“Let food be thy medicine and medicine be thy food” - NCHN · 2016. 5. 26. · Anorexia Nervosa (AN) 1-2% 90% Bulimia Nervosa (BN) 2-4% 85% Binge Eating Disorder (BED) ≥4% 65%

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26/05/2016

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Talia CecchelePaediatric DietitianChildren’s Hospital at Westmead

“Let food be thy medicine and medicine be thy food” – the inpatient management of adolescent eating disorders

“Let food be thy medicine and medicine be thy food”

The inpatient management of adolescent eating disorders

Talia CecchelePaediatric Dietitian- Children’s Hospital Westmead

[email protected]


26/05/2016


Learning Objectives• To identify adolescent eating disorders (ED) including current

prevalence and diagnostic criteria

• To describe nutritional, cultural and lifestyle risk factors for developing an ED in children and adolescents

• To describe the behavioural approaches children and adolescents use to lose weight

• To understand the re-feeding process for medically unstable patients

• To describe the energy and dietary requirements of children and adolescents with an ED and develop appropriate meal plans

• To discuss evidence based treatment methods and be aware of current treatment and policies at CHW including the role of the Dietitian

Treatment of Eating Disorders at CHW

• State-wide service

• Maudsley Family Based Therapy

• Inpatient (and outpatient) treatment

• Dietitian’s role is limited


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Maudsley Family Based Therapy (1986)

• Most effective treatment for anorexia nervosa in children/adolescents

• Evidenced based

• Most successful for <3 years illness duration

• Parents are the best resource for recovery

• 12 month program over 15-20 sessions

• Three core phases

Phase 1- Re-feeding

• Medical stability and symptom management

• Weight restoration

• Externalisation of eating disorder

• Parents are empowered

• Focus on the family meal

• Hospitalisation sometimes essential


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Phase 2- Returning control to the adolescent

• Occurs at 90% IBW (weight restoration)

• Adolescent gradually re-gains control of eating over a few months

Phase 3- Normal adolescent behaviour

• Weight maintenance and resumption of menstruation

• Re-address issues of normal adolescent behaviour – Healthy beliefs and development

– Assist family to adjust to life without eating disorder

– Comorbidities

Looking for Maudsley practitioners? Contact CHW or go to maudsleyparents.org


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ED Team at CHW• Psychiatrist x 2

• Paediatrician x 2

• Registrars x 2

• Clinical Nurse Consultant

• Clinical Nurse Specialist

• Social Worker/Maudsley family therapist x 2

• Clinical Psychologist/Maudsley family therapist x 4

• Dietitian (0.2 FTE) + other Allied Health (Physio)

8-16 patients admitted at one time

Dietitian’s role• Dietary assessment not provided

• Educating parents

• Consultation/support to the team

• Staff education

• Food service (menu planning, nutrition support)

• Ongoing support to parents post discharge


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What we know about Eating Disorders?

** 13-18 years most common. Peaking at 14 and 16 years of age

Prevalence % female

Anorexia Nervosa (AN) 1-2% 90%

Bulimia Nervosa (BN) 2-4% 85%

Binge Eating Disorder (BED)

≥4% 65%

Other Specified Feeding and Eating Disorders (OSFED)

≥5% 85% (?)

• Eating disorders are the 3rd most common chronic illness for young females (15-24yrs)1

• Anorexia nervosa has the highest mortality rate in any psychiatric disorder1

• Dieting is a leading risk factor for developing an eating disorder2

• Amongst 12 to 17 year olds, 90% of females and 68% of males have been on a diet of some kind3

• Adolescents with diabetes may be up to 4x more likely to develop an eating disorder1

What we know?


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• ~90% children/adolescents expected to be well in 1-3 years

• Outcome is significantly better with short duration of illness (<3 years)

• Up to 60% children will have another comorbid mental health issue

• Although 70% of patients regain weight within 6 months of onset of treatment, 15-25% of these relapse, usually within 2 years4

What we know?

Diagnostic Criteria


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Risk factors• Low self-esteem, perfectionism, obsessive

personality

• Family environment (emphasise on weight and physical appearance)

• Sport (ballet, boxing)

• Career e.g. modelling

• Family history (genetic factor)

• Traumatic childhood experiences

• Western culture “thin ideal”http://www.eatingdisorders.org.au/key-research-a-statistics#63

Eating disorder behaviours


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The starvation experiment by Dr Ancel Keys (1944-1945)

• No scientific information on physiological effects of starvation existed

• 36 young men enlisted

• 1 year long study

http://www.madsciencemuseum.com/msm/pl/great_starvation_experiment

Control Period

• 12 weeks• 3200 calories per day• Active lifestyle + walking 35km per week

Starvation Period

• 6 months• 1570 calories per day• Two meals- carbohydrate rich and protein poor• Maintain activity

Re-feeding Period

• 12 weeks• Four subgroups (2800, 3200, 3600, 4000 calories)


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During starvation period:

• Physical changes

• Weight loss (average 17kg)

• Preoccupation with food

• Changes in mood

• Distorted/disturbed thoughts

• Changed table manners

• Obsessiveness

Why is re-feeding so important?


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PSYCHOLOGICALDepressionAnxietyLow self esteemMood swingsWithdrawing/social isolationDistorted body imagePre‐occupation or obsessive thoughts about food and weightJudging their self‐worth based largely or entirely on weight and appearance

Difficulty accepting eating disorder diagnosis and that their weight is too low

Self‐harm and feeling unsafe

Re-feeding for medical stability

Medical instability classified as:• HR <50 bpm• Temperature <35.5°c• BP <80/40 mmHg

• Rapid re-feeding follow policy• Need to add macronutrient (enteral/oral feeds),

micronutrient (multivitamin) and PO4 (500-1000mg sandoz phosphate)


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If patient unstable:STEP 1

Bloods taken

Commence continuous NG feeds (24 hours) 100ml/hr

- If PO4 < 1mmol and/or dehydrated, feeds to be 0.5kcal/ml

- If PO4 > 1mmol, feeds to be 1kcal/ml (23% Ensure)

500mg Sandoz Phosphate

Cardiac monitoring

Bed rest

STEP 2

(once HR >50 during the day)

Change to overnight feeds (10 hours) and commence 1500kcal meal plan (for adolescents)

500mg BD Sandoz Phosphate and multivitamin

Cardiac Monitoring overnight and q4h obs during day

Minimal mobilisation around ward

Daily bloods


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STEP 3

(once HR >50 for >2 nights)

Overnight feeds 5 hours (500ml)

2100kcal meal plan

Bloods twice weekly

STEP 4

(HR remains >50 for >2 nights)

Cease overnight feeds

2400kcal meal plan*

20mins off ward supervised per day

Bloods weekly

*Increase meal plan as required for continued weight gain

If patient medically stable:

• Commence ~2100-2400kcal meal plan (for adolescents)

• Commence ~1500kcal meal plan (for children)


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Energy requirements• Calculation of energy is difficult due to changing

BMR and abnormal behaviours

• Adolescents need 2500kcal-3000kcal or greater to gain 1kg/wk

• At CHW aim for 0.8kg-1kg weight gain per week

• Approximating HWR for children- aim for between the 25th-85th centile for BMI

• At CHW calculated using DEXA results aiming for 20% body fat

Dietary Requirements• Australian Dietary Guidelines

• Normalise food choices and eating behaviours

(Vegetarian at a minimum!)

• Encourage a wide variety of foods

• Challenge feared foods incrementally

• Increase meal plan as weight gain slows

• No low fat/diet foods


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Inpatient Management• Eating Disorder Patient menu (CBORD)

• 7 day rotating menu completed by parents- Why?

• Patients eat all meals and snacks together in the dining room once medically stable

• 30mins for main meals, 20mins for snacks

• Supervision by nursing staff

• Toppings and fruit prepared on ward

• “Level System”

Re-

feed

ing

and

wei

ght

rest

orat

ion


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Meal Plans

• 1500kcal up to 3000kcal (6 meal plans)

• Junior meal plans

• Additional oral/enteral nutrition support if needs >3000kcal/d


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Bolus Exchange• Using 1.5cal/ml


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What does 2700kcal look like?

Breakfast

Snack

Lunch

Snack

Dinner

Snack


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Other Dietary Guidelines

• Soy products not allowed unless diagnosed lactose intolerance

• All bread serves require a topping

• No swapping of food items

• Vegemite and oranges limited (x1 per day)

Educating Parents• 1 hour session

• Menu selection (inpatient)

• Education for diet at home including:

– Why re-feeding is important

– Physical and psychological effects of re-feeding

– What changes might their child experience

– Difference between re-feeding and normal eating

– How meal times will differ at home


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How is re-feeding different to normal eating?

• Food is medicine

• Three meals and three snacks everyday

• Parents have complete control over food. Not only how much but when, what and where the child eats

• Meal planning to ensure consistency and variety

• Child should not be involved in cooking or shopping

How will meal times differ at home?

• Meal time distraction

• Meal supervision

• Eating 30% more than normal

• Do not label foods

• Do not talk about weight, diets, calories, how food is prepared and nutrition information


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Example of a days mealsMeal Item Food

Breakfast

1st course Large serve of muesli with yoghurt

2nd course Piece of fruitNourishing drink Glass of milk

Morning TeaSubstantial snack Savory biscuits with cheese Other snack Piece of fruit

Lunch

1st course Large ham and cheese wrap with hummus/pesto/mayonnaise and salad

2nd course Muesli barNourishing drink Juice poppa

Afternoon Tea

Substantial snack MuffinOther snack Tub of yoghurt

Dinner

1st course Family meal e.g. chicken and vegetable stir fry served with rice.

2nd course Ice-cream with toppingNourishing drink Glass of juice

SupperSubstantial snack Glass of milo made on milkOther snack Sweet biscuits

Portion Sizes

No measuring or weighing food!


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This to that


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This to that

This to that


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• Dessert ideas

• Snack suggestions

• Eating out

Snack and meal suggestions

Weight• Inpatient:

Twice weekly weightsMonday + FridayGown and underwearPost void (specific gravity)

• OutpatientWeeklyRemove scales at homeWeight in clinic


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Further Information• CHW Eating Disorder Service Inpatient Program

• CEDD (Centre for Eating and Dietitian Disorders) http://cedd.org.au

• NICE Guidelines. Eating Disorders- Core interventions in the treatment and Management of Eating Disorders http://cedd.org.au/wordpress/wp-content/uploads/2014/09/Eating-Disorders-Core-Interventions-in-the-Treatment-and-Management-if-Eating-Disorders-NICE-Guidelines.pdf

• MH Kids Eating Disorders Toolkit- A Practice Based Guide to the inpatient Management of Adolescents with Eating Disorders http://cedd.org.au/wordpress/wp-content/uploads/2014/09/MH-Kids-Eating-Disorders-Toolkit-A-Practice-Based-Guide-to-the-Inpatient-Management-of-Adolescents-with-Eating-Disorders.pdf

• DAA Eating Disorder Interest Group

• SCHN Re-feeding Flowchart for Children and Adolescents who present medically unstable

QUESTIONS?


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References1. The National Eating Disorders Collaboration. (2012). Eating Disorders

in Australia. Retrieved from http://www.nedc.com.au/eating-disorders-in-australia

2. Kenardy, J., Brown, W.J. & Vogt, E. (2001). Dieting and health in young Australian women. European Eating Disorders Review, 9 (4), 242

3. Shisslak, C.M., & Crago, M. (2001). Risk and protective factors in the development of eating disorders. In J.K Thompson & L.Smolak (Eds), Body image, eating disorders, and obesity in youth: Assessment, prevention, and treatment (pp.103-125). Washington, D.C,: American Psychological Association.

4. Hillege, S, Beale, B & McMaster, R. (2006). Impact of eating disorders on family life: individual parents' stories. Journal of Clinical Nursing, 15 (8), 1016-22

Documents

“Let food be thy medicine and medicine be thy food” - NCHN · 2016. 5. 26. · Anorexia Nervosa (AN) 1-2% 90% Bulimia Nervosa (BN) 2-4% 85% Binge Eating Disorder (BED) ≥4% 65%