Week 8 lectures - Lecture notes 15, 16 PDF

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Eating disorders, weight gain, and evidence based approaches to weight management...

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NUTRITION, EXERCISE AND WEIGHT MANAGEMENT: EATING DISORDERS, RED-S (ENERGY DEFICIENCY IN ATHLETES), PRACTICAL MANAGEMENT OF UNDERWEIGHT – WEEK 8 Who has an Eating Disorder? - You can’t tell by looking - Eating disorders come in all shapes and sizes Eating Behaviours are Highly Variable

Overview of Eating Disorders Today - “eating disorders and disordered eating together are estimated to affect over 16% of the Aus population. Binge eating disorders (BED) and other specified feeding or eating disorders (OSFED) are the most common eating disorders, affecting approximately 6% and 5%, respectively, while anorexia nervosa (AN) and bulimia nervosa (BN) each occur in below 1% of the general population” - In comparison to the general population, mortality rates are almost twice as high for people with eating disorders; this rises to 5-6 times higher for people with anorexia - Lifetime prevalence for eating disorders is approximately 9% of the Aus population DSM-5 - The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a publication of the American Psychiatric Association (APA) - The DSM contains sets of diagnostic criteria to assist with diagnosis of mental health disorders - Most recent version 5 released May 2013 included some changes in ED classification - Not our job to diagnose but important to be aware what a diagnosis means SCOFF Questionnaire - Ask the following 5 questions: o Do you ever make yourself sick (S) because you feel uncomfortably full? o Do you worry you have lost control (C) over how much you eat? o Have you recently lost (O) more than 6kg in a three month period? o Do you believe yourself to be fat (F) when others say you are too thin?

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o Would you say that food (F) dominates your life? One or two positive answers should raise your index of suspicion and indicate full assessment for an eating disorder and consultation with an eating disorder expert or mental health clinician is needed

Anorexia Nervosa – DSM 5 - Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health) - Either an intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain (even though significantly low weight) - Disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight - Subtypes o Restricting type o Binge-eating/purging type Warning Signs, Side Effects and Symptoms - Obsession with body shape/weight and inaccurate assessment of self - Self-criticism - Mood swings, fatigue - Interest (obsession) and knowledge of food/cafes - Increased panic or anxiety around meal times and excuses not to eat, avoiding social situations - Excessive or compulsive exercise - Impaired school or work performance - Changes in food preferences - Feels full easily Starvation – (Minnesota Starvation Study) - 36 conscientious war objectors WW2 (1944) voluntarily entered 12 month study to help professionals learn about recovery from starvation o Provided with normal intake (3200 cal/day) 12 weeks o Restricted to to about half that amount for 24 weeks to lose 25% BW o Controlled reintroduction of food and supplements 12 weeks o Unlimited intake – monitored 8 weeks - Physical findings: muscle and fat loss, physical fatigue, lowered heart rate, decreases in strength, temp and sex drive - Psychological findings: food obsession (food dreams), irritability, distress, anxiety, depression, mental/motivational fatigue (apathy) - Many participants struggled to manage weight following experiment

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Helps to understand why physical nourishment is required in recovery from AN not just psychological treatment

Effects of Starvation/Restriction/Diets - Draining on the person, physically and psychologically - Has long term health impacts physically and psychologically - Metabolic and hormonal adaptation is real - Associated stress can further impact weight and hormones - Impacts individuals differently but impacts both males and females - Even people who are at a healthy weight and not inclined toward disordered eating, become obsessed with food and eating when they are deprived of adequate nourishment or subjected to restrictive eating Bulimia Nervosa – DSM 5 - Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following: o Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances o A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating) - Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise - The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months - Self-evaluation is unduly influenced by body shape and weight - The disturbance does not occur exclusively during episodes of Anorexia Nervosa Warning Signs, Side Effects and Symptoms - May be under, average or overweight - Mood swings, apparent shame or guilt - Depression, self-harm - Sensitive about references to weight/shape - Frequently ‘diets’, previous history of food restriction or even AN - Frequent trips to the bathroom, especially after eating - Fluctuations in weight

Binge Eating Disorder (new to DSM 5) - Recurrent episodes of binge eating o An episode of binge eating is characterised by both of the following:  Eating, in a discrete period of time (within any 2 hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances  A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating). - The binge eating episodes are associated with 3 or more of the following: o Eating much more rapidly than normal o Eating until feeling uncomfortably full o Eating large amounts of food when not feeling physically hungry o Eating alone because of feeling embarrassed by how much one is eating o Feeling disgusted with oneself, depressed or very guilty afterward - Marked distress regarding binge eating is present - Binge eating occurs, on average, at least once a week for 3 months - Binge eating occurs, on average, at least once a week for three months - Binge eating not associated with the recurrent use of inappropriate compensatory behaviours as in Bulimia Nervosa and does not occur exclusively during the course of Bulimia Nervosa, or Anorexia Nervosa methods to compensate for overeating, such as self-induced vomiting - Note: Binge Eating Disorder is less common but much more severe than overeating. Binge Eating Disorder is associated with more subjective distress regarding eating behaviour, and commonly other co-occurring psychological problems Other Eating Disorders Exist Too - Pica – DSM 5 o Eating non-foods e.g. chalk, dirt. May occur with other mental health conditions - Rumination Disorder – DSM 5 o Repeated regurgitation of food, e.g. chew and spit or re chew and swallow - Avoidant/Restrictive Food Intake Disorder(ARFID) – DSM 5 o Restriction of food or certain foods to point of impacting health but not related to body weight or image - Other Specified Feeding or Eating Disorder (OSFED) – DSM 5 o Where behaviours cause clinically significant distress/impairment of functioning, but do not meet the full criteria of any of the Feeding or Eating Disorder criteria. E.g.night eating, atypical AN or BN - Orthorexia (not official diagnosis currently) o Obsession with ‘healthy eating’ o Often eliminating food groups and impacting on social eating

Eating Disorders – Contributing Factors - All eating disorders are a complex mental health conditions and often coincide with another psychiatric comorbidities. There is not one single cause - Important that no individual is blamed - Some contributing factors may include; o Genetic inheritance o Perfectionist traits o Pressure to perform/external pressures o Exposure to media and culture where thinness is idealised o Difficult family situations or failed relationship o Recent trauma or other stressors o History of abuse General Treatment Aims - Together with multidisciplinary team f psychologists, psychiatrist, doctors, exercise physiologists o Prevent or identify early – best chance o Decrease risk of immediate danger and address malnutrition and any other nutrition risks o Assist to develop regular eating patterns, food variety, appetite, behaviours and food relationships o Address underlying psychological issues - No one model of treatment - Some important treatment aims and principles:

General Meal Planning Advice for ‘Disordered Eating’ – will vary significantly - Avoid providing kilojoule information or targets (time consuming, creates obsession, prevents normal appetite regulation, ignores micronutrient needs) - Usually 3 meals, 2-3 snacks, avoiding gaps of ~3 hours without food - Balance of all macronutrients and all food groups with good food variety - Avoid ‘diet’ or ‘lite’ products - May need extra nourishing fluids in underweight - * be aware of any additional issues, e.g. diabetes, allergies, hypertension - * work with a team of experts in the area What it all means for me - All practitioners have a role in helping to prevent eating disorders and assist in early referral - Remember, disordered eating is not always obvious and not all diet histories are accurate - Always be clear with documentation - Caution before posting, commenting or even suggesting “a diet” – this can snowball concerning behaviours - Encourage exercise and good nutrition as nourishment, this will look different for everyone - Acknowledge physiological and psychological barriers that exist in making it more difficult for some people to make lasting weight changes - LISTEN RED-S (Relative Energy Deficiency in Sport Athletes and Energy Balance - Athletes have high nutrition demands - High training volumes (including possible exercise ‘addiction’) - Regular signs and symptoms of ED can be masked in athletes… normal to have low body weight, train regularly and be careful with intake Female Athlete Triad and RED-S - 1980s triad discussed, 1992, triad named - 2007, ACSM redefined as clinical entity between 3 interrelated components that may move along spectrum from health to disease - 2014 IOC published concept of RED-S - 2018 update published Relative Energy Deficiency in Sport (RED-S) - “impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, CV health caused by relative energy deficiency” - A ‘syndrome’ - Also impacts males - Individual variation - Acute and chronic variations

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Energy deficiency is a consistent underlying factor

LEA – Low Energy Availability - EA – energy left over after training/PA to fuel normal body function - EA = (Energy Intake (EI) – Energy cost of activity) / athletes FFM kg - 45 Cal/kg FFM estimated to be healthy balance,...