The  Inner  Demon:    An  Unspoken  Truth  

ISNA  Conference  Eating  Disorder  Presentation  March    2015  Gabrielle  K.  Tuscher,  MS,  RDN  

 ©Tüscher  Nutrition    

What  is  an  Eating  Disorder?  

•  Four  eating  disorders  that  are  recognised  by  the  (DSM).  

•  Deadly  mental  illness.  

•  Highest  mortality  rate.  

•  NOT  a  choice  or  a  diet  gone  ‘too  far.’    

Dual  Diagnosis  or  Co-­‐Morbidity  

•  The  presence  of  one  or  more  diseases  or  disorders  in  one  individual.  

•  A  person  with  an  eating  disorder  will  often  be  diagnosed  with  another  mental  health  problem.  

•  Eating  disorders  are  most  commonly  accompanied  by  depression  and  anxiety  disorders;  however,  substance  abuse  and  personality  disorders  are  also  prevalent.  

•  Approx  60%  of  people  with  an  eating  disorder  will  also  meet  diagnosis  for  one  of  these  other  psychological  disorders.  

Signs  &  Symptoms  

•  Due  to  the  nature  of  EDs  many  characteristics  &  behaviours  may  be  concealed.    

•  A  person  with  an  ED  will  go  to  great  lengths  to  hide,  disguise  or  deny  behaviours,  or  don’t  recognise  that  there  is  anything  wrong.  

•  Disturbed  eating  behaviours  coupled  with  extreme  concerns  about  weight,  shape,  eating  and  body  image.  

E.D.D.D  

!  Eating  Disorders  Don’t  Discriminate.  

!  No  longer  the  “white  rich  girl”  disease.  

!  ALL  genders.  

!  Both  adolescents  and  adults.  

!  ALL  cultural  backgrounds.  

!  ALL  financial  backgrounds.  

EDs  in  Asia  !  In  the  past  five  years,  the  “self-­‐starvation”  syndrome  has  

spread  to  all  socioeconomic  and  ethnic  backgrounds  across  Asia.  

!  Now  estimated  to  afflict  one  in  100  young  Japanese  women,  almost  the  same  incidence  as  in  the  United  States.    

!  Debate  as  to  causes:    !  Western  pathologies  that  have  “infected”  their  cultures  via  

globalized  fashion,  music  and  entertainment  media,  or  are  an  ailment  of  affluence,  modernization  and  the  conflicting  demands  placed  on  individuals.  

EDs  in  Asia  !  Thin  is  in,  fat  is  out!  

!  Weight  plays  an  important  role  in  whether  someone  can  find  employment  and  how  good  a  job  he  or  she  can  get.  

!  The  Attitude  is:  “The  better  you  look,  the  more  opportunity  you  have”.  

!  Dangerously  unhealthy  practices  used  as  ways  of  “dieting”  or  as  “weight  loss”  tools  where    mothers  restrict  children’s  intakes  to  as  low  as  500  calories  a  day  or  teach  them  to    purge    their  food  to  stay  skinny.  

DSM-­‐5  Diagnostic  Criteria  ! Anorexia  Nervosa.  

! Bulimia  Nervosa.  

! Binge  Eating  Disorder.  

! Othorexia.  

! Other  Specified  Feeding  or  Eating  Disorder  (OSFED).  

DSM-­‐5  Anorexia  Nervosa  

1.  Restriction  of  energy  intake  leading  to  a  significantly  low  body  weight  (in  context  of  age,  sex,  developmental  trajectory,  and  physical  health).  

2.  Intense  fear  of  gaining  weight  or  becoming  fat,  even  though  underweight.  

3.  Disturbance  in  the  way  in  which  one's  body  weight  or  shape  is  experienced,  undue  influence  of  body  weight  or  shape  on  self-­‐evaluation,  or  denial  of  the  seriousness  of  the  current  low  body  weight.  

• Significant  weight  loss;  Distorted  body  image  

• Intense  fear/anxiety  about  gaining  weight  

• Preoccupation  with  weight,  calories,  food  

• Feelings  of  guilt  after  eating;  Excuses  for  not  eating  

• Denial  of  low  weight  &  hunger  

• High  levels  of  anxiety  and/or  depression;  Low  self-­‐esteem    

• Self-­‐injury  

• Withdrawal  from  friends  and  activities  

• Food  rituals  Intense,  dramatic  mood  swings  

Potential    Warning  Signs  

!  Amenorrhea  

!  Bradycardia  

!  Hypotension  

!  Anaemia  

!  Hypothermia/  Poor  circulation  (esp  in  hands  and  feet)  

!  Muscle  loss  and  weakness  (including  the  heart)  

!  Dehydration/kidney  failure;  Edema  

!  Memory  loss/disorientation  

!  Chronic  constipation  

!  Growth  of  lanugo  hair  

!  Bone  density  loss/Osteoporosis  Health  Implications  

DSM-­‐5  Bulimia  Nervosa  !  Recurrent  episodes  of  binge  eating  characterized  by  BOTH  of  

the  following:  !  Eating  large  amounts  of  food  in  a  discrete  amount  of  time  (within  a  

2  hour  period).  Lack  of  control  over  eating  during  an  episode.  

!  Recurrent  inappropriate  compensatory  behaviours  in  order  to  prevent  weight  gain  (purging).  

!  The  binge  eating  and  compensatory  behaviors  both  occur,  on  average,  at  least  once  a  week  for  three  months.  

!  Self-­‐evaluation  is  unduly  influenced  by  body  shape  and  weight.  

!  The  disturbance  does  not  occur  exclusively  during  episodes  of  anorexia  nervosa.  

•           Preoccupation  with  food;  Secretive  eating  and/or  missing  food  

•  Visits  to  the  bathroom  after  meals  

•  Excessive  weight  fluctuations  

•  Self-­‐injury  

•  Excessive  and  compulsive  exercise  regimes  —  despite  fatigue,  illness,  or  injury  

•  Abuse  of  laxatives,  diet  pills,  and/or  diuretics  

•  Swollen  parotid  glands  in  cheeks  and  neck  

•  Broken  blood  vessels  in  eyes  and/or  face  

•  Calluses  on  the  back  of  the  hands/knuckles  from  self-­‐induced  vomiting  

•  Heartburn/reflux  

•  Feelings  of  shame  and  guilt;  Self-­‐criticism  and  low  self-­‐esteem  

•  High  levels  of  anxiety  and/or  depression  

Potential    Warning  Signs  

!  Electrolyte  imbalances  that  can  lead  to  irregular  heartbeat  and  seizures  

!  Edema/swelling  

!  Dehydration  

!  Vitamin  and  mineral  deficiencies  

!  Gastrointestinal  problems  

!  Chronic  irregular  bowel  movements  and  constipation  

!  Inflammation  and  possible  rupture  of  the  esophagus  

!  Tears  in  the  lining  of  the  stomach  

!  Chronic  kidney  problems/failure  

!  Discoloration  and/or  staining  of  the  teeth;  Tooth  decay  

Health  Implications  

DSM-­‐5  Binge  Eating  Disorder  

!  Recurrent  episodes  of  binge  eating,  characterized  by  both  of  the  following:  !  Eating,  in  a  discrete  period  of  time  (i.e.  within  a  2-­‐hour  period),  an  

amount  of  food  excessive  to  what  most  would  consume  in  a  similar  period  of  time.  

!  A  sense  of  lack  of  control  over  eating  during  the  episode  (i.e.  a  feelings  of  inability  to  stop  eating  or  control  what  or  how  much  one  is  eating).  

!  Binge-­‐eating  episodes  are  associated  with  3  (or  more)  of  the  following:  !  Eating  much  more  rapidly  than  normal.  

!  Eating  until  uncomfortably  full.  

!  Eating  large  amounts  of  food  when  not  feeling  physically  hungry.    !  Eating  alone  due  to  feeling  embarrassed  by  how  much  one  is  eating.  

!  Feeling  disgusted,  depressed,  out  of  control  or  very  guilty  afterwards.  

!  Eating  large  quantities  of  food  (without  purging),  even  when  not  hungry  

!  Eating  until  uncomfortably/painfully  full  

!  Weight  gain/fluctuations  

!  Feelings  of  shame  and  guilt  

!  Self-­‐medicating  with  food  

!  Eating  alone/secretive  eating  

!  Hiding  food  

!  High  levels  of  anxiety  and/or  depression  

!  Low  self-­‐esteem  

Potential    Warning  Signs  

!  Overweight  or  obese  

!  Type  II  Diabetes  

!  Osteoarthritis  

!  Lipid  abnormalities  (hypercholesterolaemia)  

!  Hypertension  

!  Chronic  kidney  problems  

!  Gastrointestinal  problems  

!  Heart  disease  

!  Gallbladder  disease  

!  Joint  and  muscle  pain  

!  Sleep  apnea  

Health  Implications  

DSM-­‐5  Other  Specified  Feeding  or  Eating  Disorder  (OSFED)  

!  Disturbances  in  eating  behaviours  that  don’t  necessarily  fall  into  the  specific  category  of  anorexia,  bulimia,  or  binge  eating  disorder.    

!  Most  common  ED  diagnosis.  

!  Warning  signs  and  related  medical/psychological  conditions  of  OSFED  are  similar  to,  and  just  as  severe  as,  those  for  the  other  eating  disorders.  

•  Atypical  Anorexia  Nervosa:  All  criteria  of  AN  met,  except  despite  significant  weight  loss,    individual's  weight  is  within  or  above  the  normal  range.  

•  Bulimia  Nervosa  (of  low  frequency  and/or  limited  duration):  Occurs    less  than  once  a  week  and/or  for  less  than  3  months.  

•  Binge-­‐Eating  Disorder  (of  low  frequency  and/or  limited  duration):  Occurs,  on  average,  less  than  once  a  week  and/or  for  less  than  3  months.  

•  Purging  Disorder  (in  the  absence  of  binge  eating):  to  influence  weight  or  shape  (i.e.  self-­‐induced  vomiting,  laxatives,  diuretic  or  other  medication  abuse).  

•  Night  Eating  Syndrome:  Recurrent  episodes  of  night  eating,  as  manifested  by  eating  after  awakening  from  sleep  or  by  excessive  food  consumption  after  the  evening  meal.    

Presentation  Signs  

!  Avoid  eating  out  due  to  mistrust  in  food  preparation  or  fear  of  “contamination”.  

!  May  originate  from  several  sources  (i.e.  family  habits/beliefs,  society  trends,  recent  illness,  or  overhearing  negative  comments  about  a  food  groups  (i.e.  sugar  make  you  fat),  which  then  leads  to  ultimately  eliminating  the  food  or  foods  from  their  diet.  

!  The  severe  restrictive  nature  of  Orthorexia  has  the  potential  to  morph  into  Anorexia.  

Orthorexia  

Orthorexia  !  Defined  as  an  obsession  with  "healthy  or  righteous  

eating”.    

!  Often  begins  with  a  simple  and  genuine  desire  to  live  a  healthy  lifestyle.    

!  Fixation  on  defining  “organic”  “clean”  or  “right”  foods.  

!  Time  and  energy  spent    obsessing  about  food  (similar  to  Anorexia  or  Bulimia).  

!  May  not  think  in  terms  of  calories,  but  about  overall  "health  benefits"  and  how  food  was  processed,  grown  or  prepared.    

While  adolescence  represents  a  peak  period  of  onset,  eating  disorders  can  occur  in  people  of  all  ages.  

Regardless  of  age  of  onset,  there  can  be  considerable  period  of  time  before  first  treatment.    

Common  misdiagnosis  by  health  professionals  before  receiving  a  correct  diagnosis.    

Delay  in  treatment  negatively  influences  the  duration  of  the  ED  and  outcomes  of  treatment.  

Early  diagnosis  and  intervention  can  greatly  reduce  the  duration  and  severity  of  an  eating  disorder.    

Onset  &  Duration  

Several  factors  can  contribute  to  the  onset  of  an  eating  disorder.    

No  1  single  cause  of  eating  disorders  has  been  identified;  however,    known  contributing  risk  factors  include:  

!  Genetic  vulnerability.  

!  Psychological  factors.  

!  Socio-­‐cultural  influences.  

Why  Me?  

!  Socio-­‐cultural  influences  can  play  a  key  role  in  the  development  of  eating  disorders,  particularly  among  those  who  internalise  the  Western  beauty  ‘ideal  of  thinness’.    

!  Predominant  images  in  media  suggest  that  beauty  is  equated  with  thinness  for  females  and  a  lean,  muscular  body  for  males.    

!  Internalising  this  ‘thin  ideal’  leads  to  a  greater  risk  of  developing  body  dissatisfaction  which  can  lead  to  eating  disorder  behaviours.  

!  Like  most  other  psychiatric  illnesses  and  health  conditions,  a  combination  of  several  factors  may  increase  the  likelihood  that  a  person  will  experience  an  eating  disorder  at  some  point  in  their  life.  

Why  Me?  

Eating  Disorders  in  Adolescents    !  Period  of    intense  change  which  can  bring  with  it  a  

great  deal  of  stress,  confusion  and  anxiety.  

!  Enormous  physical  transformations  intertwined  with  feelings  of  self-­‐consciousness,  low  self  esteem  and  comparison  with  peers.    

!  Hormonal  and  brain  changes  take  place,  which  affect  them  physically,  mentally,  emotionally  and  psychologically.    

!  Social  and  environmental  changes  in  a  short  period  of  time  -­‐    changing  schools,  friendship  groups  and  developing  interests  in  the  opposite  or  same  sex.  

Eating  Disorders  in  Adolescents    

!   Tremendous  pressure  and  feelings  of  confusion    to  find  “my  place  in  the  world”.  

!  Struggle  to  deal  with  the  whirlwinds  of  change,  uncertainty  and  often  low  self  esteem.    

!  EDs  are  very  often  a  coping  mechanism  in  attempts  to  “gain  control”.    

!  When  quest  for  control  goes  too  far,  the  risk  of  developing  an  eating  disorder  dramatically  increases.  

!  In  addition,  body  image  concerns  and  peer  pressure  are  heightened  during  adolescence,  and  are  potential  risk  factors  in  the  development  of  an  eating  disorder.  

Eating  Disorders  in  Adolescents    

!  Thinness  is  now  at  our  “fingertips”.  

!  95%  of  adolescents  use  social  media  on  a  daily  basis  –  facebook,  instagram,  snap  chat,  etc…  

!   Social  Media  serve  as  platforms  teaching  adolescents  to  obsess  over  their  appearance    -­‐  hello  “selfie’,  -­‐  their  weight,  and  whether  their  bodies  are  "good  enough”.  

!  By  the  time  they  reach  high  school,  1  in  10  students  will  have  an  eating  disorder.  

How  to  Deal  with  a  Suspected  Eating  Disorder?  

!  Evidence  shows  the  sooner  treatment  for  an  eating  disorder  starts,  the  shorter  the  recovery  process  will  be.    

!  Seeking  help  at  the  first  warning  sign  is  much  more  effective  than  waiting  until  the  illness  is  in  full  swing.    

!  Address  and  tackle  eating  disorders  as  early  as  possible.  

!  Do  NOT  ignore  it,  it  will  NOT  go  away.  

!  No  right  or  wrong  ways  to  start  this  discussion  as  every  situation  and  person  is  different,  however  there  are  some  points  to  consider…….  

!  Be  calm,  honest  and  open  about  your  concerns  for  the  person.    

!  Think  about  what  you  would  like  to  say  to  maximise  chances  of  a  positive  conversation.    

!  Use  your  knowledge  of  the  person  to  decide  the  best  way  and  time  to  approach  them.    (Role  play  your  conversation  with  another  person,  or  role  play  your  approach  in  your  own  mind).  

!  Express  genuine  care  and  concern,  rather  than  coming  across  as  making  accusations  or  judgments.    

!  Use  ‘I’  statements  rather  than  ‘You’.  ‘You’  statements  can  lead  to  the  person  feeling  attacked.    

Communicate  

Communicate  !  Avoid  Judgmental  Language.  

!  Focus  on  behavioural  changes,  rather  than  weight,  food  consumption  or  physical  appearance.    

!  Try  to  avoid  the  words  “eating  disorder”  and  focus  more  generally  on  your  concerns  about  his  or  her  moods,  behaviours,  or  isolation.  

!  Pick  a  safe  comfortable  place  to  have  the  conversation,  when  you’re  both  feeling  calm  and  are  unlikely  to  have    distractions.    

How  Will  She/or  He  Respond?  Be  prepared  for  emotional  reactions,  which  may  be:  

!  Anger  –feelings  of  privacy  being  threatened,  embarrassed  or  ashamed.    

!  Denial  –  denial  there  is  a  problem  due  to  feelings  of  guilt  or  shame.  They  may  feel  protective  about  their  eating  disorder,  especially  if  it  serves  a  purpose  for  them.  

!  They  may  be  confused  or  shocked  because  they  had  not  yet  identified  themselves  as  having  an  eating  disorder.  

!  Relief  –  they  may  feel  relieved  that  you  noticed  and  offered  them  support  or  help.    

!  Reassure  him/or  her  that  you  are  there  to  help  and  support,  and  that  they’re  not  alone  in  their  situation.  

!  Encourage  them  to  seek  support  from  the  people  in  their  life  who  love  them,  such  as  friends,  family,  parents.    

!  The  importance  of  seeking  help  as  soon  as  possible  cannot  be  overstated.    

!  Strong  evidence  supports  that  the  earlier  help  is  obtained,  the  shorter  the  duration  of  the  disorder  and  the  greater  the  likelihood  of  a  full  recovery.  

Seek,  Help,  Support…    

!  Have  a  referral  resource  list  on  hand  for  medical  professionals    who  are    specifically  trained  to  help  people  with  Eating  Disorders.  

!  Consider  speaking  to  one  of  these  professionals  before  approaching  the  person  you  care  about  (or  prior  organising  an  intervention  or  conversation).  

!  Remember  everyone  responds  differently  to  different  types  of  treatment  so  a  specialist  will  advise  you  on  which  treatment  will  be  most  beneficial.  

Know  Who  to  Talk  to  

A  group  of  specialised  clinicians  who  are  able  to  guide  someone  with  an  eating  disorder  through  the  treatment  and  recovery  process:  

!  GP  or  Pediatrician  (may  not  be  formally  trained  in  detecting  presence  of  an  eating  disorder,  but  can  be  a  good  ‘first  base’  for  discussing  your  concerns).  

!  Registered  Dietitian.  

!  Clinical  Psychologist.  

!  Psychiatrist.  

!  RNs  &  Mental  Health  Nurse.  

The  Therapeutic  Team…  

"I.D.E.A."    Code  word  used  online  by  sufferers  of  eating  disorders    -­‐  Short  for  the  chilling  slogan:  “I  don't  eat  anymore”  -­‐  2015  

Q&A…  

"I.D.E.A."    

Gabrielle  K  Tuscher  MS  RDN  

Registered  Dietitian/Nutrition  Therapist:  Eating  Disorders  &  Mental  Health  Disorders,  

Global  Nutrition  &  Wellness  Consultant:  Hospitality,  F&B  &  Spas  

Tüscher  Nutrition  International:    

Los  Angeles:  9730  Wilshire  Blvd.,  Suite  205A,  Beverly  Hills,  CA  90212  

Asia:  1  D'Aguilar  Street,  Central,  Hong  Kong    

Global:  Consultancy  &  Skype  Consultations  

US  Mobile:  +1  (310)  864  6800  973  /  HK  Mobile:    (+852)  6085  3066    

Email:    tuschernutrition@yahoo.com    or    inquiry@nutrituscher.com  

Skype:  tigertush    

Website:  http://www.nutrituscher.com