Reprinted from Eating Disorders Review
May/June Volume 27, Number 3
At the 2016 iaedp Symposium, “The Complexity of Best Practices: Evolving and Changing,” held at Amelia Island, FL, in mid-February, three sessions addressed challenging topics: choosing websites that offer valid information about eating disorders, the ramification of weight stigma, and improving treatment outcome for young patients through a more complete understanding of neurobiology.
How Valid Is That Eating Disorders/Health Website?
On the Information Superhighway, there are many exits you hope your patients won’t take. Misinformation about supplements, “miracle diets,” and pro-anorexia (pro-ana) websites are just a few of the wrong turns that lead to invalid and sometimes harmful information. Families also report great frustration when they try to obtain clear-cut results from studies reported from individual eating disorder treatment programs. Few websites report data-based outcomes, and the information offered may not be derived from rigorous research.
Millie Plotkin, MLS, with Craig Johnson, PhD and Carrie Arnold, MPH, from the Eating Recovery Center, Denver, offer some helpful hints for sorting out useful from useless information on the Internet. Plotkin said one positive note is that professionals and consumers alike report seeking information from the websites of professional eating disorders organizations such as BEDA, iaedp, and NEDA. One less positive trend, however, was reflected in a survey showing that more than half (57.58%) of professionals regularly use social media for health information, compared with 76.58% of consumers.
Another factor complicating the process of finding valid information on the Internet is the marked increase in the number of scientific research articles being posted. Plotkin added that results from many studies also seem to contradict one another.
Six guidelines for grading validity
Plotkin offered six guidelines for evaluating the validity of a study. “When you see a study, she said, “first, look at the type of research. Was this a pilot study, a longitudinal study, a case-control study, a case report, or a review?” Next, she advised looking at the size of the study sample, as well as the use of randomization, the statistical analysis, where the study was published and, very importantly, who funded the research.
Judging news stories
Patients can be advised that “not all news stories are created equal,” according to Plotkin, and professionals can advise them to look for certain details within any news story. Some details include: where was the story published, what are the writer’s credentials, who specifically was interviewed, and who was quoted? That is, did the writer talk to people who weren’t involved in the study to get an unbiased opinion about the results? Last, is this a true news story or merely a press release?
Evaluating eating disorders websites
Many of the same details apply when evaluating the validity of information presented on eating disorders websites, Plotkin noted. First, who publishes the website? Check to see when the information was last updated—once placed online, materials can remain for a long time, even if the information becomes outdated. Another good question to ask is, was the information on the website reviewed by professionals? And, is the website trying to sell you something? Finally, does the site give references for the information? Plotkin showed the results of a study by Smith et al. (Adolesc Psychiatr Nurs. 2011. 24:33) showing the percentage of websites that fully describe and include DSM-IV criteria. The highest percentage was 15.8% for bulimia. Criteria for the diagnosis of anorexia nervosa were given on only 13% of websites. In the same study, while 92% of the sites provided options for treating patients with AN/BN, only 36% outlined treatment options for patients with eating disorders not otherwise specified (EDNOS).
An online tool that may be helpful for clients
The DISCERN Instrument (www.discern.prg.uk) is designed to judge the quality of written consumer health information on treatment choices (J Epidemiol Community Health. 1999. 53:105).
Some of the questions DISCERN evaluates as to treatment choices on a website include:
- Does the information describe how each treatment works?
- Does it describe the benefits of each treatment?
- Does it describe the risks of each treatment?
- Does it outline what would happen if no treatment is used?
- Does it describe how the treatment choices affect quality of life?
- Is it clear there may be more than one possible choice for treatment?
Readers are then asked to rate the overall quality of the publication, on a scale of 1 to 5, as a source of information about treatment choices based on the answers to these questions.
One last suggestion from Plotkin was to consider the methods used in the study, including patient satisfaction, treatment effectiveness, and benchmarks of the study.
The Heavy Toll of Weight Stigma
In their workshop, “A Heavy Price: The Effect of Subtle Weight Stigma on our ED Field, Our ED Clients, and Ourselves AND What To Do About It,” Jamie Atkins, RD, and Jen Henretty, PhD, CEDS, of the Center for Discovery, Rancho Palos Verdes, CA, highlighted the prevalence of weight stigma in our society, and how it is found in children’s programs, in advertising, and within families. Weight stigma is twice as common among women as among men, they noted.
They urged eating disorders professionals themselves to become more aware of how weight stigma and weight biases can quietly creep into eating disorders treatment via nonverbal biases. Professionals need to be mindful of unconscious attitudes, where subtle but damaging messages perpetuate stigma about weight. A questionnaire available to workshop attendees demonstrated this very clearly. Even a seemingly kind and innocent message, such as “Oh, you’ve lost weight and look wonderful,” can be stigmatizing. Wasn’t the individual also wonderful when she was at a higher weight? Part of the therapist’s challenge is to help clients identify their own stigmas and to become more aware of nonverbal clues.
Atkins and Henretty said that using “health at every size” principles (J Am Diet Assoc. 2005.105:929), which supports homeostatic regulation and eating intuitively (i.e., in response to internal cues of hunger, satiety, and appetite), can also be helpful. These guidelines help people develop compassionate self-care, which means eating in a flexible, aware manner that values pleasure and honors hunger, satiety, and appetite and finding joy in moving one’s body and being physically active. Next, critical awareness helps the patient challenge scientific and cultural assumptions and values body knowledge and life experiences.
Dieting and intuitive eating
As the speakers pointed out, in 2012, Tribole and Resch developed guidelines for intuitive eating, rather than dieting (Intuitive Eating: A Revolutionary Program That Works. New York: St. Martin’s Press, 2012). As opposed to dieting, intuitive eating encourages the dieter to shift from relying on physiological causes, such as hunger and fullness, to using cognitive control over eating behaviors. It may be helpful to talk with the patient and discuss reasons for eating, such as responding to hunger, emotional distress, and boredom while in social settings, the workshop leaders said. ED professionals can help clients identify their internalized weight stigma and help create a safe milieu within treatment groups of all body sizes.
There are many ways to help clients become involved in body-positive and anti-weight stigma advocacy, for example, referring them to the BEDA website, participation in Weight Stigma Awareness Week or the Obesity Action Coalition (http://www.obesityaction.org/2016). Clients can also be encouraged to become savvy consumers who watch for hidden weight stigma messages in ads, movies, and other media.
Understanding Brain Development Across The Life Cycle To Improve Treatment For Young Patients
Better understanding of neuro-development and the concept of brain development across the life cycle can help clinicians improve treatment of teens and young adults, according to Dr. Scott E. Moseman, Medical Director, and Leah Graves, RDN, Nutrition Therapy Manager, at the Laureate Eating Disorders Program, Tulsa, OK.
Dr. Moseman told symposium attendees that dividing eating disorders into traits and states can be helpful for understanding the development and maintenance of eating disorders among young patients. Underlying traits are genetically determined and affected by hormonal, developmental, and environmental pressures that eventually lead to illness. The illness is then sustained by intrinsic and environmental states.
Traits leading to risk
Temperament and personality traits that lead to anorexia are well known, including anxiety, negative emotionality and low self-esteem, along with low reactivity to reward, and harm avoidance. Some of the same traits, including negative emotionality and low self-esteem, can put an individual at risk of developing bulimia. The internal and external influences that promote risk include normal changes at puberty (estrogen changes that affect serotonin, corticotropin-releasing hormone [CRH], cortisol, and developmental changes in the frontal and limbic circuits), and body weight increase and distribution (due to leptin and ghrelin changes). Dr. Moseman added that during puberty, psychological and environmental influences activate, including “trauma and stress during sensitive periods to a sensitive brain.” Other elements include separation and individualization in a high-stress environment, coupled with a fat-phobic culture that holds up thinness as an ideal measure of success and that perpetuates high activity and low caloric intake.
Dr. Moseman said that several physiologic realities prevent anorexic patients from stopping their harmful behaviors. The anorexic patient’s brain, now malnourished, is state-dependent to continue the illness. Along with this is a regression to prepubertal gonadal function and excess limbic serotonin. One more element is that starvation causes increased excretion of CRH, leading to dysphoria, hyperactivity, and decreased feeding.
Serotonin’s role in perpetuating anorexia has become clearer, too, he noted. With dieting, serotonin decreases, improving mood. Then, weight loss decreases CRH, worsening mood, which leads to dieting, and improved mood. For bulimic patients, there is a disconnect between ideal body image and urges to eat. Bulimics get positive reinforcement from stopping harmful behaviors, and this reduces dysphoria. However, the neurobiological model of intermittent excessive behavior may then come into play; this is behavior common to binge eating, drug abuse, alcoholism, and excessive gambling. Dopamine-related systems also power excessive eating.
Age and drug effectiveness
A patient’s age has much to do with the effectiveness of pharmacotherapy, according to Dr. Moseman. For example, he explained that most psychotropic agents act through neurotransmitters such as dopamine, serotonin, and norepinephrine, and their receptors undergo major changes during normal physical development. Receptor density peaks in the preschool years and then gradually declines toward adult levels in the late teens. In the few studies that have been done, results have shown that stimulants are less likely to induce euphoria in children than in adults, while antipsychotics are more likely to produce metabolic effects in younger patients than in adults. Thus, the younger the patient, the lower the tolerance to stimulants. Perhaps the most controversial example is the use of SSRIs and risk of suicide, he said.
Dietitian Leah Graves told attendees that nutritional intervention is essential for healing and for helping patients get back on track with normal growth and development. Puberty brings significant increases in height, weight, bone mass, body composition, and sexual maturation, making nutritional needs greater at this time than at any other stage of development–other than the first year of life. For females, a linear growth spurt occurs prior to menarche and 15% to 25% of final adult height is often reached by menarche. Growth spurt begins later in males, who often gain 2 to 5 inches in height per year. Half of adult weight is gained during puberty, and 50% of bone mass and peak bone mass are reached during adolescence. By the age of 18 most teens have accumulated 90% of their bone mass.
Graves told the audience that when an eating disorder occurs, food-related behaviors disrupt the availability of the essential energy, vitamins, and minerals needed for normal growth and development. Energy needs are high during these years; for males this can mean 3000 to 4000 kcal per day or more, and for females 2400 to 3000 or more per day. Patients need energy for healing in addition to the energy needed for normal growth and development. Those with restricting-type anorexia nervosa (AN-R) require more energy intake than do all other subgroup, while AN patients who have been obese require less energy in order to gain weight.
Some strategies to improve nutrition
According to Graves, two keys to improving nutrition among these patients are: (1) involving parents or caregivers in meals and (2)establishing a structured and consistent eating pattern for patients. Early weight gain is essential, and clinicians may find that their patients benefit from having fewer food choices at first. More recent studies have also suggested that younger patients tolerate a higher caloric load with larger incremental advances, such as 1500 to 1800 kcal/day, with subsequent daily increases of 120 to 200 kcal. Increased use of energy-dense foods may also improve outcome.
Later, patients can benefit from a variety of selections, including added fats, starchy carbohydrates, and caloric beverages. Graves described a newer approach to help patients deal with eating-related fears during weight restoration. Exposure and Response Prevention for AN (AN-EXRP) uses a technique first presented by Dr. Joanna Steinglass of Columbia University. This approach specifically addresses maladaptive eating behavior by targeting eating-related fears and anxiety during weight restoration (Int J Eat Disord. 2014. 47:174).
Graves advised addressing patients’ eating-related fears, and emphasized that weight restoration should be personalized, starting with the least-fear-producing foods and graduating to those that produce the most fear. When setting goal weights, it is also good to remember that a weight range is a moving target, she said, and should start where growth would be without the interference of the eating disorder. In this light it is helpful to determine an individual’s pattern of growth prior to the onset of his or her eating disorder. Weight expectations increase each year, to keep up with projected growth and development. This pattern is easier to explain to the patient with weight tables from the Centers for Disease Control and Prevention, Graves said.