesity in primary care: an RCT. Pediatrics. 2015;135(4):649–657pmid:25825539 66.Miller WR, Rollnick S Motivational Interviewing. Helping People Change. 3rd ed. New York, NY: The Guilford Press; 2013 67.American Academy of Pediatrics Motivational interviewing. Healthy Active Living for Families Implementation Guide. Available at: www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/HALF-Implementation-Guide/communicating-with-families/Pages/Motivational-Interviewing.aspx. Accessed November 10, 2015 68.?Resnicow K, Harris D, Schwartz R, et al Can brief motivational interviewing in practice reduce child body mass index? Results of a 2-year randomized controlled trial [abstr]. Presented at: Pediatric Academic Societies Annual Meeting; Vancouver, British Columbia, Canada; May 4, 2014 69.Forman SF, Grodin LF, Graham DA, et al; National Eating Disorder QI Collaborative An eleven site national quality improvement evaluation of adolescent medicine-based eating disorder programs: predictors of weight outcomes at one year and risk adjustment analyses. J Adolesc Health. 2011;49(6):594–600pmid:22098769 70.Golden NH, Katzman DK, Sawyer SM, et al; Society for Adolescent Health and Medicine Position paper of the Society for Adolescent Health and Medicine: medical management of restrictive eating disorders in adolescents and young adults. J Adolesc Health. 2015;56(1):121–125pmid:25530605 71.Lock J, Le Grange D, Agras WS, Moye A, Bryson SW, Jo B Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Arch Gen Psychiatry. 2010;67(10):1025–1032pmid:20921118 72.Le Grange D, Crosby RD, Rathouz PJ, Leventhal BLA randomized controlled comparison of family-based treatment and supportive psychotherapy for adolescent bulimia nervosa. Arch Gen Psychiatry. 2007;64(9):1049–1056pmid:17768270 73.Katzman DK, Peebles R, Sawyer SM, Lock J, Le Grange D The role of the pediatrician in family-based treatment for adolescent eating disorders: opportunities and challenges. J Adolesc Health. 2013;53(4):433–440pmid:24054079 74.Austin SB, Field AE, Wiecha J, Peterson KE, Gortmaker SL The impact of a school-based obesity prevention trial on disordered weight-control behaviors in early adolescent girls. Arch Pediatr Adolesc Med. 2005;159(3):225–230pmid:15753264 75.Robinson TN, Killen JD, Kraemer HC, et al Dance and reducing television viewing to prevent weight gain in African-American girls: the Stanford GEMS pilot study. Ethn Dis. 2003;13(1, suppl 1):S65–S77pmid:12713212 76.Shrewsbury VA, Steinbeck KS, Torvaldsen S, Baur LAThe role of parents in pre-adolescent and adolescent overweight and obesity treatment: a systematic review of clinical recommendations. Obes Rev. 2011;12(10):759–769pmid:21535361 77.Strasburger VC; Council on Communications and Media Children, adolescents, obesity, and the media. Pediatrics. 2011;128(1):201–208pmid:21708800 78.Barr-Anderson DJ, van den Berg P, Neumark-Sztainer D, Story M Characteristics associated with older adolescents who have a television in their bedrooms. Pediatrics. 2008;121(4):718–724pmid:18381536 79.Bauer KW, Neumark-Sztainer D, Fulkerson JA, Hannan PJ, Story M Familial correlates of adolescent girls’ physical activity, television use, dietary intake, weight, and body composition. Int J Behav Nutr Phys Act. 2011;8:25pmid:21453516 80.Barlow SE; Expert
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Pediatrics. 2007;120(suppl
4):S164–S192pmid:18055651 12
Questions You Should Ask Your Kids at Dinner It’s time to eat. Where are the kids? Parents: Do you routinely sit down to family meals? Research suggests doing so may be beneficial, helping bolster kids’ social skills while improving their eating habits. An American Academy of Pediatrics report in the journal Pediatrics last year noted that regular family meals may help ensure adolescents eat more fruits and veggies, and are associated with a decreased risk of developing eating disorders, particularly for girls. But the benefits may be reduced if you give into distracted dining, constantly checking your mobile device. You must engage – and be thoughtful about what you discuss. To make the most of your time together, parenting experts suggest asking the following questions. What is something interesting (or fun or difficult) you did today? While questions you ask will vary
depending on your child’s age, this can be a great
place to start. “Sharing what your child's day was like
and what is important to them grows your relationship,”
says Dr. Gail Saltz, a clinical associate professor of
psychiatry at the Weill Cornell Medical College in New York
City. “Then it's also important to tell them what you
valued in your day.” For school-age
kids, you might also ask,
"What was the most interesting thing you learned today?"
This will be helpful for understanding what excites your
child, where she may need extra opportunities or help, and
in fostering love of learning, Saltz says. 7 Things You Need to
Know About Eating Disorders In the United States, eating disorders affect up to 30 million people across age and gender, including anorexia, bulimia and binge eating disorder. And the number keeps growing. That’s why it’s important to understand what eating disorders are, how to recognize the warning signs and symptoms and what you can do to help as a certified Mental Health First Aider. Here are 7 things you need to know about eating disorders. What are eating disorders? Eating disorders occur when a person distorted thoughts and emotions relating to body image that lead to marked changes in eating or exercise behaviors that interfere with their life. What are common types of eating disorders? Health professionals recognize three different types of eating disorders: anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified (EDNOS), such as binge eating disorders. All eating disorders have different warning signs that often depend on the person. Learn more about these common types of eating disorders in this blog post. What causes eating disorders? Like other mental disorders, there is no single cause for eating disorders. A range of biological, psychological and social factors may contribute. Most eating disorders occur when a person has distorted thoughts and emotions relating to body image. Who are eating disorders most likely to affected? Eating disorders affect all ages, genders, races and cultures. They are two to three times more common in females than in males. The median age of onset for eating disorders ranges from 18 to 20 years old (half of people have onset before these ages). What are the risks and side-effects of eating disorders? A person with an eating disorder can experience a wide range of physical and psychological health problems. Many people with eating disorders also have another mental disorder, particularly anxiety, mood or substance use disorders. Serious physical health consequences can include severe malnutrition, brain dysfunction and heart or kidney failure. Unfortunately, eating disorders have the highest mortality rate of any mental illness. Where can you go for help? The National Eating Disorders Association (NEDA) is a nonprofit organization dedicated to helping individuals and families affected by eating disorders. You can call their confidential hotline at 800-931-2237 or chat with a trained volunteer online at nationaleatingdisorders.org for information and support. What can you do to help others? Get trained in Mental Health First Aid. You will learn the risk factors and warning signs for eating disorders and other mental disorders and addictions, strategies for how to help someone in crisis and non-crisis situations and where to turn for help. IMPORTANT NOTE: If you or someone you
know is experiencing a crisis, call 911 or text SOS to
741741. Study
Shows Social Media May Play a Role in Eating Disorders Among
Teens
Skipping meals and other behaviors related to eating disorders were reported by 52% of girls and 45% of boys who participated in the study. While social media wasn’t cited as a direct cause of eating disorders, according to the study, there is a connection that should be acknowledged and monitored. Vegan food blogger Jordan Younger shared her experience of using her Instagram to promote a healthy lifestyle as a façade as “healthy eating” quickly escalated into an eating disorder. “The obsession with my diet took up my every waking hour. It was stopping me from leading a normal life full of social activities and other interests,” she said. Jordan isn’t alone. Eating disorders affect up to 30 million people in the United States, and the median age of onset for these disorders is 18 to 20 years old. Young people are influenced daily by the pressure of social media to look and act a certain way, and if not careful, these thoughts can have a serious impact on their mental and physical health. Luckily, social media platforms are starting to take responsibility for the power they have and are making positive changes to help young people. In September 2019, Instagram announced new policies to protect people under the age of 18 from certain weight loss products and cosmetic procedures on its platform. People can report problematic content, and, in some cases, it may be removed entirely. Recently, Snapchat announced the launch of a new tool called “Here For You.” The service connects people searching for topics like depression, anxiety and thinspo (an abbreviation for thinspiration) to informative and helpful content written by mental health experts. We don’t know if social media has a direct link to eating disorders. But, if there is a connection, you can help monitor it too. As the use of social media increases, it is important that you take steps to lessen its negative effects and even make it a positive influence on your life. With the right focus, it can be a place to connect with loved ones and share inspiring stories. You can also take a Mental Health
First Aid course. Mental Health First Aid will teach you
about the signs and symptoms of an eating disorder, how they
impact young people specifically and what you can do to help
someone who might be struggling. With the knowledge and
skills, you can #BeTheDifference and connect your loved ones
to the support and care they
need. 5
Questions to Ask Someone Who Might Have an Eating
Disorder Whether the signs are obvious to the naked eye or not, eating disorders affect up to 30 million people in the United States across age and gender. And unfortunately, less than a third of people with eating disorders received treatment for a mental health problem in the past 12 months. That’s why it is important that you know the signs and symptoms of eating disorders and how to approach someone who may be struggling. There are 5 key signs that identify a person who may have an eating disorder. Ask these questions from the MHFA curriculum to help detect if a person in your life is developing or living with an eating disorder.
If you are still not sure if your loved one is living with an eating disorder, call the National Eating Disorders Association (NEDA) helpline at 800-931-2237 for information and support. You can also learn to recognize the
signs and symptoms of eating disorders and other mental
illnesses and addictions by getting trained in Mental Health
First Aid. Get trained today and #BeTheDifference for the
people in your life.
Talking about mental health can be hard. It can be hard to admit that you’re not feeling okay, and even harder to ask for help. This is especially true when you’re a young person facing the pressure to look, act and be a certain way. But, it’s important to know that asking for help is okay. You don’t need to tell everyone, but there are some things that you shouldn’t keep a secret. If you or someone you know is struggling with a mental health or substance use challenge, connect with a responsible and trusted adult. Use these tips from teen Mental Health First Aid to find an adult you trust and reach out for help.
These tips are just a place to start. You can also be trained in Mental Health First Aid and learn about other ways to talk about your mental health and get the support you need. teen Mental Health First Aid (tMHFA) teaches high school students about common mental health challenges and empowers them with an action plan to support each other in times of need. Learn
more about this exciting new
program, run by the National Council and supported by Lady
Gaga’s Born This Way Foundation. Right now, select
schools across the country are training students in tMHFA.
We’re looking forward to expanding to more schools
across the country in the coming
years. Boys and Eating
Disorders When we think of those affected by eating disorders, we usually think of girls and young women. The fact is, females do make up the bulk of those who struggle with eating disorders, including anorexia, bulimia and binge eating. But disordered eating also affects boys and men. Estimates vary, but it is believed that a quarter to a third of those struggling with an eating disorder are male. And disordered eating behaviors are increasing at a faster rate in males than females. Because eating disorders often manifest themselves differently in boys, they are harder to detect by parents as well as healthcare providers. Stigma is another issue. Men may not want to be associated with a problem that primarily affects women, and men are less likely to admit weakness and seek help. Understanding the differences Girls with eating disorders are typically obsessed with being thin. While boys with anorexia are driven by a similar motive, the majority of them tend to be more focused on achieving a muscular physique. This manifestation is sometimes known as “reverse anorexia” or “bigorexia,” explains Douglas Bunnell, PhD, a clinical psychologist and expert on eating disorders. “These boys have all the psychological features of anorexia, except they’re pushing it in the opposite direction.” To achieve what they perceive to be the “ideal” physique, boys may work out excessively, or use steroids or over-the-counter supplements to minimize body fat and increase muscle mass and definition. An obsession with “clean eating” — cutting out carbs, increasing protein, or adhering to restrictive fad diets — is another common feature. And it may develop earlier than eating disorders in girls, notes Dr. Bunnell. “We think boys may have onset earlier—sometimes during early and mid-adolescence — but there are all sorts of nuances.” Signs of eating disorders in boys Of course not all boys who express dissatisfaction with their bodies will develop an eating disorder. Here’s what to look for if you’re trying to determine whether a boy’s habits are within the normal range of eating behavior or have crossed into something that needs attention:
Hiding in plain sight Unlike with girls, who often become alarmingly skinny and visibly unhealthy, eating disorders in boys are harder to recognize because often nothing looks “wrong” on the outside. Eating disorders in boys are also easier to hide under the guise of what is considered acceptable, even laudable, male behavior. “Exercising, even excessively, is socially valued in men,” says Dr. Bunnell, who adds that overeating is also more socially condoned in men than in women. “A group of 17-year-old boys eating multiple Big Macs, for example, might be considered amusing or even cool,” he says. “In fact, these behaviors may be masking an eating disorder, but we don’t notice the psychological suffering piece.” Causes of eating disorders The underlying causes of eating disorders in boys are thought to be the same as in girls — a combination of genetic disposition, environment and societal messages that promote and reward an “ideal” body. For men, muscular physiques and “six-pack abs” might be the goal. Athletes who compete in certain sports that emphasize weight and appearance, including gymnastics, wrestling, rowing, bodybuilding, running, and dancing, are at higher risk. Eating disorders affect people of all sexual orientations. Overall, many more straight men have eating disorders, but homosexual men seem to be at higher risk for them. As with young women, a negative body image can trigger disordered eating, and men have been shown to react to media images of highly chiseled men the way young women react to images of very thin models. In addition to things like movies and advertising, playing a body-emphasizing video game has been shown to increase boys’ negative body-image. And one study of young men documented the negative impact of toy action figures popular with boys, noting that the extreme muscularity in action figures is as unrealistic for young men to achieve as a Barbie doll’s figure is for young women. Negative health effects All eating disorders can result in serious health problems. Menstruation is often halted in women, and both women and men can develop a loss of bone density — osteoporosis or its precursor, osteopenia — as a result of nutritional deficits. Men and boys with anorexia nervosa, in particular, usually exhibit low levels of testosterone and vitamin D; in some cases, testosterone supplementation is recommended. Other health consequences of eating disorders in men include damage to muscles, joints and tendons from over-exercising. Using steroids to bulk up can result in acne, testicular atrophy, decreased sperm count, high blood pressure, high cholesterol, abnormal liver function, constipation and bursts of anger (known as “’roid rage”). People with eating disorders are also more likely to struggle with depression, anxiety disorders, substance abuse and personality disorders. Men are more likely to die from an eating disorder than women due to the fact that they lose weight more easily, lose body fat more quickly, and tend to be diagnosed later, if at all. There is also the risk of suicide in boys who suffer from depression and other mental health problems concurrently. Getting help Research shows that boys and men respond well to the same eating disorder treatments that have been successful for females. Whether in an in-patient or out-patient setting, the focus is on restoring health and addressing the psychological and emotional components with psychotherapy. Parents are engaged to help establish an environment that supports healthy eating habits and body image. The challenge is getting males to seek help. Most eating disorder programs are centered on girls, which can make boys feel out of place. There are some male-only programs, and the hope is that, as awareness grows and stigma decreases, there will be more. “We know a lot more about boys
and eating disorders compared to, say, two or three years
ago,” says Dr. Bunnell. “We just think there are a
lot more boys and men out there who feel inhibited or
ashamed about coming forward. It’s critical for
parents, pediatricians and school counselors to develop
awareness of eating disorders being as much of as a
potential issue for boys as for girls. We have treatments
and we want boys to be sure they know they can have access
to them.” Early
Bird? Night Owl? It May Matter for Eating Disorder Risk
1/5/24 People with anorexia nervosa may be more likely to be early risers, a genetic association study suggested. Looking at nearly 17,000 cases with this eating disorder, genetic liability for anorexia nervosa was associated with a more morning chronotype -- or a preference for the morning (ß=0.039, 95% CI 0.006-0.072, P=0.02), Hassan Dashti, PhD, RD, of Massachusetts General Hospital in Boston, and colleagues found. The same was true when looking at the other direction of this link, they wrote in JAMA Network Openopens in a new tab or window. The researchers found that having a genetic liability for morning chronotype was associated with increased risk of anorexia nervosa (ß=0.178, 95% CI 0.042-0.315, P=0.01). "Our study indicates anorexia nervosa is uniquely morning based, which is surprising as no other psychiatric disorder we are aware of has yet been morning-associated," Dashti told MedPage Today. While the effect sizeopens in a new tab or window of both associations would be considered small, the researchers suggested several clinical implications. "Sleep is not often considered when treating patients living with anorexia nervosa or other eating disorders," Dashti explained to MedPage Today. "Our study highlights the importance of asking about sleep timing and sleep quality, as sleep possibly impacts eating disorder symptoms." The findings lend themselves to investigating whether circadian and sleep-based interventions might be effective in the treatment or prevention of anorexia nervosa in randomized controlled trials, Dashti noted. "For example, bright light therapy in the evening or addressing insomnia might be part of a clinicians' treatment toolbox for anorexia nervosa," he suggested. "This research indicates a possible circadian and sleep basis to anorexia nervosa, opening research into circadian mechanism-based possible treatments for the disorder." Finding new anorexia treatments is urgent as current ones are "limited, with relapse rates of up to 52%," said Dashti. "No mechanism-based treatment for anorexia nervosa currently exists, as the cause of the disease is still unclear," he pointed out. "Treatments are limited to behavioral therapy and the use of medications created for the treatment of other disorders, such as depression or anxiety. With anorexia nervosa having the second highest mortality rate of psychiatric diseases, more research is desperately needed into new prevention strategies and treatments." Other than a morning chronotype, genetic liability for anorexia nervosa wasn't significantly linked with other circadian and sleep traits, like daytime napping, daytime sleepiness, insomnia, or sleep duration. Likewise, genetic liabilities for sleep traits beyond morning chronotype and insomnia weren't linked with anorexia. However, the researchers found in a sensitivity analysis that there may have been some bias due to horizontal pleiotropyopens in a new tab or window with this insomnia link. Genome data for the analysis came from the Eating Disorders Working Group of the Psychiatric Genomics Consortium, which included 16,992 anorexia cases and 55,525 controls. Upwards of 88% of cases were female, but half to two-thirds of controls were also female. Anorexia nervosa was defined as a lifetime diagnosis from hospital or register records, structured clinical interviews, and online questionnaires based on standardized criteria like the Diagnostic and Statistical Manual of Mental Disorders or ICD codes. The research team also looked at data in the Mass General Brigham Biobank, which contained 47,082 adult patients of European ancestry with genetic data. Around 54% of this cohort was female, and the average age was 60.4. A polygenic risk score for anorexia was calculated for each patient in this cohort and associations were tested with prevalent sleep disorders derived from electronic health records. Here, each additional standard deviation in the anorexia nervosa polygenic risk score was tied with 10% higher odds for organic or persistent insomnia (OR 1.10, 95% CI 1.03-1.17), even after controlling for lifestyle factors. Links with other sleep disorders including sleep apnea and restless legs syndrome weren't significant. These findings were somewhat
surprising, Dashti said, explaining how they seem to
contradict previous observational data suggesting that
people with anorexia nervosa tend toward later chronotypes
with later bed and wake times. "This likely is due to
evening-based psychiatric disorders, like depression and
anxiety, being very common among those living with anorexia
nervosa," he noted. "Observational studies are confounded by
the presence of other common evening-based disorders,
obscuring the relationship between anorexia nervosa and
chronotype."
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