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Understanding eating disorders in adolescence

Intervention and treatment

Principles of treatment

  • Regular doctor’s appointments
  • Parents should take control of the child’s nutrition and keep the child safe from the eating disorder (e.g. prevent symptoms)
  • Caregivers should supervise all nutrition and provide empathic support at meals
  • Limit activity as necessary; focus of treatment must be on weight gain and symptom interruption
  • Psychoeducation for parents: recommended website is Canped.ca

Treatment

Nutrition:

  • Most important - only treatment that can reverse all of the medical and psychological complications that arise as a result of inadequate intake
  • Recovery requires weight restoration; cannot be achieved without normalized nutrition.
  • Food variety should be encouraged, including high density foods and desserts (“No bad foods”)
  • Adolescent’s nutritional needs are higher than adults’
    • Recovering adolescents need to eat more than their parents.
  • Adolescents should target plans that include three meals and two to three snacks per day plus any additional snacks following activity/exercise.
  • Patients are in a hypermetabolic state when the refeeding starts, so low weight patients often need in excess of 3,000 kcal per day, depending on baseline factors and level of activity
  • How many calories do patients need in a day?
  • Although 2100 – 2400 calories is normal for most teenage girls to maintain weight, it takes more nutrition that this to gain weight, or if they are active, and boys need more than girls
  • For underweight patients, give enough food for them to gain weight and get to their treatment goal weight
  • For patients who don’t need to gain weight, give them enough food to maintain their weight

Activity:

  • For underweight patients, during the weight restoration phase, physical activity should be kept to a minimum
  • If patients and families insist on the value of exercise, explore options with them as there are no “hard and fast” rules about exercise as long as the patient gains weight (i.e. more activity means eating more food)
  • Patients may need to be removed from gym and/or school temporarily (for many anxious patients, they are too stressed at school to eat enough)
  • After weight has been restored, the goal is to promote a healthy approach to active living so that health benefits, and not health costs, can be derived.
  • The focus should not be exercise for weight control, but for fun and fitness (at a healthy weight).

Medication:

  • Pharmacotherapy is targeted at comorbid symptoms of depression and anxiety (which are very common in youth with EDs)
    • SSRIs are not effective in malnourished patients (< 88% of goal weight).
  • Olanzapine has been shown to be effective in improving weight gain and dysfunctional thinking in low weight patients with anorexia nervosa.
  • Olanzapine should be used with caution and at low doses (2.5 – 7.5 mg) due to the risk of side effects
  • Olanzapine should not be continued once the patient reaches full weight restoration.
  • Polyethylene glycol 3350 can be used to treat constipation
    • Avoid other laxative medications (which can be abused)
  • Supplemental estrogen, bisphosphonates, calcium and Vitamin D replacement have not been shown to be effective in improving bone mass density. They are not a substitute for nutritional recovery - not recommended.

Team up with parents to support a young person with an eating disorder 

  1. Help the parents understand the illness and empathize with the child
  2. Compare the illness to obsessive-compulsive disorder, in which the child has obsessive thoughts telling them that they are “fat” and “eating too much” and feel compelled to have symptoms directed at weight loss
  3. Recognize that the illness is controlling the child, the child is compelled to lose weight
  4. Blame the illness, not the patient or the family
  5. Help the parents prevent opportunity for symptoms
  6. Provide family therapy focused on making recovery from the eating disorder a priority in the family
  7. Recommend that the family have regular, supervised meals
  8. Help the patient cope with the eating disorder thoughts and urges, anger, stress and body image issues
  9. Treat and offer resources for the depression or anxiety if needed

For patients with AN and underweight youth with any kind of eating disorder:

  • Treatment involves raising anxiety in the family and helping parents to understand that their child will die unless they can overcome their compulsion to lose weight.
  • Help the family to understand that the illness actually is driven by the brain not getting enough nutrition, the only way out is to eat
  • The patient must get to their healthy weight and stay there for a few months for the eating disorder thoughts and urges to go away

Recommended psychological therapy

  • Family-Based Therapy
    • Parents are empowered to take charge of their child’s nutrition and to be responsible for their weight gain, within a compassionate, non-blaming and supportive environment
    • Refer patients to the parent educational website, Canped.ca, for more information on this

For patients with AN and underweight youth with any kind of eating disorder:

Medications for AN

  • Insufficient evidence for the use of medication (on its own) in the treatment of Anorexia Nervosa in children or youth
  • The essentials of treatment are nutrition/weight gain and FBT
  • Medication (i.e. olanzapine) may be used if there is extreme agitation and resistance in a severely ill child
  • Once nutrition and weight have been established, SSRIs such as fluoxetine may be helpful to treat anxiety and/or depression
  • Olanzapine is an antipsychotic medication with calming properties, that helps decrease anxiety that has shown some benefit in specific studies in adults with Anorexia Nervosa

For patients with BN, or normal weight youth with any kind of disordered eating:

  • Help youth take regular snacks and meals and not restrict, purge or over-exercise
  • Try to identify specific triggers that make the eating disorder thoughts/urges worse
  • Suggest that parents have supportive conversations with the child about expectations around meals and how distractions will be planned for support in a calm and loving manner
    • Parents should have conversations outside of meal times, and during periods of low stress
    • Structure is key: regular consistent supervised meals and snacks every day
  • Help parents deflect the youth’s anger, without getting angry back
  • Present yourself as being on their team and wanting to offer support, not as trying to control them

CONSIDER psychological therapy

  • Individual or group Cognitive-Behavior Therapy (CBT)
    • Help the child separate from, and challenge the ED thoughts
  • Dialectical Behavior Therapy (DBT)
    • Focused on helping the child to cope with urges without acting on them

Medication for BN

  • Studies have shown that SSRIs such as higher dose fluoxetine decrease urges to binge and purge
  • SSRIs may also be offered to help in targeting anxiety and/or depression symptoms
  • Medications to help with sleep (melatonin, trazodone) may also be considered
  • Team up with parents to support a young person with an ED

Empower and encourage parents to:

  • Make weight gain a priority
  • Help their child eat food that they don’t want to eat and are terrified of eating
  • Monitor and distract them after meals, when they feel very agitated with strong urges to purge or exercise
  • Increase child’s self-esteem and help them to feel better about themselves
  • Regularly have supervised meals
  • Stay positive and remain strong against the eating disorder
  • Help patient maintain healthy weight until thoughts and urges fade away
  • Be both firm and empathetic
  • Decrease child’s stress
  • Work on coping skills

Resources on how to do this can be found at Canped.ca

Family Based Therapy (FBT)

Family based therapy (FBT) is an effective evidence based treatment for adolescents with anorexia nervosa and is considered first line treatment when medically stable.

There are three phases:

  1. Weight restoration
  2. Returning control of eating back to the patient
  3. Focus on adolescent development & treatment termination
  • The patient is treated in the outpatient setting by an interdisciplinary team.
  • Blame is removed from the families, since families do not cause eating disorders.
  • Parents/caregivers are empowered to refeed their child back to health.
  • The eating disorder is externalized from the child to release blame directed at them.

The role of the primary care clinician:

  • Function as a consultant to the parents and therapist
  • Monitor for medical stability or weight gain
  • Offer feedback to patients and family
  • Assess for and treat any co-morbid anxiety, depression or other mental illnesses, or refer to a psychiatrist for treatment of co-morbidities

FBT

  • Follow up medical visits should be frequent and regular, once a week at the beginning and depending on the severity of the illness.
  • The patient should be seen individually then with the parents present.
  • The goal is to see consistent weight gains of 0.5-1kg weekly and should be discussed with the parents/caregiver and patient.

Mealtime:

  • Guidance should be provided to the parents how the weight gain can be achieved
    • E.g. 3 meals per day with 2 snacks, reduction in physical activity, temporarily removed from school, etc.
  • Most parents have a good sense of how much to feed their child but a dietitian can get involved
  • All nutrition eaten by the patient must be observed by the parents/caregivers.
    • If it is not observed, it is considered not to have happened.
    • Distractions are very helpful support at mealtimes and afterwards, to help distract from the intolerable eating disorder thoughts

Lifestyle Adjustments:

  • May require a leave of absence or reduced work hours for the parents to facilitate this at the beginning. Physicians can provide letters of support for the parents or school.
  • Patients may also need special accommodations at school, or time away from school
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