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Identify Eating Disorders_Final

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>> Hi, everyone. Welcome to the portion of the course that focuses on the intersection of eating disorders and emotional eating. My name is Monica Ostroff. I am a therapist, author, and consultant and I specialize in treating eating disorders for the past 25 years now. As an Integrative Nutrition Health Coach, you might have quite a few questions about eating disorders, how to recognize one, and what to do when you find someone struggling with one. The good news is that over the next three sessions, we're going to answer those questions for you. The reality is that 70 million people in the world suffer from eating disorders, and 30 million of those reside in the United States alone. So it's really likely that you're going to run into one of those individuals. Let's start with a few basics. I mean, almost everyone has heard of anorexia, bulimia, binge-eating disorder, and that's a really good start. But the problem is that most people have a pretty extreme view of what those things look like, and they might be completely unaware of the other lesser known but equally serious eating disorders. When I say anorexia nervosa, I'm betting most of you conjure up images of a skeletal young woman obstinately refusing to eat a meal or stubbornly insisting on eating only carrots while being at risk of dying. Or maybe when I say bulimia, you envision someone running into the grocery store buying boxes of donuts and cookies just to run home and binge and purge them. Or when I say binge-eating disorder, you might call to mind a really fat woman. I'm gonna pause just for a moment here for anyone that I just offended by using the word fat just to acknowledge that I've stopped using the terms obese, and overweight because I'm really a proponent of size acceptance and Health at Every Size movements, and they've rejected those terms as made up and irrelevant, and I have to agree. Getting back to the main issue, my point here is that there are stereotypes I get called to mind when people hear the three most well-known eating disorders. But here's the thing. You can't tell just by looking at someone if they have an eating disorder, not at all. In fact, far from it. For the most part, these stereotypes are a byproduct of how the medical and psychiatric community chose to categorize them. If you were to look at the DSM-IV, that's the Diagnostic and Statistical Manual of Mental Disorders or the Bible for how we diagnose mental illness. That edition listed anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified. Arguably, we used to look for extremes if you will. But we also recognized that people have problems that interfered with their functioning and quality of life that didn't neatly fit into the anorexia and bulimia buckets, if you will. So we had this kind of catch all bucket that we called, EDNOS or eating disorder not otherwise specified. Basically that meant, "Hey, this person has a really big problem but doesn't meet the specific criteria spelled out for anorexia or bulimia." Back then, for example, it could've been someone who pretty clearly had anorexia but was still menstruating since the cessation of menses was one of the criteria you had to meet in order to be diagnosed with anorexia. The problem is twofold. Medical insurance didn't really take EDNOS seriously even though some of the individuals were sicker and more at risk for death than some of those with bona fide anorexia or bulimia diagnoses. Also, it was still really exclusive, meaning there were still a lot of individuals who were really sick, who weren't getting access to care or even recognized as having a problem. I think, today, we can all agree that binge-eating disorders are a big problem. You know, people really struggle, they get very ill, and their quality of life really suffers. But did you know that binge-eating disorder wasn't even officially recognized until 2014? The eating disorder professional community has long recognized that we need to be more inclusive in order to ensure access to care for as many people as possible. And we had to find a way to legitimize it so that insurance companies would stop dismissing very serious disorders simply because we were calling them "not otherwise specified." Not only that, but we needed to legitimize it for people who were struggling. I mean, can you imagine being somebody that is restricting your food intake and you're starving and you're absolutely miserable, but somebody has labeled you with a disorder called "not otherwise specified." How serious does that sound to you? Are you gonna feel deserving of even seeking care? Most of them didn't. So when the DSM was updated to the fifth edition, we went from what you just saw to this. On the one hand, it was absolutely awesome because we went from three diagnoses to eight, so a lot more people can get screened in for treatment and a lot more people could feel like their disorders were important enough to get treatment. On the other hand, it was pretty confusing to suddenly wonder how in the world we're categorizing those behaviors. So we went from dumping them all into the EDNOS category to having to sort them into five more buckets. And for example, one of the new diagnostic categories is this thing called avoidant/restrictive food intake disorder. It was meant to capture kids who were previously in the failure to thrive category, but it also had to capture teens and adults who were not eating enough to sustain a healthy bodyweight and who also had some medical complications as a result, but they didn't really have the body image issues so frequently associated with eating disorders. We call it ARFID for short. And I have definitely had people ask me what an ARFID was and if it's related to the aardvark family. That's actually a true story. So, you know, it's fantastic that we have these diagnoses that are more inclusive, it's really created a learning curve for a lot of people. What does this mean for you as an up and coming Health Coach? Well, the good news is that you don't have to know what each and every one of these diagnoses are in explicit detail, and you don't have to treat them. It just means that you need to know that eating disorders come in all shapes and sizes. They're found in all socioeconomic brackets, in all age groups, and across all walks of life. Eating disorders don't discriminate and you can't tell just by looking at someone if they have one. So how can you tell if someone has an eating disorder? Well, first and foremost, it's important to look at your own biases. If you're a fat phobic or have highly rigid eating behaviors, it will be quite difficult to really get a good feeling for whether or not someone else is struggling with an eating disorder. For example, if you're fat phobic, the likelihood of you seeing a "too thin" body as potentially problematic is low making it more likely that you could miss a serious and potentially life threatening problem. If you have highly rigid rules around what you will and won't eat, that will also make it likely that you will see someone else's rigid and potentially eating disorder rules as normal. So be clear within yourself what your perspectives are. And once you've done that, get in touch with your intuition. Your intuition is typically a really good guide. If something doesn't feel right, it probably isn't. For more concrete yet sample guidance, the Journal of General Internal Medicine published an article titled, four simple questions that can help screen for eating disorders that describes a review of various eating disorder screening tools. They found four questions that were highly reliable in screening for an eating disorder. They were, "Do you worry that you have lost control over how much you eat? Do you make yourself sick when you feel uncomfortably full? Do you currently suffer with, or have you ever suffered in the past, with an eating disorder? Do you ever eat in secret?" If any of these questions are answered as yes, the individual should be referred to a specialist for a more thorough assessment. They also found the two best individual questions for ruling out an eating disorder were, "Does your weight affect the way you feel about yourself?" If the answer is no, it's unlikely that they have an eating disorder. "Are you satisfied with your eating patterns?" Theoretically, if the answer is yes, it is unlikely that they have an eating disorder. However, somebody who has an eating disorder and is ambivalent about recovery may actually answer that question as yes. So really, the first four questions are gonna be a more reliable guide for you than the last two that I just mentioned. There are a large number of behaviors and thought patterns that go into having an eating disorder, and we can't possibly cover them all here today. But we can look at some categories that can signal trouble. So some physical signs and symptoms to keep in mind that might signal trouble and suggest the need for a more thorough assessment are things like persistent sore throats that aren't associated with a virus, gastroesophageal reflux disorder or infection. Chronic stomach pain with no medical basis, for example, when doctors can't identify a reason. I've done numerous assessments, often of adolescents, who have complained vociferously about stomach pain that made it impossible for them to eat lunch at school or have dinner with their families. They were losing weight, their concerned parents took them to GI doctors, they underwent a wide variety of tests from endoscopies to upper GI series to swallow studies and even more, and all of those tests came back within normal limits. When the GI specialist had no medical explanation, they sent them for an eating disorder assessment which revealed that they were consciously using extreme measures to restrict calories in an attempt to lose weight, and no weight was low enough. Their sense of self-worth was highly tied to what they ate and weighed. You can also look for things like red marks on the back of their knuckles which can be a sign that someone has been purging. Persistent bloodshot eyes or veins bursting in their eyes from purging, swollen parotid glands, which are just down here underneath and behind the jaw which can signal purging. Chronic constipation, if nothing's going in, nothing can come out. Chronic diarrhea, which can be from laxative abuse. If you see these things especially in combination, it's wise to simply ask your client to be assessed by a therapist who specializes in eating disorders before you can continue working with them. There are also a few telltale habits, eating habits, that can indicate an eating disorder. Eating in secret is extremely common in eating disorders. Many people feel ashamed of their bodies when consuming food and will avoid eating with others. Another one is mixing food in strange combinations or having specific food rituals that they have to engage in in order to eat. For example, one person might have to cut a sandwich up and eat it with a knife and fork, another may float pretzels in coffee, and yet another may put mustard or vinegar on absolutely everything. This is especially common in anorexia nervosa. Hoarding food is also very common. There are also some psychological components that can tip you off that an eating disorder is brewing. Most people with eating disorders have, what we refer to in the field as, low distress tolerance, and that basically means they can't stand having any kind of heightened emotion. If they're sad, angry, or frustrated, they'll typically act out by using an eating disorder behavior of say restricting, bingeing, or purging. The biochemical changes that happen in the body change how the individual experiences their emotions and brings them a sense of relief or at least a sense of distraction. All that time, thinking about what to eat, not to eat, how much to work out to work it off, how to convince others that they've eaten when they really haven't, coupled with all the mental gymnastics and complex mathematical equations of calories in and out, metabolic rates, an average of 15 weigh-ins per day, that's all time spent not figuring out resolutions to real life problems that they face every day. Rigidity is extensive in eating disorders. What they'll eat, how much they exercise, and what their weight is, are three areas where rigidity is high. And what do I mean by that? Well, it's really common to have preferences, we all have them. But when you can never deviate from those preferences, what you have are rigid rules that control a person signaling an eating disorder, and that's not a preference. In eating disorders, you'll typically see features that look very obsessive compulsive. Generally speaking, normal healthy eaters can miss something out of their diets from time to time with no issue, maybe you forgot your calcium source or you didn't have any complex carbs with lunch or dinner. The next day, you'll generally have your calcium source or you'll have your complex carbs. For someone who has an eating disorder, once they take something out, it's really challenging to put it back in. Once milk or yogurt goes missing from breakfast, you are typically not gonna see that put back in without a whole lot of prodding on a provider's part. That's because once the yogurt or milk was left out, a new "rule" was formed. Similarly, if they're working out say 30 minutes 4 times a week, but one day they work out 45 minutes, now suddenly that's the new rule. The eating disordered voice in their head is not gonna let them stop following. Along the same lines, if they go from four to five days of exercising a week, they'll not be able to stop that either. The theme here is really a lack of control. On the outside, they may seem really disciplined, always working out for X amount of time, always eating exactly Y, but the salient point here is that they can't stop doing those things even though they may desperately want to. You can check on this aspect quite easily by asking them to vary what they're doing and see if they're able to do it. Can they not exercise for a week? Can they exercise for a lesser amount of time? Can they freely go back and forth? If the answer is no, you very likely have a bigger problem on your hands and you're gonna want to refer out. Beliefs that aren't founded in fact are common. Many believe that carbohydrates are gonna automatically translate into fat in their bodies. Others believe that as soon as they eat something, they'll immediately gain weight and they'll check their bodies extensively for proof of this. They tend to be highly susceptible to and triggered by pop culture media that perpetuates misinformation around food and weight. People who don't have an eating disorder can be fairly educated and can change their beliefs and behavior to accommodate new information in reality whereas those struggling with eating disorders have a much harder time readjusting and will often hang onto and act on misinformation, "just in case," it's correct after all. Genetics will also lend some insight, you know, thanks to researcher Dr Cynthia Bullock at the University of North Carolina, Chapel Hill, we know with absolute certainty that eating disorders have a genetic component. If your client mentions that they have a family member who has or had an eating disorder, it's likely in their genes too. If you see some of the multiple factors that we just talked about, you know, the likelihood of an eating disorder developing if not already in motion, is pretty high. And the need for an assessment is non-negotiable. A great metaphor for eating disorders is that genetics load the gun, the environment pulls the trigger or activates it, while the American public stands around screaming "shoot, shoot" which is a testament to the fact that our society is hostile to eating disorder recovery. Just think about all the ads you're subjected to every day that are designed to make you feel insecure about your body so you'll buy their product. Just think about how enormous the diet industry is. These are things that create an environment that's hostile to eating disorder recovery. Now as an Integrative Nutrition Health Coach, what can you do if you suspect a client has an eating disorder? Can you continue to work with that person? The first thing you're always gonna want to do is send them to a licensed therapist for an assessment and have a list of experienced eating disorder professionals in their area ready to give to them. Let them know that you're really interested in working with them, but you have some concerns and you want to make sure they're okay. So it's important for them to have this assessment before you begin formally working together. Let's suppose the assessment comes back with a diagnosis of an eating disorder. That doesn't necessarily preclude you from working with the client. What it means is that you're going to be one piece of their treatment team, and this entails having regular weekly contact with their therapist and their dietitian and possibly their physician in order to ensure that you're on the same page providing consistent similar information to the client. You all share the same goal for your client, which is to have the best outcome. The therapist, doctor, and dietitian will not be successful telling the patient to restore body weight if the coach is telling the client that their body weight seems okay. You'll want to have a conversation with the therapist, dietitian, and doctor to agree on what your role is going to be. Your primary job is going to be assisting your client in normalizing his or her eating patterns, supporting the determination of the dietitian, and encouraging your client to make healthy choices, embracing moderation of all foods. The key is really communication with the team. Make sure it's regular and open with both your client and their team. In summary, diagnoses have really changed over time and they continue to change. As an Integrative Nutrition Health Coach, all you need to know is that eating disorders come in all shapes and sizes and are found in all socioeconomic brackets. They are in all age groups and across all walks of life. Eating disorders don't discriminate. You can't tell just by looking at someone. It's important to look at your own biases and perspectives and really get in touch with your intuition. Being familiar with common eating habits and psychological components can also help. And we've included some on this module's handout. Finally, remember your scope of practice. Refer out if you need to and coach as you would any other client but as part of a treatment team. I'll see you again soon.

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Posted by: integrativenutrition on Aug 30, 2018

Identify Eating Disorders_Final

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