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Welcome: A Few Things to Note 1. Participants will be muted upon entry and videos turned off 2. For technical assistance, please use the chatbox 3. You will receive an email in approximately 3 months requesting feedback/impact on this presentation 4. Visit www.nceedus.org/training to view other training opportunities
Assessing Growth in Children & Adolescents for
the
Screening, Treatment and Prevention of
Eating Disorders
Anna M. Lutz, MPH, RD, LDN, CEDRD-S
NCEED Webinar ~ March 5th, 2021
Introduction
Anna M. Lutz, MPH, RD, LDN,
CEDRD-S
NCEED Content Expert
Objectives • Describe how accurate interpretation of growth charts can be essential in eating disorder identification and screening. • Explain how to establish expected body weight to support eating disorder recovery and relapse prevention. • Identify ways to approach growth and development in their own practice to support eating disorder prevention.
Eating Disorders Rates Have Doubled
• 2019 Systematic Review Shows:
• 2000-2006: 3.5% worldwide ED Rate
• 2013 – 2018: 7.8% worldwide ED Rate
• OSFED is the most prevalent, followed by BED, BN and AN
(Galmiche et al. 2019)Estimated Prevalence in Adolescents • Anorexia Nervosa: 0.3% • Bulimia Nervosa: 0.9% • Binge Eating Disorder: 1.6% • Behaviors suggestive of Anorexia Nervosa: 0.8% • Behaviors suggestive of Binge Eating Nervosa: 2.5% • Mean age of onset: 12.5 years old (Swanson et al., 2011)
Eating Disorders Do Not Discriminate Eating Disorders Affect: • All races • All ages • All socioeconomic backgrounds • All genders • All body types/sizes • All sexual orientations (Hornberger et. al, 2021; Sonneville KR, Lipson SK. 2018; Mitchison et al, 2014, Flament, 2015 )
Hornberger et. al, 2021
Important! • Eating Disorders are defined by behaviors not weight • You can’t tell by looking at someone or by weighing them, if they do or do not have an eating disorder
SCREENING
PCP's Role in Screening for Eating Disorders • Annual review of weight and height • Assessment of growth charts • Ask about: • Eating and body image concerns • Change in eating or exercise • Major life events • Mood changes/concerns • Refer, if needed
Female Body Composition Changes
During Puberty
Lean Body Mass 80% → 74%
Average Body Fat 16% → 27%
Change in Body Fat +120%
Peak Body Fat % ~15-16 years of age
Fat mass ∆ 2.5 lb/year
Weight gain in 4 years ~40 poundsTypical Growth – High Tracking
Typical Growth: Low Tracking
Negative Dysregulation
Possible Causes of Negative Dysregulation
(Falling off the growth curve)
• Eating disorder
• Appetite suppressing medication leading to inadeqate intake
• Sensory Processing Disorder and/or Autism Spectrum Disorder interfering with adequate intake
• Endocrine
• Thyroid
• Growth Hormone
• Type I DM
• Late onset puberty
• Significant change in activity level
• Autoimmune
• GI illness
• Celiac, IBD, IBSAcceleration Weight-for-age
Possible Causes of Weight Acceleration
• "Natural growth" that doesn't follow population averages
• Emotional/psychological factors affecting intake
• H/o restrictive feeding (physiological, psychological)
• Early onset puberty mimicking acceleration
• Restrictive Eating/Eating Disorder
• Endocrine
• Medication side effect
• Significant change in activity level (increase or decrease)
• Illness - tumor, nephrology
• Regardless of cause, trying to "control" weight can lead to weight acceleration and weight
cycling.Assessment Using Growth Charts
• Is the patient plotting on their own growth curve?
• Has their weight for age crossed percentile lines?
• Accelerated weight gain
• Decelerated weight gain
• Slowed rate of weight gain
• No weight gain – weight maintenance
• Weight loss
• Check height curve
• Assess for early or late onset of puberty
• Ask follow up questionsTo BMI or Not to BMI?
• BMI growth chart is volatile
• Small changes in height or weight can appear as large changes on BMI
chart
• BMI is not a helpful tool for individuals
• Using height-for-age and weight-for-age charts can be more helpful
• If height has drastically crossed percentile lines, it may be helpful to use BMI
chart to estimate an expected body weight
• When height-for-age percentile is high BMI percentile is more likely to be
"high"Z Scores • Spaces above and below chart lines on growth charts are not calibrated • Changes in percentile cannot be assessed by eye • If child is plotting outside of calibrated space, use z-scores to determine amount of change in percentile • Z-Score Calculator: https://peditools.org/growthpedi/
Case Example: Jane
Case Example: Jane
Case Example: Jane
Case Example: Jane
Weight and Height Are Only Clues
Ask About:
• Dieting behaviors
• Body Dissatisfaction
• Experiences of Weight Stigma
• Changes in eating habits
• Those with eating disorders were more likely to report having been vegetarian
currently or in the past
• Changes in exercise habits
• Psychosocial assessment – including assessment for physical and sexual abuse
• Amenorrhea
(More extensive questions in: Hornberger et al.)"Atypical Anorexia" • Patient meets criteria for Anorexia Nervosa without being "significantly underweight." • Medical complications the same as for Anorexia Nervosa • Any weight loss in teens needs to be evaluated with concern, not praised
Weight Suppression • Weight suppression: difference between current weight and highest weight • Higher weight suppression associated with more severe eating disorders behaviors • Higher Weight suppression, less improvement in symptomatology (Lowe et al, 2007; Berner et al, 2013)
Ears Open • "He just thinned out. That's what his siblings did, too." • "I've never weighed this much in my life." • "I gained 15 pounds over the last year!" • "I exercise a lot – that's why my periods are irregular."" • "I've been trying to eat healthier. No more junk food." • "My BMI was unhealthy last year, it's in the healthy range now."
TREATMENT
The Eating Disorders Treatment Team
Medical Provider
Registered
Psychotherapist DietitianThe PCPs' Role on the ED Treatment Team • Assess/Monitor medical stability • Establish "Treatment Goal Weight" or "Expected Body Weight" along with Registered Dietitian • Give clearance for exercise • Meds management? • Emphasize health & vitality
WHAT IS A "HEALTHY WEIGHT?"
"Ideal Body Weight" vs.
"Expected Body Weight"
"Ideal Body Weight" "Expected Body Weight"
(or "Treatment Goal Weight")
• 50th percentile weight-for-age takes into account:
• 50th percentile BMI for age
• Historical weight, height and BMI
• Growth trajectory
• Pubertal stage
• Menstrual History
• Energy Intake and expenditure
• Extent client is malnourishedDetermining Expected Body Weight
Project 6 months out:
• Determine EBW to be a return
Assess historical growth Has height-for-age to premorbid weight-for-age
trajectory crossed percentiles? %ile (taking into account
changes in height-for-age
%iles)
Expected Body Weight Reassess every 3-6
should be a range or months, always projecting
minimum 6 months aheadCase Example: Jane
Case Example: Jane
Case Example: Jane
Last 5 pounds • Evidence shows that even a small change of weight, as little as 5 pounds, can be the difference between having amenorrhea and having regular periods. • Evidence suggests "expected body weight" or "treatment goal weight" may need to be set 2kg above weight (or weight-for-age percentile) where menstruation stopped, or more for continued menstruation. (Sterling et al, 2009; Faust et al 2013)
You May Get Push Back... • "I don't want him to be overweight." • "She was uncomfortable before her eating disorder." • "They don't want to be that heavy. We are okay with this weight." • "I feel fine now at this weight." • "They've never weighed that much..."
Full Weight Restoration Supports Recovery • As little as 2.2kg has been shown to drastically reduce a person's risk of relapse (Arnold, 2013). • Rate of weight gain has been shown to reduce risk of relapse. (Lund et al., 2009)
What if historical
growth data isn't available or is unhelpful?
• Defer determination of EBW
• Focus on:
– Normalizing eating patterns
– Vital signs
– Physical exam findings
– Menstrual function
– Laboratory findings
– Absence of eating disorder behaviors
(Norris et al.. 2019)True Signs of Health • Energy Level • Regular menses • Heart rate, blood pressure, body temperature in normal ranges • Appropriate time spent thinking about food and body • Regular, Adequate Sleep • GI Function • Health of skin and nails • Normal lab values • Decrease of eating disorder behaviors • Hunger and fullness cues • Social interaction
PREVENTION
Risk Factors of Eating Disorders
Biological: Psychological:
Having a close relative with an eating disorder Perfectionism
Having a close relative with a mental health condition Body image dissatisfaction
History of dieting History of an anxiety disorder
Negative energy balance History of depression
Type 1(insulin-dependent) diabetes Behavioral inflexibility
Social:
• Weight stigma
• Teasing or bullying
• Appearance ideal internalization
Source: National Eating Disorders Association • Acculturation
www.nationaleatingdisorders.org • Limited social networks
• Trauma
• Food InsecurityDieting Doesn't Work • Dieting behaviors in children and adolescents is associated with increased BMI and binge eating in both boys and girls (Field et al, 2003; Neumark-Sztainer, 2007). • In 14 – 15 year olds, dieting behaviors were the strongest predictor of eating disorders at 3 year follow up (Patton et al,1999). • "Weight talk" is associated with both increased risk of eating disorders and high BMI (Golden et al, 2016).
Dieting Doesn't Work – Feeding Practices
• Children that have restricted access to highly palatable foods have
increased intake of those foods.
• Maternal restrictive feeding predicted daughters’ eating in the absence of
hunger and increased change in BMI.
• Parents' attitudes about overweight predict restrictive feeding practices
(Fisher & Birch 1999; Birch et all, 2003; Musher-Eizenman et al, 2007)Weight Stigma • Weight stigma is discrimination against or stereotyping others based on their weight. • Research shows that weight stigma often comes from healthcare professionals, family members and teachers. • Experiencing weight stigma leads to: depression, anxiety, poor body image, social isolation, unhealthy eating behaviors, and increased BMI (Pont et al, 2017)
2016 AMERICAN ACADEMY OF PEDIATRICS: FOCUS ON HEALTHY BEHAVIORS RATHER THAN WEIGHT. Golden et al., 2016)
What to do instead? • Treat weight only as one piece of information – a possible clue – Consider not discussing with children and adolescents – Concerned? Ask about behaviors – Talk to parents without child – Refer for further assessment/support • Screen for: – Trauma – Food insecurity – Teasing and bullying
What to do instead?
• Encourage Health Promoting • Discourage Behaviors that don't
Behaviors promote health:
– Being Active – Dieting
– Family Meals – Skipping Meals
– Regular meals and snacks with a – Diet Pill Use
variety of foods – Weight Talk
– Adequate Sleep – Prolonged screen time
– (Positive Body Image – by not
focusing on weight)“Longitudinal data of adolescent females suggest that even though body weight percentiles track throughout adolescence, little consistency guides the intakes of the energy, nutrients, vitamins, and minerals from early to late adolescence. Health Professionals must therefore refrain from jumping to conclusions about the dietary habits of adolescents even if they have been evaluated for nutritional status at an earlier age) and take the time to assess the current dietary intake of the individual.” (Cusatis DC et al. 2000)
Conclusion • Weight can be one clue into the development of an ED, but not the whole story • Be curious about what may be behind dysregulation - it could be a sign of disordered eating. • Full Weight Restoration and nutrition rehabilitation decreases rates of ED relapse • Focus on behaviors, not weight • Do not talk with children/adolescents about their bodies being wrong • Genetics influences body size and shape • Weight gain is normal (and expected) throughout childhood and rate is higher during teen years
References
• Arnold, C. (2013). Decoding anorexia. Routledge.
• Berner LA, Shaw JA, Witt AA, Lowe MR. The relation of weight suppression and body mass index to symptomatology and
treatment response in anorexia nervosa. J Abnorm Psychol. 2013 Aug;122(3):694-708. doi: 10.1037/a0033930. PMID:
24016010; PMCID: PMC4096540.
• Birch LL, Davison KK, Fisher JO. Am J Clin Nutr. 2003;78:215-220.
• Cusatis DC et al. Longitudinal nutrient intake patterns of US adolescent women: the Penn State Young Women’s
Health Study. J Adolesc Health. 2000;26:194-204.
• Faust JP,Goldschmidt AB,Anderson KE,. Resumption of menses in anorexia nervosa during a course of family-based
treatment. J Eat Disord 2013;1:12.
• Field AE, Austin SB, Taylor CB, et al. Relation between dieting and weight change among preadolescents and adolescents.
Pediatrics. 2003;112(4):900–906
• Fisher JO, Birch LL; Appetite. 1999; Vol 32:3, 405-419.
• Flament MF, Henderson K, Buchholz A, et al. Weight status and DSM-5 diagnoses of eating disorders in adolescents from
the community. J Am Acad Child Adolesc Psychiatry. 2015;54(5):403–411.e2
• Galmiche, M. et al. 2019. Prevalence of Eating Disorders over the 2006-2018 period: a Systematic Literature Review. Am J
Clin Nutrition. 109: 1402-1413.
• Golden NH, Schneider M, Wood C, AAP COMMITTEE ON NUTRITION. Preventing Obesity and Eating Disorders in
Adolescents. Pediatrics. 2016;138(3):e20161649
• Hornberger, L. Lane, M. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics Jan
2021, 147 (1) e2020040279; DOI: 10.1542/peds.2020-040279
• Lebow J, Sim LA, Kransdorf LN. Prevalence of a history of overweight and obesity in adolescents with restrictive eating
disorders. J Adolesc Health. 2015;56(1):19–24.References (con't)
• Lowe MR, Thomas JG, Safer DL, Butryn ML. The relationship of weight suppression and dietary restraint to binge eating in bulimia
nervosa. Int J Eat Disord. 2007 Nov;40(7):640-4. doi: 10.1002/eat.20405. PMID: 17607698.
• Lund BC, Hernandez ER, Yates WR, Mitchell JR, McKee PA, Johnson CL. Rate of inpatient weight restoration predicts outcome in
anorexia nervosa. Int J Eat Disord. 2009 May;42(4):301-5. doi: 10.1002/eat.20634. PMID: 19107835.
• Mitchison D, Hay P, Slewa-Younan S, Mond J. The changing demographic profile of eating disorder behaviors in the
community. BMC Public Health. 2014;14:943
• Mark L Norris, Jacqueline D Hiebert, Debra K Katzman, Determining treatment goal weights for children and adolescents with
anorexia nervosa, Paediatrics & Child Health, Volume 23, Issue 8, December 2018, Page 551, https://doi.org/10.1093/pch/pxy133
• Musher-Eizenman DR, Holub SC, Hauser JC, Young KM. Obesity (Silver Spring). 2007 Aug;15(8):2095-102.)
• Neumark-Sztainer DR, Wall MM, Haines JI, Story MT, Sherwood NE, van den Berg PA. Shared risk and protective factors for
overweight and disordered eating in adolescents. Am J Prev Med. 2007;33(5):359–369
• 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):765–768
• Pont SJ, Puhl R, Cook SR, Slusser W; Section on Obesity; Obesity Society. Stigma experienced by children and adolescents with
obesity. Pediatrics. 2017;140(6):e20173034
• Sonneville KR, Lipson SK. Disparities in eating disorder diagnosis and treatment according to weight status, race/ethnicity,
socioeconomic background, and sex among college students. International Journal of Eating Disorders 2018: 1-9.
• Sterling WM, Golden NH, Jacobson MS, Ornstein RM, Hertz SM. Metabolic assessment of menstruating and nonmenstruating
normal weight adolescents. Int J Eat Disord. 2009 Nov;42(7):658-63. doi: 10.1002/eat.20604. PMID: 19247996.
• Swanson SA, Crow SJ, Le Grange D, Swendsen J, Merikangas KR. Prevalence and correlates of eating disorders in adolescents.
Results from the national comorbidity survey replication adolescent supplement. Arch Gen Psychiatry. 2011;68(7):714–723Thank you & Questions
Anna M. Lutz, MPH, RD, LDN, CEDRD-S
anna@lutzandalexander.com
www.sunnysideupnutrition.com
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