Putting Eating Disorders on the Radar of Primary Care Providers

Putting Eating Disorders on the Radar of Primary Care Providers
Putting Eating Disorders
on the Radar
of
Primary Care Providers
ASSESSMENT TOOLS
GUIDELINES
RESOURCES
CWEDP-2007
CWEDP-2010
Dear Practitioner,
We are delighted to present to you, the resource binder and learning DVD entitled: Putting
Eating Disorders on the Radar of Primary Care Providers: Assessment Tools, Guidelines
and Resources. Inside you will find practical written materials and tools for your day–today interactions with patients. These are designed to promote comfort and confidence
in identifying and managing those patients in your practice with eating disorders. These
materials are not designed to replace a multidisciplinary team, but rather to promote
collaborative working relationships.
The resources have been designed to get patients with eating disorders and their families
comfortably started on the road to recovery from your office. They do not replace
comprehensive specialized care. We encourage you to build a supportive `virtual’ multidisciplinary team to whom you can refer. The list of services that we have provided includes
the outpatient eating disorder programs in your area as well as contact information for
physician- to- physician support. Each of these sites in turn can help you connect with private
practitioners in your community should the need arise. These professionals are often needed
given the shortage of specialized resources in our communities.
We will be updating this binder regularly through the `Professionals’ section of our website
(www.cwedp.ca). We have also created links to popular journals, upcoming educational
events and referral documents and information for each of our programs. We encourage
you to connect with us online to provide us with your contact information. Clients and family
members are also encouraged to check out the resources within the `Public’ section of our
website.
We welcome all feedback and have included an evaluation form that can be faxed or mailed.
This resource tool is intended to reflect current resources and practices in the field. If you
have updates or information that might be of assistance to other physicians or healthcare
practitioners, we would like to encourage you to pass this information along to us.
With appreciation for your continued interest and compassion,
CWEDP- Regional Team
905-815-5124
CWEDP-2007
CWEDP-2010
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Acknowledgements
We would like to express our heartfelt thanks to all the family physicians and clinical
nurse practitioners from across the region who took the time to complete the needs
assessment, attend the training sessions and let us know what they needed to develop
greater comfort and confidence in identifying and managing those patients in their
practices with eating disorders.
We would like to thank our physician team who planned the learning day, facilitated
the mentoring sessions and reviewed materials including Dr. Colleen Flynn,
Dr. Christina Grant, Dr. Erinn Owens, Dr. Janos Pataki, Dr. Barry Simon, Dr. Rod
Wachsmuth and Dr. Blake Woodside. We would also like to extend huge thanks to
Mike Pollington of Pollington Productions for his expertise and patience in creating the
DVD set. Thanks to the great folks at Gateway Reproductions for their help in printing
the binders. To our clients and family members, we are grateful for your feedback
and participation. Our thanks also go to the staff of the Central West Eating Disorder
Program (CWEDP) partner sites that completed questionnaires, contributed materials,
followed clients and provided general feedback.
The members of the CWEDP Regional team are to be congratulated for their hard
work in proposing, delivering, reporting and disseminating this information. At various
points the team included: Alison Colavecchia, Tracey Curwen, Darla Da Costa, Diane
Fahey, Amanda Ninaber, Jenn Nourse and Kristina Trim.
The completion of this project has been made possible through a Primary Health Care
Transition Fund Grant.
CWEDP-2007
CWEDP-2010
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TABLE OF CONTENTS
Welcome Acknowledgements
PAGE
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5
ORGANIZING YOUR APPROACH
Organizing Your Approach
The Role of the Primary Care Physician
Providing General Feedback to Patients with Eating Disorders and Their Families
11
13
15
SCREENING TOOLS
Quick Screening Tools
Behavior of Parents and Children Associated with the Onset of an Eating Disorder
General Eating Disorder Screen
Anorexia Nervosa Quick Screen Bulimia Nervosa Quick Screen Binge Eating Disorder Quick Screen
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25
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ASSESSMENT AND DIAGNOSIS Comprehensive General Assessment: Eating Disorders
Possible Signs and Symptoms Accompanying Significant Weight Loss in Eating Disorders:
Female and Male
Comprehensive Medical Assessment: Eating Disorders
Body Mass Index (BMI) CD Growth Charts: Body Mass Index for Age Percentiles: Boys 2-20 years
CD Growth Charts: Body Mass Index for Age Percentiles: Girls 2-20 years
CD Growth Charts: Weight for Age Percentiles: Boys 2-20 years
CD Growth Charts: Weight for Age Percentiles: Girls 2-20 years
DSM-IV Criteria: Eating Disorders
Tips on Conferring an Eating Disorder Diagnosis
ONGOING MANAGEMENT
Ongoing Medical Management and Monitoring: Overview
Checklist for Ongoing Medical Monitoring of Patients with Eating Disorders
What To and What Not To Say
Levels of Eating Disorder Care
Readiness for Change Indications for Hospitalization in Children, Adolescents and Adults
Weighing Your Patients
Discussing Nutrition
Activity Levels, Sports Involvement and Eating Disorder Recovery
Preparing for an Eating Disorder Hospitalization: Information for Physicians
Ethical Issues in the Compassionate Care of Those with Eating Disorders
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TABLE OF CONTENTS
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HELPING PATIENTS HELP THEMSELVES
Helping Your Patients to Help Themselves: An Introduction for Physicians
Helping Yourself Recover
Readiness for Change Thinking About Getting Better
Food Journal
Managing Binges
Preparing for an Eating Disorder Hospitalization: Information for Patients
Eating Disorder Resources for Patients and Families
Danielle’s Place- Support and Resource Centre
Sheena’s Place- Support and Resource Centre
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HELPING FAMILIES
Helping Families: An Introduction for Physicians
Guidelines for Families and Friends Readiness for Change Fathers Helping Daughters with Eating Disorders
Getting Through Meals
Preparing for an Eating Disorder Hospitalization: Information for Families
Eating Disorder Resources for Patients and Families
Family Psychoeducation Group Danielle’s Place: Support and Resource Centre
Sheena’s Place: Support and Resource Centre
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PHYSICIAN SUPPORT
Support Resources for Primary Care Providers
Physicians: Eating Disorder Connections and Links
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SUPPLEMENTAL RESOURCES
Contact Us
References
Evaluation
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Organizing your Approach
“The big challenge family practitioners face is not being overwhelmed
by the severity of this illness.”
Dr. Colleen Flynn, MD, FRCPC
Previously- Psychiatrist/Medical Director
Eating Disorder Program
Credit Valley Hospital
“In this kind of work, doctors need to set aside the classic vision of the
doctor and the patient only. This is team work where the doctor is at
the centre of a whole team network.”
Dr. Rod Wachsmuth, MD DipCPsy, FRCPC
Staff Consultant, Eating Disorders Program
Toronto General Hospital
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Organizing Your Approach
Eating disorders are complicated and difficult to treat. They often remain resistant in the face of
even the very best practices and practitioners. They require attention to both medical and psychiatric
information. Symptoms if left untreated, can lead to a broad range of chronic health problems. Treating
these disorders, however, can also be very rewarding as you bear witness to one individual, or even
an entire family, reclaiming their lives and health.
There are two key roles for primary care providers in the treatment of eating disorders. The first is to
develop your radar for identifying those people for whom more detailed tracking is necessary. Through
early identification and timely and thorough medical follow-up, you may limit the potential chronicity of
these disorders. Your investment early in the course of the illness can help prevent significant suffering in
the long term. The second role is to closely monitor the medical health of your patient, and to advocate
for their health as much as possible. Remember, you are likely to be the most consistent health care
provider in the patient’s life.
Once you have identified that someone in your practice has an eating disorder, assessed his/her
medical health and have an idea of how ready for change they are, you will need to consider what
other resources might be needed for the care of this person. It is important to remember the impact of
starvation and/or malnourishment on both your patient’s brain functioning and personality. Keep in
mind how terrified most eating disordered patients are of eating, food and weight gain and typically,
efforts to trick those around them are anxiety- based management strategies, rather than symptoms of
core personality deficits. Despite the significant role nutrition plays in recovery, eating disorders are
not just about food ! Assessing the individual’s family functioning and supportive network is also very
important. Encourage parents not to permit the eating disorder to “run the household” and help the
family as a whole support their loved one who is attempting to recover, often in the face of tremendous
ambivalence.
Below are recommended steps to take in getting organized. Each item has a sheet for your reference
and use. Refer to the accompanying DVD set for expanded information on each item.
ORGANIZING YOUR APPROACH
1. Screen
2. Assess A) General Information
B) Medical
C) Supports – schools, friends, family/parents, siblings
3. Diagnose
4. Medically Monitor – Check-ins
* younger more often
* more acute more often
5. Discuss the role of weigh-ins
6. Discuss the role of nutrition
7. Discuss levels of appropriate activity and sports
8. Discuss readiness for change
9. Provide resource and referral information
10. Access physician support needs
11. Monitor overall health and revise goals and
treatment approach as required
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The Role of the Primary Care Provider in the Provision of Care
to Children, Adolescents and Adults with Eating Disorders
Primary care providers are an integral component of the care provided to children, adolescents and
adults with eating disorders both over the course of the illness and perhaps more importantly, over the
lifespan of the patient. Eating disorders can persist over decades, waxing and waning in their severity
over time and developmental/life milestones. The establishment of a strong therapeutic alliance is
ultimately the best tool in the practitioner’s toolbox no matter the age of the patient. A strong alliance
facilitates early detection of symptoms, positive collaborative working relationships with family members
and secondary providers, and for ongoing medical monitoring and management. The therapeutic
alliance helps the physician–patient relationship to survive those rare occasions where difficult decisions
around competence and breaches of confidentiality must be made. A strong alliance is essential
when working with children and adolescents or young adults still living at home. Appropriate parental
involvement, supported by you, is critical.
Your Role
Main Focus
Key Recommendations
Binder Resource
Page
Early Identification
Who is at risk?
Who to follow?
-Establish alliance with patient and
parents as appropriate
-Keep a growth chart
-Monitor general coping skills
-Assess family history
-For children and adolescents, get
parents on board right from day
one, they are needed!
-Warning Signs
-Growth charts
-Comprehensive
General and Medical
Assessment
-Resources for
patients, families and
physicians
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Medical
Management
Preventing patient
mortality
-Monitor medical status as
appropriate (1 – 2 X per week)
-Brief hospitalizations for
stabilization
-Monitor suicidality
-When to Admit
-Preparing for a
Hospitalizationphysician, family and
patient sheets
-Physician Support
service
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85,105,125
-Maintain alliance with patient and
his/her family
-Monitor blood work with a
frequency appropriate to medical
status
-Maintain growth charts
-Ongoing Medical
Monitoring
-Symptoms Associated
with an Eating
Disorder
-Growth charts
65,67
-Monitor patient’s stage of change
and refer for specialized treatment
as appropriate
-Encourage patient to assess pros
and cons of illness
-Establish linkages with local and
tertiary providers
-Seek consultations
-Readiness for Change
-Treatment Resources
Sheet
-Worksheets for
patients
-CWEDP Site
Information
(www.cwedp.ca)
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107,127
-Advocate for timely and
appropriate medical admissions
-Encourage help seeking
-Encourage parents to advocate for
appropriate resources
-Treatment Resources
sheet
Medical
Monitoring
Treatment
Advocacy
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Monitor physical
and mental
health
Improving quality
of life
Improving
opportunities for
self/health care
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Early Identification
Identifying children and adolescents at risk for developing an eating disorder versus those who are `picky eaters’ or have
other metabolic issues can be challenging.
Recommendations may focus on:
➢ Rule out other metabolic conditions
➢ Keep a detailed, frequently plotted growth chart
➢ Ensure supports for the child exist, assess general stress management and coping skills
➢ Assess for co-morbid conditions, family history (e.g. mood disorders, substance abuse, post-traumatic stress
disorder)
➢ Ask parents to note what the child eats and describe family eating patterns
➢ Develop strong supportive and coaching style relationship with parents of children, adolescents and young
adults
Medical Management
Keeping patients alive largely through medical stabilization is the main focus.
Recommendations may focus on:
➢ Nutritional stabilization through the use of food and/or supplemental nutrition as necessary (e.g., oral
supplements, tube feeding, TPN)
➢ Safety: is the patient suicidal or engaging in self-harm behaviors that warrant a psychiatric assessment or
admission?
➢ Palliative care- is the patient in the final stages of the illness i.e. vital organs are now shutting down?
Medical Monitoring
Ongoing medical monitoring ensures that the overall health of the patient is always front and centre. Changes in health
can be detected right away to enable more timely access to care.
Recommendations may focus on:
➢ Regular bloodwork
➢ Regular height/weight measurement (varies with age and level of acuity)
➢ Regular assessment of achievement of life milestones
➢ Regular check-ins with family members to ensure adequate coping, perception of treatment progress and/or
concerns, participation in treatment plan
Treatment
The Primary Care Provider should not expect to provide all aspects of care or they are likely to end up feeling
overwhelmed and isolated given the dual components of these disorders: medical and psychiatric. They are best
supported in their work as a member of a “virtual team” i.e. a group of professionals brought together to meet the
multidisciplinary needs of the patient despite not being from the same practice or organization. Members may or may not
include a multi-disciplinary specialized eating disorder program, consulting dietitian, psychiatrist or therapist.
Recommendations may focus on:
➢ A referral to a specialized outpatient eating disorder program for a comprehensive assessment, diagnosis
and treatment plan
➢ Consultations with a:
• Psychiatrist
• Dentist
•Dietitian
➢ Education- for clients and families. Provide resource lists, support group information and family
psychoeducation
➢ Encourage families not to let the eating disorder run the household through continued maintenance of family
meals, non-food or weight oriented discussions and an emphasis on whole health for the whole family
Advocacy
To build a “virtual team” and to access acute care should the need arise; the primary care provider must be willing
to connect with other sites, providers and/or physicians. Given the paucity of specialized acute resources in most
communities, speaking directly with specialized care providers can ensure clarification around admission criteria, bed
availability, and steps to take while waiting for a bed. Alternative or temporary care options can better be explored and
facilitated through direct physician-to-physician contact should no local/regional tertiary care facility be able to offer care.
Recommendations may focus on:
➢ Advocating for the right admission at the right time
➢ Establishing collaborative linkages with local specialized providers
➢ Establishing collaborative linkages with tertiary care providers
➢ Utilizing physician-to-physician support services
➢ Encouraging families to advocate for improved access to specialized resources where none or few exist
References: Silber et al (1991); Weiner in Piran et al (1999)
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CWEDP-2007
CWEDP-2010
Providing General Feedback to Patients with
Eating Disorders and Their Families
1.Communicate your role as an advocate for your patient’s health.
2.Communicate the importance of food as medicine. Regular intake of 2-3,000
calories is normal, depending on the age and sex of the patient- See “Nutrition
Guidelines” sheet.
3.Communicate diagnosis as appropriate- see “Conferring a Diagnosis” sheet
for tips.
4.Communicate appreciation for ambivalence patient may have around recovery,
despite clear messages from everyone else around him/her.
5.Communicate understanding of the challenging and often exhausting role parents
and partners play in recovery. They are responsible for living out the treatment
plan 24/7.
6.Communicate importance of non-dieting, cessation of excessive exercise and
other purging behaviors including vomiting and laxatives abuse.
7.Discuss role of weight and weigh-ins. This represents one measure of medical
health which can be handled in a dignified and respectful way as agreed
between the patient (see “Weighing your Patient Tips” Sheet) and practitioner.
The goal is sustained medical health and improved quality of life. Encourage
patients to get rid of their scales at home.
8.Communicate circumstances under which you will breach confidentiality (e.g.,
concerns that patient’s health is in danger zone, risk of self-harm, suicidality).
9.Communicate belief that everyone is on the `team’ and that you alone are not
the key to patient’s recovery. You will refer as appropriate.
10.Acknowledge that recovery from an eating disorder is complicated and can be
lengthy, but that you are willing to be involved for the long term.
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Screening Tools
“Often the problem presents during the middle of a busy day…
Practitioners need to have some idea of how to do a quick screen to
make the diagnosis and understand that their existing knowledge is
very applicable to the medical management of these patients.”
Dr. Blake Woodside, MD, FRCPC
Director, Inpatient Eating Disorders Program
The Toronto Hospital
“Take the time to ask the overweight or obese patient who
comes into your office recurrently asking about weight loss programs:
“Many people overeat in an out of control fashion…
does this happen to you?”
Dr. Barry Simon, MD, FRCPC
Psychiatrist, Leadership Centre for Diabetes
Mount Sinai Hospital
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Quick Screening Tools
These quick screens have been put together to help you to determine whether a more
comprehensive assessment for an eating disorder may be warranted. They are not
meant to be lengthy or comprehensive; rather they are intended to raise flags for
further investigation. Individual screens are on printable sheets designed so that you
can use them during an appointment. They include space for name, date and notes.
1. Consider asking the general questions of all new patients.
2. Use the General Screen followed by the specific screen where/when warranted.
3. Consider using the screens when these or similar questions are raised:
• A mother asks about her daughter who has been hiding food
• A girl asks about why her periods have stopped
• A woman expresses concerns about her weight gain
• You are asked about the long-term impact of laxatives
• A mother indicates that her daughter is not seeing her friends anymore, spends
most of her time doing school work, and is avoiding eating meals with the family
• A teen has a significant drop in his or her weight, changing the trajectory of his/
her growth curve
• A woman complains about a sudden unexplained weight increase, states it is non-food related and is now dieting to reduce weight (use the screens to link
metabolic issues to an eating disorder)
• A man asks about getting help for his unmanageable nighttime food cravings
4.Refer to the `Possible Signs and Symptoms Accompanying Significant Weight Loss
in Eating Disorders’ Figures.
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Behavior of Parents and Children that Might be Associated With the
Onset of Eating Disorders or Impaired Eating Attitudes and Behaviours:
Guideline for Healthcare Providers
1.Parents express degree of worry about child’s shape, appearance, or weight that is not
supported by the primary care physician’s clinical findings or observations.
2.Child expresses dissatisfaction with body shape and weight to parents or pediatrician.
3.Child imposes food restrictions in a variety or quantity that:
a. compromises nutritional status
b. stimulates family conflict
c.suggests child is concerned about body shape or weight or is engaged in a control
battle with parents
4.In response to questions about the child/parent interaction around eating, parents or child
reveal information that suggests that:
a.parent is uncomfortable with child having food preferences or feeding him or herself
b.child is reluctant to experiment with food of variable textures, smells, consistency,
and taste
c.there is no structure to mealtime and few family interactions around food consumption
or there is heightened tension in family at mealtimes
d.parents anxiety about child’s eating behaviours or weight intrudes upon interactions
with child around food purchase, preparation, presentation and consumption
e.there is an intense emphasis in the family on physical fitness and low-fat eating
patterns, which may promote an overly restricted pediatric diet and a child who feels
compelled to work-out beyond child’s interest, body capacity or need
5. Child sneaks [hoards or hides] food.
6.Child resists parent’s efforts to involve them in physical activities, or parents believe child
should only engage in physical activities that are of interest to them (parents).
7.Parents express discomfort about establishing expectations and consequences for child
regarding eating behaviours. [A helpful benchmark is to compare this to the parent’s
capacity to instruct regarding toilet training, sleep behaviours and brushing teeth.]
8.There is a history of eating disorders or impaired eating behaviours in the family,
including parent, grandparent, siblings or cousins.
Weiner (1999)
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General Eating Disorders Quick Screen
Name: Date:
1) Are you unhappy with your body weight and shape?
2) Are you dieting? Have you dieted much in the past?
3) Have you lost weight?
4)Some people eat large quantities of food in an out of control way. Has this ever happened
to you?
If yes, continue:
5)Many people, after eating in this way, feel very badly about themselves. Do you ever feel badly
about yourself after eating in this way?
6)Many people then try to compensate for this eating or to get rid of the food somehow. Has this
ever happened to you?
7)How often do you currently exercise? Do you feel comfortable missing a day here and there?
Does your exercise feel out of control?
8) Have others expressed concerns about your eating, exercising or weight?
9) Are you concerned about your health?
Key
Those with bulimia tend to express concerns for their health unlike those with anorexia who may report
that others have indicated concern for their health, but that they, themselves, are not concerned (may
be in state of denial). Those struggling with issues related to bulimia or binge eating disorder are more
likely to report that they have not told anyone of their struggles and physically there may be less visible
evidence of ongoing issues.
Other Notes:
Follow-Up Plan:
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Anorexia Nervosa (AN) Quick Screen
Name: Date:
1) What is the most you have ever weighed? When was that?
2) What is the least you have ever weighed? When?
3) What do you think you should weigh?
4) When you look in the mirror do you think you should gain weight, lose weight or stay the same?
5) How often do you exercise each week? How long does each session last?
6) Is your menstrual cycle regular?
Key
Consider the age of patient and the period of time during which weight loss has occurred and whether
menstrual irregularity is present. The most distinguishing feature of AN is a perception that despite
being at a healthy weight for age they still see themselves as needing to lose more weight or still feel
dissatisfied with their weight and shape.
Notes:
Follow-Up Plan:
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Bulimia Nervosa (BN) Quick Screen
Name: Date:
1) Has your weight fluctuated much over the last few years?
2)Some people eat large quantities of food in an out of control way. Does this ever happen to you?
3)Many people, after eating in this way, feel very badly. Do you ever feel badly about yourself
after eating in this way?
4)Many people, then try to compensate for this eating by getting rid of the food or compensating
for it somehow. Has this ever happened to you?
a. Have you ever tried to make yourself sick/vomit?
b. Have you ever taken laxatives?
c. Have you ever exercised to make up for a meal/snack/binge?
5)How frequently do you exercise each week and how long does each session last?
6) What is your motivation for exercising?
7)Do you feel your exercise is out of control?
Adapted from Mehler & Anderson, A Guide to Medical Care and Complications:
Eating Disorders. John Hopkins, 1999
Key
The main difference between BED and BN is that those who struggle with BN purge or try to
compensate for the binges in some way. In BN, binges tend to be shorter, but more intense, as
compared to those with BED.
Notes:
Follow-Up Plan:
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Binge Eating Disorder (BED) Quick Screen
Name: Date:
1)Many people eat large quantities of food in an out of control way. Does this ever happen to you?
How often?
2) How long does each eating session last?
3)Many people, after eating in this way feel very badly. Do you ever feel badly about yourself after
eating in this way? e.g., experience guilt, shame or despair?
4)Many people then try to compensate for this eating by getting rid of the food or compensating
for it somehow. Has this ever happened to you? E.g. making yourself sick/ exercising/using
laxatives?
5) Have you undergone any surgery to help with your weight concerns? E.g. Bariatric surgery?
Key
The main difference between BED and BN is that those who struggle with BED do not purge or try to
compensate for their binges. Binges also tend to last over a longer period of time as compared to those
with BN.
Notes:
Follow-Up Plan:
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Assessment and Diagnosis
“I think there are probably a hidden number of patients in every
practice that have an eating disorder.”
Dr. Erinn Owens, MD, FRCPC
Consultant to Eating Disorder Program
Grand River Hospital
“A direct, compassionate approach will help people talk about things
they otherwise are too ashamed to bring up spontaneously.”
Dr. Blake Woodside, MD, FRCPC
Director, Inpatient Eating Disorders Program
The Toronto Hospital
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Comprehensive General Assessment:
Eating Disorders
You may wish to keep this assessment as part of your patient file and/or sign off and use to forward to
a secondary provider. Completion will likely require more than 1 visit.
SUMMARY
NAME
DATE
AGE
FAMILY DOCTOR
PRESENTING COMPLAINT
SUMMARY OF HISTORY OF PRESENTING COMPLAINT
GENERAL INFORMATION:
PERSONAL SITUATION: (INCLUDE MARITAL STATUS, STUDENT/EMPLOYED, LIVING ARRANGEMENTS)
EATING DISORDER DIAGNOSIS AND COMORBID CONDITIONS:
RECOMMENDATIONS:
Reviewed with Patient
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Reviewed with Family
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WEIGHT HISTORY
Height:
inches
Current weight:
How much would you like to weigh?
lbs.
lbs.
How old were you when you became serious about trying to control your weight?
What is the heaviest weight you remember being at?
What is the lightest weight you remember being at?
Years old
lbs. How old were you?
lb. How old were you?
MENSTRUAL HISTORY
At what age did you first start menstruating?
Years old OR
I have never had a period
Do you have menstrual periods now?
Yes, regularly every month
Yes, but I skip a month once in a while
Yes, but not very often (i.e. once in 3 months)
No, I have not had a period in at least 3 months
I am post-menopausal or have had a hysterectomy
How long has it been since your last period?
weeks OR
months OR
years
Where was your weight when your periods became irregular/stopped?
lbs.
Have you previously been prescribed birth control? For what purpose?
BODY IMAGE
When you look in the mirror do you feel you need to
gain a little weight
lose a little weight
stay just where I am
Are there specific body parts that you are uncomfortable with?
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Have you undergone any procedures to alter your physical appearance including such things as
bariatric surgery, plastic surgery or breast augmentation/reduction?
PROCEDURE
DATE OF PROCEDURE
NUTRITION
How many meals do you eat each day?
How many snacks do you eat each day?
Please describe a typical day of eating:
How many calories do you estimate you eat each day?
How many meals each week do you eat with your family?
none
1-2
3 - 5
6-10
Do you eat what the rest of your family is eating?
yes, always
most of the time
once and a while Are you vegetarian?
yes – Since when?
11-15
15+
never
no
WEIGHT CONTROL
Have you ever restricted your food intake due to concern about your body size or weight?
yes
no
How old were you the very first time that you began to restrict your food intake due to concern about
your body size?
years old
How old were you when you became very serious about trying to control your weight?
years old
How often do you exercise in a typical week?
How long do you exercise each time?
times a week
minutes
What kinds of exercise do you like to do? Why do you exercise?
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Do you ever experience episodes of eating a very large amount of food (binge) in a relatively short
period of time?
yes
no
How old were you when you first had a binge?
years old
How old were you when you began binge eating on a regular basis?
years old
During the last 3 months, how often have you typically had an eating binge?
I have not binged in the last 3 months.
Monthly, I usually binge
time(s) a month.
Weekly, I usually binge
time(s) a week.
Daily, I usually binge
time(s) a day.
What is the longest period you have had without bingeing since you began bingeing on a regular
basis?
days
How long does a binge usually last?
Less than one hour
More than 2 hours
1 – 2 hours
All day or all evening
Many people find it embarrassing to talk about their binges but it would be helpful for me to understand
a little bit about them. What do you typically eat during a binge?
Many people try to rid themselves of the food when the binge is over, have you ever tried to make
yourself sick (vomit)?
yes
no
How old were you when you made yourself sick (vomited) for the first time?
years old
When things were at their worst, how often did you make yourself sick (vomit) each week?
a)
times per week
b) How long ago was that?
months
What is the longest period you have had without vomiting since you began vomiting on a regular
basis?
days
How often
36
do you eat a “normal” meal without binge eating and/or without vomiting?
Never
Less than one meal a week
About one meal a week
Several meals a week
One meal a day
More than one meal a day
CWEDP-2007
CWEDP-2010
Have you ever used laxatives to control your weight or to “get rid of food”?
yes
no
How old were you when you first took laxatives to control your weight?
years old
How old were you when you began taking laxatives on a regular basis?
years old
During the last 3 months how often have you taken laxatives to help control your weight?
I have not taken laxatives in the last 3 months.
Monthly, I usually take laxatives
time(s) a month.
Weekly, I usually take laxatives
time(s) a month.
Daily, I usually take laxatives
time(s) a day.
How many laxatives do you usually take each time?
Have you ever taken diet pills?
yes – What kind?
laxatives
no
During the last 3 months, how often have you typically taken diet pills?
I have not taken diet pills in the last 3 months.
Monthly, I usually take diet pills
time(s) a month.
Weekly, I usually take diet pills
time(s) a week.
Daily, I usually take diet pills
time(s) a day.
Have you ever taken diuretics (water pills)?
yes
no
During the last 3 months, how often have you typically taken diuretics?
I have not taken diuretics in the last 3 months.
Monthly, I usually take diuretics
time(s) a month.
Weekly, I usually take diuretics
time(s) a week.
Daily, I usually take diuretics
time(s) a day.
TREATMENT HISTORY
Have you ever received treatment for an eating disorder?
no yes – please indicate type and when (Check all that apply)
inpatient when I was
day hospital when I was
outpatient when I was
individual therapy when I was
group when I was
years old for
months
family when I was
years old for
months
other
when I was
CWEDP-2007
CWEDP-2010
years old for
months
years old for
months
years old for
months
years old for
years old for
months
months
37
Have you ever attended treatment for issues other than your eating disorder?
no
yes – please indicate type and when (Check all that apply)
inpatient when I was
day hospital when I was
outpatient when I was
individual therapy when I was
group when I was
years old for
months
family when I was
years old for
months
other
years old for
months
years old for
months
years old for
months
years old for
when I was
months
years old for
months
These treatments were for help with:
Have you been admitted to the hospital in the past 2 months?
Yes
No
If yes, how many times were you in the hospital?
times
If yes, how many days in total were you in the hospital?
days
Have you ever been hospitalized for eating problems?
no
yes how many times
CURRENT AND PAST BEHAVIOURS
Alcohol Use
Drug Use
Self-Harm
ABUSE HISTORY
Have you been physically, emotionally or sexually abused in the past? Are you currently in an abusive
relationship?
38
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FAMILY HISTORY AND RELATIONSHIPS
(Note: substitute any significant family member/guardian/caregiver who has raised or is raising the
individual)
Which category best describes/or described your mother’s weight?
Underweight
Normal weight
Above average weight
How preoccupied with food or weight is/was your mother?
Not at all
Somewhat
Moderately
Very overweight
Very much
Extremely
Which category best describes/or described your other guardian/father’s weight?
Underweight
Normal weight
Above average weight
Very overweight
How preoccupied with food or weight is/was your other guardian/father?
Not at all
Somewhat
Moderately
Very much
Extremely
How many siblings do you have? 0
1
2
3
4
other
How many siblings are underweight? 0
1
2
3
4
other
How many siblings are normal weight? 0
1
2
3
4
other
How many siblings are above average weight?
0
1
2
3
4
other
How would you describe the quality of your relationship with your mother? Or other significant
caregiver?
How would you describe the quality of your relationship with your father? Or other significant
caregiver?
How would you describe the quality of your relationship with your siblings?
How would you describe the quality of your relationship with your spouse/partner/boyfriend/
girlfriend?
How would you describe the quality of your relationship with your children?
CWEDP-2007
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39
SOCIAL SUPPORTS/RELATIONSHIPS
How many close friends do you have?
no one
1
2
3
4
5
more than 5
How many people (including family) could you talk to about an important personal problem?
no one
1
2
3
4
5
more than 5
How many hours a week do you socialize with friends outside of work/school hours? (e.g. dinner, talk
on phone, etc.)
less than one hour
1-2 hours
3 - 4 hours 5-6 hours
7-8 hours
9-10 hours
more than 10 hours
How many hours a week do you engage in family activities?
less than one hour
1-2 hours
3 - 4 hours 7-8 hours
9-10 hours
more than 10 hours
5-6 hours
With whom have you discussed your current concerns?
Are they concerned for your health?
How motivated are you to do something about your current health issues?
(on a scale of 0-10, where 0=not at all, 10= do whatever I have to)
Completing Physician
Date
Adapted from Johnson (1985) and Northern Health (2006)
40
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CWEDP-2010
Possible Signs and Symptoms Accompanying Significant
Weight Loss in Eating Disorders: Females
Northern Health, Prince George Eating Disorders Clinic, 2006
Thinning and dryness of hair
Lowered total sleep time
Light-headedness
Dental caries, loss of enamel
Thermal sensitivity, gum disease
Pituitary hormone abnormalities
Enlarged Parotid glands
Mildly altered thyroid function
Reduced heart size on chest x-ray
(Loss of fat pad around heart)
Slowed heart rate
Prolonged QT Interval on ECG
Lowered amplitude of tracing EKG
Low blood pressure on EKG
Lanugo - fine, raised, white hair on body surface
Osteopenia /Osteoporosis by bone density scans
Constipation
Absence of menstrual periods (amenorrhea)
Mild anemia
Brittle nails
Cold sensitivity/Lowered Body temperature
Loss of subcutaneous body fat
Diminished muscle mass
Lowered reflexes
Dry skin
Mild fluid collection (edema)
Poor circulation-cold extremities
CWEDP-2007
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41
Possible Signs and Symptoms Accompanying Significant
Weight Loss in Eating Disorders: Males
Thinning and dryness of hair
Lowered total sleep time
Light-headedness
Dental caries, loss of enamel
Thermal sensitivity, gum disease
Pituitary hormone abnormalities
Enlarged Parotid glands
Mildly altered thyroid function
Reduced heart size on chest x-ray
(Loss of fat pad around heart)
Slowed heart rate
Prolonged QT Interval on ECG
Lowered amplitude of tracing EKG
Low blood pressure on EKG
Lanugo – fine, raised,
white hair on body surface
Osteopenia /Osteoporosis
Constipation
Reduced size of testes
Lowered libido
Brittle nails
Mild anemia
Cold sensitivity/Lowered Body temperature
Loss of subcutaneous body fat
Diminished muscle mass
Lowered reflexes
Dry skin
Mild fluid collection (edema)
Poor circulation-cold extremities
CWEDP-2007
CWEDP-2010
43
Comprehensive Medical Assessment:
Eating Disorders
You may wish to keep this assessment as part of your patient file and/or sign off and use to forward to a
secondary provider.
LAST PHYSICAL ASSESSMENT APPEARANCE DURING ASSESSMENT CURRENT REVIEW OF SYSTEMS
Cardiovascular
Gynaecologic
Gastrointestinal
Dermatologic
Endocrine
musculoskeletal
DIAGNOSIS:
PHYSICAL COMPLICATIONS: Summary
LABORATORY INVESTIGATIONS: Summary
Routine Completed:
CBC
BUN
Creatinine
Fasting Insulin
Electrolytes
FBG
Liver Function
Hormone Panel
Further Recommended:
EKG (chest pain, palpitations)
Liver function (Weight loss, alcohol abuse)
CPK (abusing Ipecac)
Amylase (gastrointestinal symptom)
Calcium, phosphorous (chronic amenorrhea or
fractures) magnesium
Endoscope or x-ray exams
OTHER:
Insight into illness/eating disorder (0-10, 10= high)
Motivation to work towards recovery (0-10, 10= high)
CWEDP-2007
CWEDP-2010
45
MEDICATIONS:
ALLERGIES:
SLEEP PATTERN
CARDIOVASCULAR FUNCTIONING (dizziness, blackouts, postural hypotension, chest pain,
palpitations and edema)
GASTROINTESTINAL FUNCTIONING (Vomiting with ___, without____blood, constipation,
diarrhea, bloating, abdominal pain, nausea)
DENTAL HISTORY (Issues reported, recent dental exam)
HAIR AND SKIN (hair loss, dullness, thinness, dryness, fingernails, lanugo)
GYNOCOLOGICAL HISTORY (secondary sexual characteristics, onset menarche, birth control,
periods, sexual history, pregnancies, fertility, PCOS)
MUSCOLOSKELETAL (weakness, cramps, pain, fractures)
NEUROLOGICAL FUNCTIONNING (headaches, seizures, night vision, visual disturbances, `black outs’)
46
CWEDP-2007
CWEDP-2010
Physical Examination
Height
Weight
Patients’ sheet
* undressed- preferably facing away from the scale (See `Weighing your
Blood Pressure:
Sitting
Standing
Pulse
Vision: Parotid: Thyroid: Dentition and Hydration: Skin: (lanugo, stria, fingernails, palm excoriation/Russell’s sign) Extremities: (cyanosis, temperature) CNS: (reflexes, strength) Heart: (chest pains, palpitations) Chest: Mental Status: (as appropriate) Measurements: BMI- (see `BMI’ instruction sheet)
Completing Physician
Date
Adapted from Johnson (1985) and Northern Health (2006)
CWEDP-2007
CWEDP-2010
47
Body Mass Index (BMI)
• C
WEDP note: The use of BMI as a sole measure of health is not recommended. In children
and adolescents, the use of BMI as a sole assessment of height/weight ratio is especially not
recommended. Calculations are based on an adult population. Consider using ideal weight for
age and plotting growth charts as per the attached child and adolescent charts.
• To estimate BMI, locate the point (on the attached charts or below) where patients’ height and
weight intersect. Read the number on the dashed line closest to this point. For example, if patient
weighs 69 kg and is 173 cm tall, the BMI will be approximately 23
• You can also calculate BMI using this formula: BMI = weight (kg)
height (m2)
Zone
A
B
C
D
BMI
<20
20-25
25-30
>30
Health Effects
Below Average
Average
Above Average
Obese
Source: Health and Welfare Canada, Promoting Healthy Weights: A Discussion Paper, Minister of Supply and Services Canada:
Ottawa, Ontario, 1988
http://www.hc-sc.gc.ca/fn-an/nutrition/weights-poids/guide-ld-adult/bmi_chart_java-graph_imc_java_e.html
CWEDP-2007
CWEDP-2010
49
CDC Growth Charts: United States
BMI
BMI
34
34
97th
32
32
30
30
90th
28
28
85th
26
26
75th
24
24
50th
22
22
25th
20
10th
20
3rd
18
18
16
16
14
14
12
12
kg/m²
kg/m²
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Age (years)
Published May 30, 2000.
SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
CWEDP-2007
CWEDP-2010
51
CDC Growth Charts: United States
BMI
BMI
97th
34
34
32
32
30
30
90th
28
28
85th
26
26
75th
24
24
22
50th
20
25th
22
20
10th
18
18
3rd
16
16
14
14
12
12
kg/m²
kg/m²
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Age (years)
Published May 30, 2000.
SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
CWEDP-2007
CWEDP-2010
53
CDC Growth Charts: United States
kg
105
lb
lb
230
230
100
220
95
210
90
200
85
97th
220
210
200
90th
190
190
180
180
80
75th
170
170
75
160
160
50th
70
150
150
65
140
25th
140
130
10th
130
55
120
3rd
120
50
110
110
45
100
100
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
60
40
35
30
25
20
15
10
kg
lb
lb
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Age (years)
Published May 30, 2000.
SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
CWEDP-2007
CWEDP-2010
55
CDC Growth Charts: United States
kg
lb
lb
105
230
230
100
220
220
95
210
210
90
200
85
200
97th
190
190
180
180
80
170
170
90th
75
160
160
70
150
65
60
55
150
75th
140
140
130
50th
120
130
120
25th
50
110
110
10th
45
40
100
3rd
100
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
lb
lb
35
30
25
20
15
10
kg
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Age (years)
Published May 30, 2000.
SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
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CWEDP-2010
57
DSM-IV Criteria: Eating Disorders
307.1 – Anorexia Nervosa
A.Refusal to maintain body weight at or above a minimally normal weight for age and height; e.g.,
weight loss leading to maintenance of body weight less than 85% of that expected; or failure to
make expected weight gain during period of growth, leading to body weight less than 85% of that
expected.
B.Intense fear of gaining weight or becoming fat, even though underweight.
C.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.
D.Amenorrhea in Postmenarcheal females i.e., the absence of at least three consecutive menstrual
cycles (a woman is considered to have amenorrhea if her periods occur only following hormone
administration).
Specific Types:
Restricting Type: During the current episode of Anorexia Nervosa; the person has not regularly
engaged in binge-eating or purging behaviors. i.e., self-induced vomiting or the misuse of laxatives,
diuretics, or enemas.
Binge-Eating/Purging Type: During the current episode of Anorexia Nervosa, the person has regularly
engaged in binge-eating or purging behaviors; i.e., self-induced vomiting or the misuse of laxatives,
diuretics, or enemas.
307.51 – Bulimia Nervosa
A.Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the
following:
(1)Eating, in a discrete period of time (within any two-hour period) an amount of food that is
definitely larger than most people would eat during a similar period of time and under similar
circumstances.
(2)A sense of lack of control over eating during the episode; e.g., a feeling that one cannot stop
eating or control what or how much one is eating.
B.Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as selfinduced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting, or excessive
exercise.
C.The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice
a week for three months.
D.Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during Anorexia Nervosa.
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59
Specific Types:
Purging Type: During the current episode of Bulimia Nervosa, the person has regularly engaged in selfinduced vomiting or the misuse of laxatives, diuretics, or enemas.
Non Purging Type: During the current episode of Bulimia Nervosa, the person has used other
inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly
engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
Research Criteria for Binge Eating Disorder
B.Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the
following:
(1)eating, in a discrete period of time (e.g., within a 2-hour period), an amount of food that
is definitely larger than most people would eat in a similar period of time under similar
circumstances
(2)a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop
eating or control what or how much one is eating)
C.The binge eating episodes are associated with three (or more) of the following:
(1)eating much more rapidly than normal
(2)eating until feeling uncomfortably full
(3)eating large amounts of food when not feeling physically hungry
(4)eating alone because of being embarrassed by how much one is eating
(5)feeling disgusted with oneself, depressed, or very guilty after overeating
D.Marked distress regarding binge eating.
E.The binge eating occurs, on average, at least 2 days a week for 6 months.
F.The binge eating is not associated with the regular use of inappropriate compensatory behaviors
(e.g., purging, fasting, excessive exercise etc…) and does not occur exclusively during the course
of Anorexia Nervosa or Bulimia Nervosa.
307.5 – Eating Disorder Not Otherwise Specified
The Eating Disorder Not Otherwise Specified category is for disorders of eating that do not meet the
criteria for any specific Eating Disorder. Examples include:
A.For females, all of the criteria for Anorexia Nervosa are met except that the individual has regular
menses.
B.All of the criteria for Anorexia Nervosa are met except that, despite significant weight loss, the
individual’s current weight is in the normal range.
C.All of the criteria for Bulimia Nervosa are met except that the binge eating and inappropriate
compensatory mechanisms occur at a frequency of less than twice a week over the last three
months.
D.The regular use of inappropriate compensatory behaviors by an individual of normal body weight
after eating small amounts of food; e.g., self-induced vomiting after the consumption of two cookies.
E.Repeatedly chewing and spitting out, but now swallowing, large amounts of food.
F.Binge-Eating Disorder: recurrent episodes of binge eating in the absence of the regular use of
inappropriate compensatory behaviors characteristic of Bulimia Nervosa.
60
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Tips on Conferring an
Eating Disorder Diagnosis
1. There are only five eating disorder diagnoses you can make. These are: Anorexia
Nervosa, Restricting or Purging Subtype, Bulimia Nervosa, Purging or Non-Purging
Subtype, and Eating Disorder Not Otherwise Specified. The latter is actually the most
common eating disorder diagnosis made, and applies to all individuals with clinical
eating disorders who do not meet full criteria for AN or BN.
2. B
e sure you’re clear on the meaning of diagnostic terms. A frequent misconception, on
the part of both patients and health care professionals, is that when someone is “bulimic,”
they are vomiting. Bulimia, in fact, is “ox-like eating” and refers to bingeing, not purging,
behavior. Not all individuals with bulimia nervosa vomit. The diagnosis is divided into the
purging and non-purging subtypes and only the former may involve regular vomiting.
3. P
atients are often surprised by their eating disorder diagnosis. This is often the case even
among severely ill individuals with very obvious and repetitive symptoms. Be gentle and
respectful when conferring a diagnosis. Hearing it formally is often very upsetting and
can take time for patients and families to integrate.
4. R
emember, diagnoses can, and do, change. This is significant, as it may mean the onset
of new symptoms and new medical challenges which previously were not part of the
picture. A common example is the transition from the restricting form of anorexia nervosa
to the purging form of bulimia nervosa. When patients begin to re-feed, they often find it
difficult to manage food and sometimes enter a cycle of bingeing and purging.
5. D
on’t forget about Binge Eating Disorder! This is actually a form of an Eating Disorder
Not Otherwise Specified and is often undetected and under diagnosed. A common
problem here is the mistaken assumption that all obese individuals are alike. However,
we know from the research literature that obese binge eaters tend to differ from obese
non-binge eaters in a number of important ways. For example, they tend to have
more psychiatric co-morbidities (e.g., depression, alcohol abuse), poorer outcomes
in weight loss programs, and more challenges after bariatric surgery. There may
also be underlying metabolic abnormalities that increase food cravings and promote
overeating (e.g., hyperinsulinemia, insulin resistance, diabetes and PCOS). Thus, correct
diagnosis is of critical importance in determining primary treatment targets. These may
include management of psychiatric comorbidities, reduction of bingeing, and/or direct
management of weight. Binge eating is often kept secret by patients due to feelings
of shame. Thus, it is incumbent on health care professionals to develop sensitive and
respectful ways of asking about this behavior.
Mary Lees, Ph.D., C. Psych
Credit Valley Hospital Eating Disorders Tea
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61
Ongoing Medical Monitoring
and Management
“Intervene early, and follow frequently if there
is ANY cause for concern.”
Dr. Christina Grant, MD, FRCPC
Adolescent Medicine, Department of Pediatrics
McMaster University
“You want to create a sense that… it’s going to take a lot of time.”
Dr. Barry Simon, MD, FRCPC
Psychiatrist, Leadership Centre for Diabetes
Mount Sinai Hospital
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63
Ongoing Medical Management and Monitoring: Overview
Eating Disorders
Once you have confirmed an eating disorder diagnosis, regular check-ins are the cornerstone
of your patient care.
PHYSICAL – You will need to monitor the following on an ongoing basis:
WEIGHT
FLUID AND ELECTROLYTE STATUS
CARDIAC FUNCTIONING
PSYCHIATRIC STATUS (E.G., SUICIDALITY)
CONSULTATIONS – You may wish to consider the following consultations:
Psychiatric
Dental
Nutritional
Internal Medicine
HOSPITALIZATIONS – You may periodically need to make a referral to an acute care
facility. Acute services typically involve either day hospital or inpatient care. Unfortunately
they are scarce, may not be in your immediate vicinity and often have lengthy wait times.
See “Levels of Care” Sheet
See “Ongoing Medical Monitoring” sheet
KEY
It is important to remember that you have a critical role to play in ongoing medical
monitoring while your patient is waiting for, or has recently been discharged from, an acute
care facility.
Pre-Admission – It is advisable to connect with the physicians at the site (including
Emergency departments) when you are making a referral or hoping to arrange stabilization
through ER. An admission may be better facilitated through physician-to-physician
contact. A simple phone call can save your patient much time and prevent unnecessary
disappointment.
Post-Admission – Monitor the patient weekly until their health has stabilized, and then move
to bi-weekly/monthly as appropriate. Obtain discharge notes from the treatment centre or
liaise with the site physician. Connect with the family as appropriate. Assess level of client
motivation to sustain changes and plans for follow-up care.
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65
Checklist for Ongoing Medical Monitoring of
Patients with Eating Disorders
The following are suggestions for the medical management of eating disordered patients in your
outpatient practice.
Medical Goals:
For Anorexics:
• normalization of eating patterns
• weight restoration to > 90% Ideal Body Weight (IBW)
• resumption/maintenance of menses
For Bulimics:
• normalization of eating patterns
• cessation of bingeing, purging and excessive exercise behaviors
• maintenance of a healthy, stable weight
For Binge Eating Disorder:
• normalization of eating patterns
• cessation of bingeing
• stabilization of weight
Visits:
The frequency of visits will be determined by age, level of illness severity and whether the patient is
transitioning into or out of an acute admission.
Each Visit:
Record information in the table attached. Review with the patient and other providers as may be
required /necessary.
Weekly and Bi-Weekly monitoring:
Recommendations are included in table attached which can be copied and kept within patient’s file.
Additionally:
Once per month (or more frequently if chest pains or palpitations):
EKG:
Every 6 months or so as needed:
LH: (if amenorrheic)
FSH: (if amenorrheic)
Ferritin:
TSH
Annually:
Bone density (should be performed if amenorrheic >6 months or if past history of osteopenia/
osteoporosis)
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67
68
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Weight
%
IBW
HR
Standing
HR
Lying
BP
Standing
BP
Lying
RR
LMP
Temp.
Height:
Date of Initial Assessment:
Date
PATIENT FILE #:
NAME:
Ca
Mg
PO4
Albumin
Routine lab investigations
(glucose)
Weight:
Eating Disorder Medical Monitoring Sheet
Electrolytes
IBW:
Renal
Function
Amylase
“What to… What not to say”
We receive a great deal of feedback from patients and families about the kind of
language that is helpful to recovery. `What not to say’ comments often speak to
biases whereas `What to say’ comments seem to communicate an appreciation for the
monumental task before families and patients in overcoming an eating disorder.
What NOT to Say to Patients
“You look better”
“You look so much healthier now”
“Your weight is healthier”
“You are looking more normal”
“You’ll grow out of it”
“I promise you won’t get fat”
“I promise you won’t die”
“Wow, you’ve lost/gained a lot of weight lately
“What you are feeling is completely normal for your age”
“Why can’t you just eat something?”
“You’ll probably end up back in the hospital again”
“Your weight is good this week”
“You don’t need to come to my office anymore, you are fine”
“You can choose what you want to eat” (kids)
What TO Say to Patients…
“You are thinking so much more clearly”
“It’s good to see your sense of humour”
“Re-nourishment has made you much more effective at communicating your needs”
“Your concentration has really improved”
“Your personality is really coming through now that your physical health has improved
a little”
“You should be proud of yourself for the steps you are taking to get/stay healthy”
“You can talk to me if you need to”
“This illness has a long course but there is hope”
“Your health is improving”
“Your parents will have to plan your meals for awhile”
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What NOT to Say to Families
“You should have brought her in sooner”
“She’ll outgrow this; it’s just a phase”
“People with eating disorders are very manipulative.”
“I think you are worrying too much”
“This illness seems to run a course of about seven years no matter what you do”
“Maybe if you just tried to cook foods she likes she would start to eat”
“She most likely does not have a problem; her weight is normal for her age and
height”
“Everyone has stress with teenagers”
“Isn’t this illness about controlling too much?”
What TO Say to Families…
“I can appreciate that you are dealing with this all day, everyday”
“I respect how vigilant you are being; it must be exhausting but is so important to
your child’s recovery. You are doing the right thing”
“I understand why you are feeling so anxious about your child’s eating as she begins
steps toward her recovery. It will be a hard balance around slowly letting go of
vigilance”
“During this stage, let me closely monitor your child’s weight and I will be able to tell
you if your child appears to be sliding back into the illness”
“This illness impacts every member of the family”
“It’s not your child fighting and resisting your efforts to help; it is the illness”
“If your child had cancer, you would be doing everything in your power to fight it.
The challenging thing about eating disorders is that, unlike cancer, however, your
child may appear to be fighting the treatment process. Always remember that it is the
eating disorder fighting you and your child. It is the common enemy. Your recovered
child will tell you this some day”
“It is important for you to take care of yourselves also and find ways to release stress
in a positive way”
“This journey could be a long or short one, but continue to have hope that recovery is
possible”
“It’s important for you to stay on top of this illness”
“Of course you would be stressed. What supports do you have?”
“You may have to take more control of his/her meals for a while”
Adapted in part from Northern Health, Prince George Eating Disorders Clinic, 2005
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Availability outside of
region
Availability in Central
West Ontario Region
*Sheena’s PlaceToronto
*Hope’s GardenLondon
*Hopewell-Ottawa
Eating Disorder
Awareness
Coalition
Danielle’s Place
*Purging Behavior All levels
(laxatives and diuretics)
*Structure Needed for All Levels
eating/gaining weight
*Motivation All levels
Patient characteristics
*Medical Status All Levels
Support services
Non-medical
Model
CWEDP Sites:
*Credit Valley Hospital
(CVH)
*Trellis
*Healthcare ServicesOakville(HHS)
*William Osler Health
Centre- Brampton
(WOHC)
Can reduce without
structured
environment
Self-Sufficient
Fair-good
stable
Level 1
CAMH- Comorbid ED +
Substance Abuse
CVH
Trellis
HHS
WOHC
Can reduce without
structured
environment
Requires more frequent
contact but is reasonably
self-sufficient
Fair
stable
Level 2
Intensive Outpatient
Level 5
Inpatient hospitalization
16+ Homewood Health
Centre
Can use support from others
or use therapeutic strategies
to reduce behaviors
Needs supervision at all
meals
Poor-to-Fair
Adapted and Modified from APA Practice Guideline for the Treatment of Patients with Eating Disorders, Third Edition
Adults:
TGH
OGH
NYG
Children and Adolescents:
HSC
CHEO
LHSC-London Health Sciences
Centre- psychiatric beds only
Adults:
CVH
Children and Adolescents
not yet available
Needs supervision at all times
Needs supervision at all times
including before and after all meals,
may require special feeding
Very Poor to Poor
History of instability or hovers Medically unstable, may require
on the border of instabilityspecial feeding; psychiatrically
special feeding not required
unstable(e.g. suicidal); pregnant;
poorly controlled diabetes
Level 4
Residential
Bellwood-Toronto
Adults:
North York General (NYG)
Ottawa General Hospital
(OGH)
Toronto General Hospital
(TGH)
Children and Adolescents:
Children’s Hospital of Eastern
Ontario (CHEO)
Hospital for Sick
Children(HSC)
North York General(NYG)
Southlake Regional Health
Centre (SRHC)
Adults:
CVH
Children and Adolescents:
William Osler- tbd
Can use support from others
or use therapeutic strategies
to reduce behaviors
Needs some structure
Partial
History of instability or often
hovers on the border of
instability
Level 3
Partial Hospitalization
(Day Hospital)
Although your local Level 1 or Level 2 specialized provider may not offer acute care services, we recommend that you connect with the program as a routine part of your approach as there
may be a need to transition patients to these services prior to or following an acute care admission.
Levels of Eating Disorder Care
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73
- “ As far as I am concerned, I don’t have an eating
disorder”
- No intention to change and not aware there is a
problem
- Makes changes only because they are under
pressure- when pressure goes, so does change
- Does not see that action is required on their part
- Will receive help for consequences of E.D. only
- “I accept that I have problems related to an E.D.,
but I am not yet ready to do anything about it”
- Usually has motivational crisis- e.g. something goes
wrong with health, family, finances etc…
- Begins to consider costs and benefits of
overcoming E.D.
- Beginning of the end of denial
- “I am planning to do something about my E.D. in
the next six months”
- Makes the decision to change
- Experiences a number of false starts
- Seeks out information about recovery options and
other needed sources of help
- “ I have taken active steps to address my E.D. in
the last 6 months”
- Symptoms are interrupted
- Confident in and committed to recovery
- Therapy can feel like a full time job
- Develops affective skills to reduce power of triggers
- Reorganizes life and roles to support recovery
- “ I am working to maintain the changes I have
made against my E.D.”
- Productive living, living a full life
- Changes are consolidated
- Active use of relapse prevention strategies
Pre-contemplation
(1 month +)
Maintenance
(varies)
Action
(1.5 years +)
Preparation
(1 month +)
Contemplation
(1 month +)
General: Clients
Stage of Change
- Work on maintaining new ways of communicating
with loved one that are both comfortable and
automatic.
- Now and again you might have to remind yourself
not to slip back
- `New normal’ begins to be established
Prochaska et al., 1992; and The Integrated Recovery Model
-P
rovide range of tools for clients to use in the
management of their symptoms
-E
stablish recovery through cessation of problematic
behaviors, and enhancement of beneficial ones (e.g.
fewer binge-purge episodes but increased healthier
meals/snacks)
-W
ork on learning to cope with life without the E.D.
- Identify what improved quality of life looks like
-B
uild affective tolerance and capacity for addressing
unresolved emotional issues
- F ollow-ups as needed e.g. booster sessions
-R
einforce use of relapse prevention tools
- Key issue is the client’s ambivalence
- Identify issues that keep client stuck
- Identify and monitor emotional states that leave the
client feeling overwhelmed, strategize around ways
to contain these feelings
- Continue
education around healthier self-care and
medical check-ups
- Support the client’s belief that they can change
- Homework has the client altering their E.D.
behaviors in small ways (e.g. delayed binges)
- Provide cognitive and behavioral strategies to
facilitate change
- Continue to notice consequences of E.D.
- Continue to listen & validate feelings
- Understand that some of your own ways of coping,
parenting even though well-intentioned may be
helping to support the eating disorder
- Consider benefits of doing things differently
- Support your loved one’s beliefs that they can
change
- Find support for yourself in your own efforts to
change
- Trial and error during meals, discussion times with
efforts to handle things differently
- Firm yet compassionate caring
- Have expectations that are in keeping with loved
ones life in recovery
- Feels like work sometimes
- Develop skills that help you not to get drawn into
power struggles
- Your own and your family life no longer revolve
around the eating disorder
- T he client wants help to fix the consequences of the
E.D., not the E.D. itself
- F ocus on client’s denial
-P
rovide education
- L isten & validate feelings
-A
ssess for co-morbid conditions e.g. depression and
anxiety
Suggestions for Health Care Practitioners
- Avoid forcing loved one to pursue change
- Encourage general self-care including visit to family
doctor
- Describe out loud, impact of eating disorder on you
- Listen & validate feelings
- Consider how you support the E.D.
Suggestions for Parents/
Supportive Others
Changing our behavior is difficult. The Transtheoretical Model of Change (Prochaska et al., 1992) suggests there is a series of stages we go through before we actually make and sustain
behavioural change. This theory also suggests that we must first develop an intention to change before we can begin to do things differently. People with eating disorders often struggle with
their decision to overcome their eating disorder. This may be related to society’s support of a thin body ideal; or the eating disorder may have become a `friend’ that they are not sure they
can live without. Supportive others are often ready for recovery long before the person with the disorder is. Consequently, it is important to match helping strategies with where the person is
at in terms of their interest in and willingness to change. The table below provides some helpful information about the stages of change, what each stage looks like in terms of illness behavior
and what to keep in mind to encourage, support or maintain change. In the treatment of children and adolescents, we don’t always wait for there to be interest in change. Ensuring continued
physical growth and development is critical and so often work will start with parents if kids are not yet ready for change.
Readiness for Change
Indications for Hospitalization in Children,
Adolescents and Adults
General
The following criteria represent guidelines for you to consider in assessing patient
acuity. Needless to say, they do not replace your best clinical judgment and
knowledge of your patient.
Treatment Reality
Unfortunately, at times hospitalization will be indicated but not immediately possible.
There is a paucity of care available for the specialized treatment of eating disorders
for children, adolescents and adults. Many community hospitals are very cautious
about admitting patients with eating disorders fearing their capacity to provide
specialized care will fall short of the patient’s needs. This may be the case when
there is no physician with eating disorder expertise in the hospital. Nevertheless, if in
your estimation a patient’s symptom constellation warrants an admission you should
seek a medical stabilization admission at the nearest community hospital. A referral
to a specialized tertiary care facility can be arranged while your patient is being
stabilized. It is possible that several stabilization admissions may be required before a
spot in a tertiary care setting becomes available.
It is important to remember and remind everyone, including the patient and his/
her family, that the initial goal is medical stabilization, not comprehensive care or
complete weight restoration.
Children and adolescents deteriorate much more rapidly than adults do. As well, the
optimal opportunity for intervention comes within the first two years of the illness.
Therefore, intervening swiftly is especially critical with young people.
Many patients can be followed safely on an outpatient basis even when they are
medically compromised depending on their access to regular medical monitoring,
outpatient multi-disciplinary care and family support. As the monitoring physician,
ensure that you have the support you require to comfortably provide this care (see
“Physician Support” sheet).
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Indications for Hospitalization:
Children and Adolescents
Adapted From Society for Adolescent Medicine
Position Paper (2003) & APA Practice Guideline
for the Treatment of Patients with Eating Disorders
(2006)
Indications for Hospitalization:
Adults
Adapted From APA Practice Guidelines for the
Treatment of Patients with Eating Disorders
(2006)
CWEDP-2007
CWEDP-2010
1. Weight loss as defined by:
a.<75% healthy body weight for age, sex and height
b.rapid weight loss even if not at <75% e.g. > 15% in one
month,
c.weightloss associated with physiologic instability
unexplained by any other medical condition
d.patient rapidly approaching weight at which physiologic
instability has occurred in the past.
2. Dehydration
3.Electrolyte disturbances (hypokalemia, hyponatremia,
hypophosphatemia, Serum K <2.5mmol/L Serum Cl <88mmol/L )
4.Cardiac dysrhythmia
5.Physiologic instability:
a.Heart Rate -resting daytime near 40 bpm
b.Orthostatic hypotension (with an increase in pulse of >20
bpm or a drop in blood pressure of >10-20 mm Hg/minute
from supine to standing
c.Blood Pressure <80/50 mm Hg
d.Hypothermic (Body temp <36°C)
e.Cardiac edema
6. Acute refusal to eat
7.Acute medical complications due to starvation (syncope,
seizures, cardiac failure, pancreatitis etc…)
8.Symptomatic hypoglycemia or fasting glucose, 3.0 mmol per
litre
9.Esophageal Tears
10.Intractable Vomiting +/- Hematemesis
11.Lack of improvement or worsening despite outpatient treatment
12.Arrested growth and development as per growth chart
13.Acute psychiatric emergencies (e.g. suicidal, psychotic)
14.Comorbid diagnosis that interferes with the treatment of an
eating disorder (e.g. severe depression, obsessive compulsive
disorder, severe family dysfunction)
1.Weight loss as defined by:
a.<75% healthy body weight
b.rapid weight loss even if not at <75% e.g. > 15% in one
month,
c.weight loss associated with physiologic instability
unexplained by any other medical condition
d.patient rapidly approaching weight at which physiologic
instability has occurred in the past.
2. BMI < 16
3. Acute refusal to eat
4.Heart Rate -resting daytime near 40 bpm
4.Blood Pressure <90/60 mmHg
5.Dehydration
6.Orthostatic hypotension (with an increase in pulse of >20 bpm
or a drop in blood pressure of >10-20 mm Hg/minute from
supine to standing
7.Hypothermic Body temp < 36°C
8.Syncope
9.Symptomatic hypoglycemia-glucose <60 mg/dl
10.K <2.5
11.Serum Cl <88mmol/L
12.Esophageal Tears
13.Intractable Vomiting +/- Hematemesis
14.Suicidal
15.Special considerations: poorly controlled diabetes, pregnancy
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Weighing Your Patients
KEY: Weight provides information about overall health and well-being. When weight is unstable or
dangerously low, family doctors need to be the professional who advocates for weight restoration
through weight gain or weight stabilization depending on the disorder being treated. It is the basis
for the restoration of health.
Weighing your patient with an eating disorder is different then weighing other patients in your practice.
For patients with eating disorders, the experience is often a very emotional one. The numbers on
the scale will often determine how they feel about themselves. Their weight can reflect for them how
in control they are of their food intake and bodies. For some people it can be like a challenge or
competition, to be weighed every week. For others, the very thought of stepping on the scales can
intensify fears and eating disorder behaviors.
It is important to establish the role of and method for collecting weight data WITH your patient. Be clear
that being weighed is a necessary part of the treatment and ongoing medical management, but ideally,
is a collaborative effort between the physician and the patient.
Guidelines for weighing and providing feedback to your patient:
• It is best to weigh your patient in a consistent fashion (e.g., clothed, mornings).
• It is usually recommended to weigh your patient with his/her back to the scale so the number cannot
be seen. This however, can be discussed depending on the stage of illness, progress towards
recovery and age and maturity level of the patient.
• Sometimes seemingly innocent comments can be twisted and misinterpreted by the patient with an
eating disorder, and so it is helpful for everyone (nurses and doctors) to remember not to comment on
the number after weight has been taken (See “What to and What not to Say” Sheet).
• If the person insists on knowing his/her weight, but you have determined this is not appropriate
explore with him/her why they want to know and explain how it can do more harm than good to
focus on a number.
• Remind patients of all ages that weight is just one piece of data used to monitor what is going on
with his/her body, health and progress towards recovery. Encourage him/her to get rid of or not use
the scales at home to reduce the focus on numbers.
• If the parents of an adolescent want to know their child’s weight, tell them when the child is not in the
room.
• In the end, if you decide to share a patient’s weight with him/her, explain that body weight will
fluctuate due to many factors including water retention, bladder and bowel contents, etc.
Lynette McGarrell, B.A. Sc., RD, Halton Healthcare- Eating Disorder Program
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Discussing Nutrition
Normalization of eating is the first step in recovery from an eating disorder. Once nutritionally stable,
the individual is better able to deal with the issues underlying the eating disorder and can proceed
with further aspects of recovery. The following nutrition points provide a starting point on the road
to recovery. Optimally, physicians should provide general guidelines only and refer to a registered
dietitian for ongoing, specialized nutritional counselling. Canada’s new Food Guide can be found at
http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index_e.html
1.Normalize eating: Normalized eating or “mechanical eating” means eating 3 non-dieting meals
plus 2 to 3 snacks each day, based on guidelines provided in ‘Canada’s Food Guide to Healthy
Eating.’
2.Timing of meals: Each meal and snack should be eaten at approximately the same time each day.
This focus on mechanical eating facilitates a return to a normal metabolism and natural hunger and
satiety cues. Note: the body needs fuel every 3 to 4 hours.
3.Variety: Normalized eating means choosing a variety of foods from each food group, eating a fat
at each meal, and eating normal portion sizes as outlined in ‘Canada’s Food Guide to Healthy
Eating.’ A snack should consist of 1-2 food groups and meals including 3-4.
4.Energy: Daily energy or caloric intake should total a minimum of 2000 calories per day or more
depending on current BMI, age and level of activity.
5.High risk foods or phobic foods: There are no “good” foods or “bad” foods. All foods have their
place within the context of healthy, normalized eating. Diet foods or low fat food choices are not
generally considered part of normalized eating.
6.Planning Ahead: Planning is of utmost importance. A meal and snack schedule needs to be set
and adequate food variety and snack choices need to be available by making a grocery list and
shopping regularly. It is desirable for the individual with the eating disorder to be involved in
shopping, food choices and food preparation, as well as planning ahead by packing meals and
snacks when away from home.
7.Family Meals: Meal time should not be about policing food intake. Family meals should focus
on topics of conversation other than food. Older individuals and young adults should be given
independence in regard to meal planning, while more family involvement is expected with younger
children.
8.Consultation: When possible involve a dietitian experienced in treating individuals with eating
disorders. Referrals can be arranged directly or through an eating disorder program.
Kathryn Duke RD, Registered Dietitian, Credit Valley Hospital Eating Disorders Team
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Activity Levels, Sports Involvement
and Eating Disorder Recovery
There are few clear guidelines that provide direction for this fairly controversial and largely unstudied
area. As a result, different approaches are followed depending on whether the individual concerned
is a child, adolescent or adult, recreational or elite athlete, in stable or unstable medical condition.
Some points for your consideration:
1.Goal: The goal is to promote a healthy approach to active living so that health benefits and
not health costs can be derived. This includes the promotion of activities that develop optimal
bone (some impact) and cardiac health, are social and not isolatory, are time limited and not
inappropriately physically taxing and have a positive impact on emotional well being. Promoting
this approach among compulsive, obsessive and excessive exercisers is exceptionally challenging,
the goals however remain the same with safety being the most paramount.
2.Medical Acuity: No matter the age or athletic status, an individual in an acute and medically
compromised state is not to be engaging in strenuous physical activity. Acute status might include
but is not limited to: recent episode(s) of fainting; cardiac instability; electrolyte disturbances due to
multiple daily binge-purge episodes, frequent daily laxative abuse; absence of adequate nutritional
intake and/or chronic dehydration.
3.Nutritional Rehabilitation: This is the first treatment of choice and must be clearly defined. Health
goals including body weight and medical status need to be established at the outset and can be
linked to activities that are to be curtailed or resumed. It is best for everyone to know up front what
the rules are.
4.
Excessive Exercisers (McGough, 2004; Shroff et al., 2006):
• choose to pursue activities in isolation
• are motivated to be active, based on compensation for calories consumed
• limit other age appropriate activities in order to exercise
• exercise at inappropriate times and in inappropriate places
• struggle to resist the urge to exercise
• exercise despite injury or medical instability
• may be in the latter stages of their illness if they have a chronic eating disorder history 5.Athletes: In the case of some athletes full cessation of participation in their chosen sport may not be
required (Alleyne, 2006):
• If the athlete is found to have disordered eating rather than an eating disorder i.e. may
have eating patterns that do not match their caloric expenditures but are not demonstrating
significant body image disturbance and are not acutely medically compromised
• If they are willing to receive nutritional education to learn how to better match nutritional intake
with athletic activities
• If once they are provided with relevant education are willing to take active steps to improve
their nutritional intake
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• If they understand and are willing to modify activities until a more optimal health state is
achieved
• If their participation in their sport is not significantly linked to body shape and weight issues
i.e. they are inspired to make changes in their eating and activities for the benefit of their sport
performance rather than reluctant to make changes for the potential impact this might have on
their body shape and weight.
6.Menses: Refrain from early use of oral contraception to assist with loss of menses as this will mask a
key determinant of physical health and nutritional rehabilitation. This is particularly critical in those
in the midst of or close to puberty. Nutritional rehabilitation and weight gain remain the treatment
of first choice for loss of menses as resumption of menses is a significant marker for improved health
and therefore an indication that activity levels may cautiously be increased.
7.Parents: Those that model active living and not exercise for weight loss are in the best position
to help their children establish a healthy relationship to sports and physical activity. Encouraging
parents to examine their own relationship to exercise and active living is important.
8.Have a Plan!: Most active living best practice guidelines promote 30-60 minutes of activity 3-5
days per week. For recreational athletes, this then becomes the benchmark for those seeking to
improve their relationship to exercise. Many treatment programs have adopted a graded activity
schedule that reflects changes in medical stability for example moving from complete bedrest to
weekly unescorted trips to a local gym (Thien et al., 2000). This same philosophy can be applied
to working with children at home as long as their medical status is monitored and fine. Starting
out with 15 minutes per day of physical activity and building to 30 minutes is not an uncommon
strategy. An agreement with an adult patient could use a similar strategy.
9.Anorexics: Encourage a range of activities rather than pursuit of only a few that follows a rigid/
fixed schedule. Monitor medical status very carefully and adjust activity levels as health improves
or declines. Promote exercise as a way to maintain overall health and not simply as a method for
weightloss.
10.Bulimics: Encourage physical activity not as a method for caloric compensation but rather as a way
to more effectively manage emotions (anxiety and depression) and derive overall health benefits.
Promote physical activity as pleasure not pain, play not work using structured activities that help to
promote a sense of consistency, predictability and routine.
11.Education: Excessive exercise may not be accomplishing what an individual believes it to be doing.
For those who always engage in the same activities that do not include strength building, fitness
might in fact be being compromised rather than built. This is particularly the case where someone is
additionally nutritionally compromised.
12.Children and School: You may need to work with parents to support requests that a child be exempt
from gym and /or temporarily removed from school teams while their health is being restored.
Children in schools today face multiple stressors that can aggravate or trigger body image
concerns and/or disordered eating. Parents can be encouraged to become aware of their child’s
school environment particularly around policies pertaining to weight based teasing, starve-a-thons,
unwarranted use of fat callipers and BMI testing by individuals ill equipped to deal with individual
responses to the testing, and promotion of physical activities that are inclusive of all sizes, shapes
and skill levels.
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Preparing for an Eating Disorder Hospitalization:
Information for Physicians
Physician’s Role
1. Assess:
• Assess the patient’s medical status immediately prior to making a referral. You will be asked for
information pertaining to weight, BMI, and other vitals. It helps if this information is recent.
2. Refer and Connect:
• Liaise with a Physician at the site you are sending the patient to
• If it is a Community Hospital Emergency Physician, be clear that you are seeking a Medical
Stabilization stay right now and not comprehensive care for the eating disorder. Explain that
you are aware the stay may be short
• If it is a Tertiary Care Centre PLEASE do not recommend to families that they simply show up
at the Emergency Department. We are seeking to streamline and coordinate admissions rather
than handle them reactively
Encourage families to follow up in the order as follows:
1. Family Physician
2. Community Hospital- Emergency Department-with advance call from GP
3. Tertiary Care Centre- with advance call from GP
4. Out-of-Country Referral- last resort, must be handled through GP or Psychiatrist
3. Educate Families and Patients:
• Provide Hospitalization Information sheets to patients and families
• Distinguish between types of hospitalizations:
➢Medical stabilization stays are typically short and predominantly attend to medical issues
aimed at keeping the patient alive and reducing medical risk of further complications.
Specialized expertise is often not available on general pediatric or medical floors. Stays
are typically 2-8 days
➢A specialized comprehensive eating disorder admission is typically longer, attends first to
weight and nutritional stabilization followed by therapies aimed at addressing motivation
for change and underpinnings of the disorder. Stays are typically 2-6 months. Admissions
are voluntary and patients will need to be willing to follow a treatment program
➢Outpatient care addresses motivation for change, psychological issues and relapse
prevention, is typically 2-7 years in duration and can precede/follow hospitalization
• During Hospitalizations:
➢Weight- will be taken regularly
➢Nutritional intake will vary with medical status, type of facility admitted to and staff training
on the unit where admitted. Meals are typically regular hospital fare- 3 meals and 2 snacks
➢ Privileges on units will often vary with medical status
➢Admissions- sometimes it takes more than one admission for individuals to stabilize. While
admissions are voluntary patients are expected to follow the program protocol while in
the hospital. If patients are not ready for this type of treatment they can be encouraged to
return to the hospital when more ready to progress in care
4. Follow-Up:
• Schedule regular monitoring appointments following discharge. Ideally, care should be
planned and coordinated with an outpatient program. Make a referral to an outpatient eating
disorder program if not already done
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Ethical Issues in the Compassionate Care of
Those with Eating Disorders
In the provision of care to those with eating disorders, a number of ethical issues can arise. Most often
these surface with increased illness severity, and mortality risk. Practitioners must reconcile their sense
of duty to protect the health of their patients with the rights of patients to make their own healthcare
decisions also bearing in mind their own personal values and beliefs. The following is a very brief list
of some of the most common issues and dilemmas:
Physician self-knowledge – It is essential that you understand your own views about body image,
dieting and weight loss in order to provide the best possible healthcare information and advice to
patients and families. Communicating what is normal and abnormal around body image, nutrition and
weight and shape preoccupation without personal biases is essential. It is helpful to examine your own
beliefs about those who suffer from eating disorders. If you see these disorders as a normal phase of
adolescence to be outgrown, or only as deliberate attempts to manipulate those around them and not
as serious mental health illnesses with potentially debilitating and chronic medical sequelae, you will
likely miss opportunities to educate and help families, reduce medical risk and advocate for timely and
compassionate care.
Therapeutic alliance – A strong therapeutic alliance with the patient is fundamental but having one can
raise some ethical issues. The physician may feel genuinely torn when faced with the task of breaching
confidentiality should a patient’s medical health become compromised. When very ill the patient
may no longer be deemed competent to make his/her own healthcare decisions and must receive
compulsory medical treatment. The cost to the therapeutic alliance must be weighed against both the
short and long term health risks to the patient.
Competence to consent to and refuse treatment – Patients with eating disorders are often bright,
articulate individuals even when severely medically compromised. They typically demonstrate an
understanding of the treatment being advised and seemingly of the consequences associated with
treatment refusal. However, their eating disorder may severely restrict their insight and ability to make
healthy treatment decisions. The health risks to the patient must be balanced with due respect for patient
autonomy.
Exercise/Sports and Anorexia – The question of whether those suffering from anorexia should
be permitted to participate in fitness classes or other sports, particularly when severely medically
compromised, is receiving increased attention (Giordano 2005). A key issue is that anorexics are not
likely to tell their instructors/coaches or physicians, who then are not able to make informed choices
around whether to permit participation. Giordano differentiates between other types of medical
illnesses and anorexia in that the exercise is PART of the anorexic’s condition and therefore the risks
outweigh the benefits. However, this argument is countered with issues of safety. For someone who is
likely to exercise anyway, perhaps doing so within the confines of a class or group may be the more
effective response since supervision and time limits are part of such forms of exercise.
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Behavioral Programs – Behavioral programming has long been used in the treatment of eating
disorders. Some view such programs as reward based, whereas others see the treatment as punitive
and coercive. Behavioral strategies continue to be used in one form or another in most treatment
programs but efforts are being made to make them more collaborative and humane.
Palliative Care – When someone with an eating disorder is in the final stage of his/her illness, issues
around palliative care may need to be discussed. Being mindful of your own beliefs and values around
eating disorders at this stage is important. How you advocate for your patient to the staff of the hospital
can impact the care he/she receives. These patients, just as anyone else with any other illness, deserve
to die with dignity and in comfort. A very controversial issue concerns when cessation of treatment is
compassionate and palliative and when it constitutes passive euthanasia.
Multidisciplinary Teams and Multidisciplinary Views – The treatment of eating disorders typically
requires the involvement of multidisciplinary professionals in addition to the patient’s family physician
and family. When complicated issues arise such as that of compulsory treatment, differing opinions
in the face of a treatment resistant patient can fraction even the most well intended professionals and
families.
Gender Issues – This is an important issue given that the majority of eating disorder patients are
female. While female physicians may be more likely to appreciate the social pressures of their female
patients, there is no body of evidence to suggest that they are better care providers than their male
counterparts. Competent physicians can provide competent care, regardless of gender. Being aware of
your own gender biases is helpful in negotiating the challenges that form part of the physician-patient
relationship.
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Helping Patients Help Themselves
“Be non judgmental, take what your patient is saying seriously,
not making light of something that was difficult
for the patient to bring up.”
Dr. Colleen Flynn, MD FRCPC
Previously Medical Director, EDP
Credit Valley Hospital
“Be really clear and transparent, up front (with adolescents)
regarding confidentiality and their rights.”
Dr. Christina Grant, MD, FRCPC
Adolescent Medicine, Department of Pediatrics
McMaster University
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Helping Your Patients to Help Themselves:
An Introduction for Physicians
Motivation… Motivation… Motivation
One of the greatest challenges for most eating disorder patients is staying motivated for
recovery. It is very hard work to recover from an eating disorder given that so many systems:
physical, mental, emotional and social, are affected. Given that the typical course of illness is
approximately 7 years and that there is significant social support for the pursuit of a thin body
ideal, this can represent an overwhelming challenge.
Individuals must seek their own reasons for overcoming their illness. These are often related
to those things that provide them with a sense of quality of life. Helping individuals to identify
and then stay focused on these despite the ups and downs, is critical to their long term
recovery and overall quality of life.
Children and Adolescents and Motivation
Although motivation issues are equally relevant in the recovery of children and adolescents,
the need to restore physical health to minimize the permanent impact on growth and
development supersedes the need to wait for motivation to `hit’. Parents need to be
encouraged, coached even, to reestablish parental authority around eating adequately,
seeking medical attention and personal safety. For example reasserting that “in our family
we take care of ourselves by eating properly, going to the doctors when we are not well
and through not taking safety risks when we are undernourished e.g. drive a car or
exercise rigorously when we have not eaten in days.
Health Monitoring… Health Monitoring…. Health Monitoring
Through helping your patients to stay focused on the things that matter most to them outside of
body shape and weight concerns at any age or stage of illness, it then becomes a little easier
to point out that without medical health and stability these things will not be possible. Through
regular medical monitoring their physical health becomes the key vehicle through which they
can return to or move towards those things they miss most in their lives. Spending time with
friends, returning to work or school, having a relationship or being able to participate in
activities they have not been able to for some time are all possible when their health permits it.
The worksheets in this section are designed to help you help your patients think about
and stay focused on what recovery means to them. You have a few tools to help get them
started and these coupled with your ongoing health monitoring and involvement of other
professionals as necessary will help your patients to better help themselves.
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Helping Yourself Recover
Recovering from an eating disorder is not easy. Many think it is just about getting back to eating again.
If only it were that simple. While there are things others around you can do to help, the key person is
you. Change takes time and energy, both emotional and physical. This can feel lonely, overwhelming
and frustrating at times. Take some time to think about the following:
1.Your role in your recovery. One of the hardest things to do in recovering from an eating disorder is
to decide that you do indeed want to `give up’ the eating disorder and take better, more healthful
care of yourself. Ultimately, this is the decision that everyone must make at some point before
change is possible. We understand that making this decision is complicated. Most people remain
ambivalent or uncertain for a long time. Ask your doctor for the `Thinking about Getting Better’
worksheet.
The following are a few reasons why people find it hard to recover:
• They feel pressure to stay thin or diet for their sports, family, friends or boyfriends/girlfriends
• The eating disorder is a life preserver, something they can hang onto during tough times
• They’re scared that they will gain a lot of weight
• The eating disorder helps to distract them from other more upsetting issues
• They are scared to consider what giving up the eating disorder might be like
• They don’t know how to give it up, where to start or who to go to for help
• It is hard work!
The following are a few reasons why people choose to recover:
• They miss having certain people or activities in their life
• They want to feel better, less ashamed, more optimistic, less moody, more fun-loving
• They want more intimacy in their lives
• They don’t want to feel depressed or completely emotionally drained anymore
• They would like to stop crying all the time
• They want to feel good about being in their own skin
• They resent all the time the eating disorder takes
• They want their life back
2. Y
our role in your physical health. You are the keeper of your body. You are in the best position to
either ignore or honor the cues that your body sends you. If you ignore important signs and signals
for long enough you will develop medical complications. If you are beginning to notice symptoms
and/or are worried about your health, check in with your doctor. Doing this doesn’t mean that
you have to make up your mind about recovery. You can then decide whether and when to `invite’
your doctor to become part of your recovery team. While your family and friends may insist that
you show up at a doctor’s office, you can decide how much they get to participate by how honest
you are with them, how much information you share. Your family doctor can monitor your health
regularly and make specialist referrals such as to Counsellors, Dietitians, Psychiatrists, and Dentists
etc.
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3. Y
our role in deciding what kind of care you need. Are you looking for support or treatment right
now?
• Support Services are those that are offered free of charge through a Support Centre. Usually
they ask few questions, do not require a referral, and offer no medical support or monitoring.
You are free to decide which of the services offered you would like. Typically, you can come
and go as your time and needs dictate.
• Treatment is different in that you are usually assessed and given a treatment plan. The first step
is usually to restore your medical health. There is usually a treatment team made up of different
professionals who have designed a program for you. This usually consists of individual and/or
group therapy. Group therapy is NOT second class care; the research supports group therapy
treatment as best practice.
• Both Treatment and Support can be used simultaneously to improve the overall quality of your
life.
4. Y
our role with your weight and getting weighed. Weight is a very sensitive topic for people with
eating disorders. It is however, a key indicator of your overall health. If your weight is too low you
are at risk for complications just as it is when it is too high. This is why it is important to have your
weight monitored. How you get weighed and the optimal weight you are aiming for in recovery
can be worked out with your family doctor as part of your care plan.
5. Y
our role with your eating. If you are a student and still living at home, your parents bring food into
the house. However, it is up to you to decide what and how much to eat. This is true as long as
you are making good health decisions. When you stop making healthy choices, the people around
you become concerned and want to get involved. As an adult, you have to both provide the food
and decide what and how much to eat. Without a doubt though, food is the medicine of choice for
eating disorders. Treatment and Support services are aimed at helping you to restore normal eating
patterns and re-establish a healthier relationship with food and eating.
6. Y
our role in creating a personal support team. Recovery is hard to do alone. It is important, both
when you’re thinking about getting better and when you have made up your mind to do so, to have
a few people who are on your team. You can help them help you by being honest, and letting them
know how they can be helpful, even if it means just listening. Your support team might include your
parents, husband/boyfriend, siblings, colleagues, friends, family doctor, teacher, coach or pastor.
Sometimes the members of your team can have different roles or `jobs’.
MY TEAM
Consider the Following Questions:
v Who listens the most and judges the least?
v Who `shows up’ when I need them most? v Whose advice has my best interests at heart? v Who do I trust?
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- “ As far as I am concerned, I don’t have an eating
disorder”
- No intention to change and not aware there is a
problem
- Makes changes only because they are under
pressure- when pressure goes, so does change
- Does not see that action is required on their part
- Will receive help for consequences of E.D. only
- “I accept that I have problems related to an E.D.,
but I am not yet ready to do anything about it”
- Usually has motivational crisis- e.g. something goes
wrong with health, family, finances etc…
- Begins to consider costs and benefits of
overcoming E.D.
- Beginning of the end of denial
- “I am planning to do something about my E.D. in
the next six months”
- Makes the decision to change
- Experiences a number of false starts
- Seeks out information about recovery options and
other needed sources of help
- “ I have taken active steps to address my E.D. in
the last 6 months”
- Symptoms are interrupted
- Confident in and committed to recovery
- Therapy can feel like a full time job
- Develops affective skills to reduce power of triggers
- Reorganizes life and roles to support recovery
- “ I am working to maintain the changes I have
made against my E.D.”
- Productive living, living a full life
- Changes are consolidated
- Active use of relapse prevention strategies
Pre-contemplation
(1 month +)
Maintenance
(varies)
Action
(1.5 years +)
Preparation
(1 month +)
Contemplation
(1 month +)
General: Clients
Stage of Change
- Work on maintaining new ways of communicating
with loved one that are both comfortable and
automatic.
- Now and again you might have to remind yourself
not to slip back
- `New normal’ begins to be established
Prochaska et al., 1992; and The Integrated Recovery Model
-P
rovide range of tools for clients to use in the
management of their symptoms
-E
stablish recovery through cessation of problematic
behaviors, and enhancement of beneficial ones (e.g.
fewer binge-purge episodes but increased healthier
meals/snacks)
-W
ork on learning to cope with life without the E.D.
- Identify what improved quality of life looks like
-B
uild affective tolerance and capacity for addressing
unresolved emotional issues
- F ollow-ups as needed e.g. booster sessions
-R
einforce use of relapse prevention tools
- Key issue is the client’s ambivalence
- Identify issues that keep client stuck
- Identify and monitor emotional states that leave the
client feeling overwhelmed, strategize around ways
to contain these feelings
- Continue
education around healthier self-care and
medical check-ups
- Support the client’s belief that they can change
- Homework has the client altering their E.D.
behaviors in small ways (e.g. delayed binges)
- Provide cognitive and behavioral strategies to
facilitate change
- Continue to notice consequences of E.D.
- Continue to listen & validate feelings
- Understand that some of your own ways of coping,
parenting even though well-intentioned may be
helping to support the eating disorder
- Consider benefits of doing things differently
- Support your loved one’s beliefs that they can
change
- Find support for yourself in your own efforts to
change
- Trial and error during meals, discussion times with
efforts to handle things differently
- Firm yet compassionate caring
- Have expectations that are in keeping with loved
ones life in recovery
- Feels like work sometimes
- Develop skills that help you not to get drawn into
power struggles
- Your own and your family life no longer revolve
around the eating disorder
- T he client wants help to fix the consequences of the
E.D., not the E.D. itself
- F ocus on client’s denial
-P
rovide education
- L isten & validate feelings
-A
ssess for co-morbid conditions e.g. depression and
anxiety
Suggestions for Health Care Practitioners
- Avoid forcing loved one to pursue change
- Encourage general self-care including visit to family
doctor
- Describe out loud, impact of eating disorder on you
- Listen & validate feelings
- Consider how you support the E.D.
Suggestions for Parents/
Supportive Others
Changing our behavior is difficult. The Transtheoretical Model of Change (Prochaska et al., 1992) suggests there is a series of stages we go through before we actually make and sustain
behavioural change. This theory also suggests that we must first develop an intention to change before we can begin to do things differently. People with eating disorders often struggle with
their decision to overcome their eating disorder. This may be related to society’s support of a thin body ideal; or the eating disorder may have become a `friend’ that they are not sure they
can live without. Supportive others are often ready for recovery long before the person with the disorder is. Consequently, it is important to match helping strategies with where the person is
at in terms of their interest in and willingness to change. The table below provides some helpful information about the stages of change, what each stage looks like in terms of illness behavior
and what to keep in mind to encourage, support or maintain change. In the treatment of children and adolescents, we don’t always wait for there to be interest in change. Ensuring continued
physical growth and development is critical and so often work will start with parents if kids are not yet ready for change.
Readiness for Change
Thinking About Getting Better
Recovery can be hard work. You have to find some very personal reasons for wanting to change.
Here are some questions to ask yourself to help you think about change and recovery in a positive
way. Answer these, and put them in a private place so that you can find them when things get tough.
Share them with your support team: a friend, your family doctor, parents or a counselor can help them
understand why you would like to get better.
1. What would getting better change?
2. What might I be doing differently if I was feeling better?
3. Who would be back in my life or in it more often, if I were felt healthier?
4.What else would I be thinking about if I wasn’t so preoccupied with thoughts
about my body, food and dieting?
5.What do I find most helpful in my efforts to take better care of myself?
6.Who do I need to invite to be on my own personal recovery team? (See “Helping
Yourself Sheet”)
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Food Journal
A food journal can be a helpful tool when you are trying to better manage your daily nutrition. It can
help you understand the link between your eating, behaviors and emotions. Keeping a food journal can
help you notice trends in how you manage your days, manage your body’s basic nutritional needs and
stay on track with health goals. You might consider sharing this information with your family doctor,
counselor or other helper. This may help them understand how challenging this part of your recovery
can be.
INSTRUCTIONS
Each time you eat something, write it down beside the date and time of day column. Indicate how
much of each item you consumed (ate or drank). Then identify whether it was a meal (m), snack (s),
or binge (b). In the forth column write down whether you had any urge to binge (b), vomit (v), use
laxatives (l), exercise (e), or restrict (r). In the comments section, put any thoughts and feelings you
may have had, and try to describe the situation, event or circumstances surrounding this occasion.
For example, one entry might look like this:
Date and Time
Sat. 10am
Food
Consumed
Urges
(1=minimum10=maximum)
Type
Cereal, bagel, m
milk
B6
Comments
stayed in the kitchen too long
after breakfast and started to get
the urge to binge-left the kitchen
and felt better!
Or this:
Date and Time
Sat. 10am
Food Consumed
Cereal, bagel, milk
Type
m
Urges
R10
Comments
Could only manage ½ the
bagel, kept thinking it was all
too much! Too scared
Please see page 2 of this worksheet for a blank copy that you can print & photocopy for use as often as needed.
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My Food Journal
Date and Time
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Food
Consumed
Type
m=meal
s=snack
b=binge
Urges:
1=min10=max
Comments
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Managing Binges
It is hard to stop bingeing but it is possible. Below are some tips that have helped others in their
struggle to overcome Bulimia. Remember that your binges are linked to how you eat throughout the
day, and to your emotions. What works one day may not be so helpful the next. Try all the suggestions
listed and see which ones work best for YOU.
1. T ry eating small meals through the day. A binge is your body’s way of screaming for nutrition. Even
eating small meals or snacks throughout the day can help to reduce the urges to binge by keeping
your blood sugar levels and mood controlling hormones stable.
2.Ditch your scale. Your personal worth should not be assessed by a scale. Ditch your scale, slowly if
you have to. Discover what really makes you feel good.
3.Track your emotions. Sort out which emotions lead to you feeling like bingeing. Use a food
journal to learn the where, what, when and who of your binges. This information will help you to
determine which tools you need in your recovery toolbox so that you can handle tough situations,
people and feelings. Use these tools to better cope and prevent relapses.
4. U
se visualization throughout the day. Your mind is very powerful. Learn to use it in helpful rather
than harmful ways. Before you start each day, visualize yourself moving through it with a sense of
calm, eating your three meals with comfort and taking care of yourself in nurturing ways. During
the day if you begin to feel like bingeing, close your eyes and visualize yourself getting through the
urge and coping with whatever has come your way.
5. C
ost- benefits analysis of your binges. Write a list of all the costs of your binges. Think about how
much money they cost, the lost time they produce, how unable to do anything afterward and how
exhausted you feel. Binges often produce a tremendous sense of shame. What are the benefits of
your binges? Do the benefits outweigh the costs?
6. B
e active! Go for a walk, get outside. Wear comfortable clothes, go with a friend. Relax. No
pressure and no image related concerns. Have fun!
7. B
uild your self-control muscles- slowly by using delay tactics. Make a deal with yourself. Start by
delaying binges or purges by five minutes. Then increase to 10, then 15 minutes or even half a
day. If, after this time, you still feel the urge, you will still have helped to develop your self-control
muscles for the future.
8. E mergency card. Make a list of all the things you have tried that have offered some help, even
just some of the time. Put the list on a card and keep it in your wallet. When you are feeling
overwhelmed and not quite sure what to do, pull the card out and pick one (e.g. go for a walk,
take a few deep breaths, have a warm cup of tea, call a friend, take a bath etc.)
9. T hings I love to do. Make a list of all the things you might enjoy doing with the time you now
spend thinking about food, weight and shape issues. Write one on your mirror with lipstick or
washable marker everyday. What time would you like to reclaim for your life?
10.Remember, you are not alone. It is easy to feel that others simply couldn’t understand or be helpful.
You would be amazed though at what a little support can do to help you feel less alone and less
ashamed. Find someone you trust and lighten your load just a little by reaching out for support.
11.See your doctor. Get checked out physically to see if underlying and untreated metabolic
abnormalities are contributing to your binge eating (e.g. elevated blood sugars, insulin resistance)
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Preparing for an Eating Disorder Hospitalization:
Information for Patients
Treatment
Depending on where you are admitted and why, you are likely to receive different levels of
care, and have different expectations placed on you. It is important to remember that you
will make the most of any treatment if you are able to think clearly, and that means being
medically stable first. It is important to remember that a hospitalization stay is very often
just the beginning of the recovery process and not a comprehensive eating disorder `fix’.
Sometimes it takes more than one admission.
• Medical Stabilization:
General community hospitals admit you to restore your medical health. Their goal is
to reduce immediate risks to your life due to symptoms related to your eating disorder.
Most often the staff working with you here do not have specialized eating disorder
expertise, but do know how to restore your medical health. It is important to remember
that the focus of the staff during this admission is to take care of your MEDICAL needs
and to keep you alive. Stays are usually short and can range from 2-8 days.
• Medical and Psychiatric Stabilization:
Sometimes you may be at risk physically AND mentally. For example you may feel
suicidal, have urges to seriously harm yourself, or be out of touch with reality. This
is when both emergency mental AND physical care may be required. Unfortunately,
this care is often hard to find. The job of the staff is to make sure you are safe both
mentally and physically. These programs don’t usually have staff with eating disorder
expertise but are experienced with managing general mental health and medical
crises. Once stable, you may go on to more specialized eating disorder care. Stays
typically are short and can range from 1-4 weeks.
• S
pecialized Eating Disorder Care: We find at all levels of care, clients typically have
ambivalent feelings about recovery.
Inpatient Admissions:
Sometimes, prior to a specialized admission, a separate medical stabilization stay
may be required. Specialized inpatient stays continue to maintain medical stability
through 24 hour medical monitoring. Treatment encourages a resumption of more
normalized eating. This may include supervised alternatives to solid food intake, safe
withdrawal from laxatives, supervised meals for reduction of purging behaviors and
monitoring for severe compromise to your physical health. Individuals who struggle to
eat anything may be appropriate. Staff have specialized training.
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Day Hospital Admissions:
These are programs where individuals are no longer at imminent medical risk. Clients
can go home in the evenings and eat some foods on their own without needing
supervision, but still struggle to maintain their activities of daily living. Motivation
for change and deeper issues at the core of the eating disorder can begin to be
addressed here. Treatment might include: group, individual and/or family therapy;
nutrition assessments and counselling; activity groups; medication review; meal
planning and support; medication treatment and team consultations. Clients are
usually placed with people around their own age. Staff have specialized training.
Outpatient Programs:
These programs are offered to those in the middle, just starting treatment but not
medically compromised and to those still undecided about recovery. Motivation
to change and deeper issues underlying the eating disorder are often addressed.
Most often, services include group, individual and/or family therapy; and nutritional
assessments and counselling. Staff will usually have specialized training.
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Eating Disorder Resources for Patients & Families
Websites
Central West Eating Disorder Program (CWEDP)
www.cwedp.ca
Danielle’s Place www.daniellesplace.org
Sheena’s Place
www.sheenasplace.org
Homewood Health Centre
www.homewood.org
National Eating Disorders Information Centre (NEDIC)
www.nedic.ca
Something Fishy Website
www.somthing-fishy.org
National Institute of Mental Health (NIMH)
www.mentalhealth.com
Canadian Mental Health Association (CMHA)
www.cmha.ca
Canada’s Food Guide www.hc-sc.gc.ca/fn-an/food-guide-aliment/index_e.html
Support Centres
Danielle’s Place- Burlington
Sheena’s Place- Toronto
EDAC- Waterloo
(905) 333-5548
(416) 927-8900
(519) 745-4875
Finding a Private Practitioner
National Eating Disorders Information Centre
v Information and Resources
v Service Provider Search Directory
www.nedic.ca
1-866-633-4220
(416) 340-4156
Specialized Treatment Contacts – CWEDP Sites
Trellis Mental Health and Developmental Services (serving Waterloo Region and Wellington County)
General Intake
(519) 821-3582
1-800-471-1732
Credit Valley Hospital, Mississauga
(905) 813-4505
Halton Healthcare Services, Oakville Trafalgar Memorial Hospital
(905) 815-5127
William Osler Health Centre, Brampton Civic Hospital
(905) 453-1160
Coalitions/Prevention
Body Image Coalition of Peel
v Directory/Resources and Services www.bodyimagecoalition.org
(905) 791-7800 ext. 2063
Eating Disorders Awareness Coalition of Waterloo Region
v Directory/ Resources and Services
Wellington-Dufferin-Guelph Eating Disorders Coalition
About Kids Health
BodySense: Promoting Positive Body Image in Sport
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www.edacwr.com
(519) 745-4875
April Gates
(519) 824-1010 (ext. 2292)
www.aboutkidshealth.ca/thestudentbody/
www.bodysense.ca
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OUR HISTORY
Over 13 years ago, Sheena Carpenter lost her battle with anorexia and bulimia. Sheena’s
Place resulted from this tragedy and through the dedication of our founders and supporters
we have been able to honour Sheena’s memory and serve thousands of other individuals and
families affected by eating disorders.
WHO WE ARE
Sheena’s Place is a community-based centre offering hope and support services to people
affected by eating disorders. Since our incorporation in 1994 we have been committed to
providing tangible help to individuals and families for whom resources are scarce to none.
Sheena’s Place is centrally located in a welcoming house in downtown Toronto.
OUR SERVICES
All those who participate in our programs do so by self-referral and there is no cost.
We offer over 50 different groups at any one time in four main areas:
Support
Body Image
Expressive Art
Skill Building
Sharing feelings & strategies in an informal setting
Heightening awareness about feelings towards the body
Exploring various art materials as a form of expression
Offering new ways of coping or making changes
Sheena’s Place also has an extensive lending library on eating disorders and related issues.
HOW TO FIND OUT MORE
You can drop in to have a tour, learn about the agency, the nature of our services or arrange
an individual information interview to ask more specific questions and get help in finding the
right group for you.
For appointments call 416 – 927-8900 or drop in on Wednesdays from 11 a.m. to 1 p.m.
For more program information please visit our website: www.sheenasplace.org or visit our
centre. 87 Spadina Road, Toronto, Ontario M5R 2T1 416 927-8900
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Helping Families
“Never falsely reassure parents about issues with regard to possible
eating disorders in their young teenage daughters.”
And…
“Think of the parents; they are the ones that have to
carry out the plan.”
Dr. Rod Wachsmuth, MD DipCPsy, FRCPC
Staff Consultant, Eating Disorders Program
Toronto General Hospital
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Helping Families:
An Introduction for Physicians
Families can present in different ways. Some families may be in complete denial, minimizing
symptoms or illness severity as well as the need for their loved one to receive treatment, a very
few will be unwilling to ensure their loved one has access to available care. The vast majority
will come forward feeling overwhelmed, exhausted and hopeless. They will have tried their
best to address the eating disorder in the best ways they know how for better or for worse.
Taking a punitive and blaming approach, no matter the family circumstances, typically does
not produce positive results.
The presence of an eating disorder within a family can produce dramatic, broad and
enduring consequences. Everything from how, what and when a family eats, to larger issues
such as financial stability, trust and closeness can be impacted. If caught early, many of these
impacts can be minimized but once family patterns are altered to accommodate the illness,
change can be an uphill battle.
Fostering a strong alliance that is `team’ oriented with the parents of children and adolescents
and an approach that promotes education and support for the parents of adult children with
eating disorders is more critical to recovery than identifying the causes of the eating disorder.
There remains no single recipe or family type that explains the reasons why someone
develops an eating disorder.
Parents:
• N
eed help and support for themselves as individuals and as a couple
• Must consider the other siblings- the illness significantly impacts the quality of their lives
and often they are forgotten
• They themselves are likely readier for their loved one’s recovery than their loved one is.
Parents are not usually struggling with the same ambivalence about recovery that their
loved one is
• Once a child becomes an adult the emphasis of care changes from one of a family
orientation to one that requires the individual to take on the responsibility for his/her
recovery. This can greatly impact the flow of information and involvement parents have
in their loved one’s recovery
• Parents need to reflect on their own beliefs, lifestyle choices, healthcare practices and
conversations, and consider whether these are conducive to recovery i.e. are they
practicing a non-dieting approach to life and living, body size, weight and shape?
• Need to learn how to support recovery and not the eating disorder
• Family therapy for those with children and adolescents is the therapy of choice when
available. Most typically this will be through a specialized treatment program
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Spouses/Partners:
• N
eed to seek help and support for themselves
• Need to be reminded that they are not responsible for their partners recovery
• Need to continue to encourage participation in treatment and permit the physician and/or
multi-disciplinary team to take on the “job” of helping their partner to recover
• Steer clear of questions such as “How do I look? Am I fat?”. There is no winning so best
not to engage in this dialogue
• Consider whether their own lifestyle choices, beliefs, healthcare practices and
conversations are conducive to recovery i.e. are they practicing a non-dieting approach
to life and living, body size, weight and shape?
• Need to learn how to support recovery and not the eating disorder
Siblings:
• Often siblings are forgotten in the effort to get help for the sibling with the eating disorder
• Encourage parents to seek support for siblings so that their concerns can be expressed
and addressed
• Ascertain that other siblings are not demonstrating signs and symptoms of an eating
disorder. This is not uncommon and may be more or less likely depending on (Honey et
al, 2006; Klump et al 2002) the following:
➢their own relationship to their parents
➢family characteristics
➢their involvement in the eating disorder of the first sibling
➢their understanding of the illness
➢professional interventions received to date
➢whether they themselves have been teased about their own weight
➢their own life events
➢their body size, weight and shape beliefs
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Guidelines for Family and Friends
There are no quick or easy solutions for recovery from an eating disorder. Therapists, physicians and
other experts have no magic that can cure your loved one. Be wary if someone offers guarantees or
quick cures.
If the sufferer is to recover s/he will need to make some attitudinal and behavioral changes. You
cannot make them for him/her. You and other loved ones will also need to make some changes to
accommodate his/her growth. It is a good idea for all of you to take advantage of professional help to
make the rough spots a little smoother.
1.Allow yourself not to know all the answers about how to help the person you love. This does not
make you any less of a parent/partner/sibling/friend. Admitting your lack of understanding of the
problem demonstrates you are human and allows the individual to seek professional help.
2.If your child is under 19 (legal adulthood), GET HIM/HER INTO THERAPY IMMEDIATELY. Do not
hesitate out of fear that s/he will hate you.
3If the individual is over 19 years of age, you need to recognize that you have no legal control over
her/him. S/he can choose to be helped, or not. You do have control however, over how much
you will let yourself be affected by the behavior. To protect yourself, you may have to negotiate
limits on the amenities you provide which reinforce the eating disorder behaviors.
4.Once the individual is in therapy, avoid getting involved in discussions or arguments over weight
and food behaviors. If you become concerned about weight loss, dehydration, or other signs
of medical deterioration call the therapist, physician, or both. If your child over age 19, your
concerns need to be discussed openly between the two of you, rather than contacting the doctor.
5.Do not let family life or your relationship revolve around the eating disorder. Make sure you and
other members of the family take time for satisfying activities and fun. Do not spend all of your time
with the person who has the eating disorder; you will encourage mutual dependence. Both of you
need to maintain outside friendships.
6.Do not give the eating disorder control over what the family eats, which restaurants you patronize,
or where you go on outings and vacations. Remember, other family members are entitled to have
input into these kinds of decisions.
7.Give the individual responsibility for the consequences of her/his words, actions, decisions, and
behaviors. Do not protect the individual by giving her/him the power to avoid all situations s/he
finds distressing.
8.Give him/her responsibility to replace what she/he has eaten on a binge, or to clean up the
bathroom in which a purge has occurred. This is intended to help the individual deal with reality
without punishing the behavior. However, in some instances the person with the eating disorder is
not always financially able to replace what she/he has consumed.
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9.Verbally and physically express unconditional love, acceptance and affection for the individual.
Do not tie your caring to sermons about eating and demands concerning weight gain.
10.Admit you sometimes feel angry, frustrated, helpless, afraid, powerless, and hopeless. Allow
yourself to show these feelings and allow her/him to see them. By sharing your feelings, you are
providing the most direct permission for the individual to feel and express her/his own emotions.
11.Participate in family therapy or a support group. Don’t become isolated with your problem; it only
escalates feelings of isolation and resentment. Keeping the disorder a secret does not help anyone.
12.Develop ways of sharing and socializing that do not involve food. Develop dialogues about topics
other than food, weight and diets at the meal table.
13.Model healthy behavior. Do not go on diets. Take an honest look at your reasons for dieting and
exercise. Are you putting priority on your appearance over your health? It is hard for an individual
with an eating disorder to try and change her/his thoughts about weight loss when significant
others around him/her are reinforcing the importance of appearance and thinness.
14.Recognize qualities, skills, abilities, values and talents in the individual that are independent of her/
his appearance. Share with him/her what you appreciate about her/him and are attracted to and
this will help in developing a more positive sense of self.
15. Avoid power struggles over gaining weight; s/he will always win.
16.Do not make statements like, “If you won’t change for yourself, do it for me (us)”, “you are
ruining the whole family”, or “why are you doing this to me?” The individual will feel guilty and
responsible for the welfare of the rest of the family. This will not change her/his attitudes and
behaviors. You must take care of your own welfare. Do not make this individual responsible for
your own happiness. That is too much for anyone to ask another.
17.Offer your support, both emotionally and psychologically. Ask “what kind of support could you use
at this time?” or “how can I support you?”
18.Do not ask, “Are you better?” This is a loaded question and calls for the response, “yes, of
course.” Look for broader definitions of recovery than just changes in eating behaviors or weight.
Attitude changes are not easily observable. You must learn to stop judging progress on behaviors
and outside appearances.
19.Realize that at best s/he is probably ambivalent about wanting to get well. At times, s/he may
want to be “normal”; at other times, s/he will retreat into old rituals and behaviors s/he perceives
as safe and secure. Be patient. This small setback may be necessary for her/him at present. Do
not reprimand her/him for these actions or add to her/his guilt.
20.Realize that you are trying to do what is right and best in an extremely difficult situation. Recovery
takes time, patience and professional help. Allow yourself to seek support and understanding from
local resources for friends and families in your same situation.
Root and Fallon (1983)
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- “ As far as I am concerned, I don’t have an eating
disorder”
- No intention to change and not aware there is a
problem
- Makes changes only because they are under
pressure- when pressure goes, so does change
- Does not see that action is required on their part
- Will receive help for consequences of E.D. only
- “I accept that I have problems related to an E.D.,
but I am not yet ready to do anything about it”
- Usually has motivational crisis- e.g. something goes
wrong with health, family, finances etc…
- Begins to consider costs and benefits of
overcoming E.D.
- Beginning of the end of denial
- “I am planning to do something about my E.D. in
the next six months”
- Makes the decision to change
- Experiences a number of false starts
- Seeks out information about recovery options and
other needed sources of help
- “ I have taken active steps to address my E.D. in
the last 6 months”
- Symptoms are interrupted
- Confident in and committed to recovery
- Therapy can feel like a full time job
- Develops affective skills to reduce power of triggers
- Reorganizes life and roles to support recovery
- “ I am working to maintain the changes I have
made against my E.D.”
- Productive living, living a full life
- Changes are consolidated
- Active use of relapse prevention strategies
Pre-contemplation
(1 month +)
Maintenance
(varies)
Action
(1.5 years +)
Preparation
(1 month +)
Contemplation
(1 month +)
General: Clients
Stage of Change
- Work on maintaining new ways of communicating
with loved one that are both comfortable and
automatic.
- Now and again you might have to remind yourself
not to slip back
- `New normal’ begins to be established
Prochaska et al., 1992; and The Integrated Recovery Model
-P
rovide range of tools for clients to use in the
management of their symptoms
-E
stablish recovery through cessation of problematic
behaviors, and enhancement of beneficial ones (e.g.
fewer binge-purge episodes but increased healthier
meals/snacks)
-W
ork on learning to cope with life without the E.D.
- Identify what improved quality of life looks like
-B
uild affective tolerance and capacity for addressing
unresolved emotional issues
- F ollow-ups as needed e.g. booster sessions
-R
einforce use of relapse prevention tools
- Key issue is the client’s ambivalence
- Identify issues that keep client stuck
- Identify and monitor emotional states that leave the
client feeling overwhelmed, strategize around ways
to contain these feelings
- Continue
education around healthier self-care and
medical check-ups
- Support the client’s belief that they can change
- Homework has the client altering their E.D.
behaviors in small ways (e.g. delayed binges)
- Provide cognitive and behavioral strategies to
facilitate change
- Continue to notice consequences of E.D.
- Continue to listen & validate feelings
- Understand that some of your own ways of coping,
parenting even though well-intentioned may be
helping to support the eating disorder
- Consider benefits of doing things differently
- Support your loved one’s beliefs that they can
change
- Find support for yourself in your own efforts to
change
- Trial and error during meals, discussion times with
efforts to handle things differently
- Firm yet compassionate caring
- Have expectations that are in keeping with loved
ones life in recovery
- Feels like work sometimes
- Develop skills that help you not to get drawn into
power struggles
- Your own and your family life no longer revolve
around the eating disorder
- T he client wants help to fix the consequences of the
E.D., not the E.D. itself
- F ocus on client’s denial
-P
rovide education
- L isten & validate feelings
-A
ssess for co-morbid conditions e.g. depression and
anxiety
Suggestions for Health Care Practitioners
- Avoid forcing loved one to pursue change
- Encourage general self-care including visit to family
doctor
- Describe out loud, impact of eating disorder on you
- Listen & validate feelings
- Consider how you support the E.D.
Suggestions for Parents/
Supportive Others
Changing our behavior is difficult. The Transtheoretical Model of Change (Prochaska et al., 1992) suggests there is a series of stages we go through before we actually make and sustain
behavioural change. This theory also suggests that we must first develop an intention to change before we can begin to do things differently. People with eating disorders often struggle with
their decision to overcome their eating disorder. This may be related to society’s support of a thin body ideal; or the eating disorder may have become a `friend’ that they are not sure they
can live without. Supportive others are often ready for recovery long before the person with the disorder is. Consequently, it is important to match helping strategies with where the person is
at in terms of their interest in and willingness to change. The table below provides some helpful information about the stages of change, what each stage looks like in terms of illness behavior
and what to keep in mind to encourage, support or maintain change. In the treatment of children and adolescents, we don’t always wait for there to be interest in change. Ensuring continued
physical growth and development is critical and so often work will start with parents if kids are not yet ready for change.
Readiness for Change
Fathers Helping Daughters with Eating Disorders
Fathers often struggle with understanding their daughter’s eating disorder and how they can be helpful
throughout her efforts to recover. Fathers need to accept how important they are in the lives of their
daughters and not assume that they are less important than mothers. This includes interactions at home
or showing up for appointments. Adolescence may be when girls need their dads the most. Girls need
to witness and understand through their fathers, that women can be valued for more than their physical
beauty. Daughters need to be re-assured that their growing `voices’ are acceptable, and that the fatherdaughter relationship will continue to be important even through the challenges of adolescence. It is
important to remember that these issues are related to normal development, but are often heightened in
girls with eating disorders.
Tips for Dads
1.Evaluate your own messages to your daughter about weight, dieting, beauty and body image.
Explore what you value most in women and how these values may or may not be communicated
to your daughter. How you relate and speak to/and about your daughters’ mother demonstrates
these values.
2.Let her know out loud that you love her no matter what she weighs.
3.Be a good role model around food and exercise. Live a non-dieting life; don’t obsess about
exercise.
4.Talk to her about the very real pressures she faces everyday to live up to a thin ideal, lose weight
or to be attractive to please others.
5.Help her to discover or even rediscover what she values most in life that has nothing to do with
food, shape or weight.
6.Appreciate that your role is to support your daughter in her efforts to address the problems she
faces. For men, resisting the urge to `fix’ the problem can be a real challenge. Instead, focus on
listening to your daughter, creating a supportive home environment, and living your own life in
ways that support her recovery.
7.Show respect for her growing maturity by showing her that she can have opinions that differ
from yours without it `costing’ her your affection, respect or company. This will teach her that she
doesn’t have to give herself up in order to please you and will foster her self-esteem.
8.Give your daughter(s) the same opportunities and encouragement you give your sons.
9.If you are a family that has separated or divorced, continue to be a presence in your daughters’
life.
10.Communicate to your daughter that you are trying to appreciate the complexity of the problem
she is facing, and that you know there is more to her recovery than just eating.
Margo Maine, Ph.D., Father Hunger (1991)
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Getting through Meals
Family meals provide a chance for family members to reconnect, show an interest in each others daily
lives, and nourish bodies and souls together. They are designed to meet emotional as well as nutritional
needs. While today’s busy family lifestyles make having regular family meals a challenge, this is further
compounded when someone in the household has an eating disorder. Meals can then become tense
and unpleasant, loaded with big issues around autonomy, power and control. Arguments can ensue
about what foods are served, how they are cooked, whether everyone has to eat at the table, or how
much food has to be eaten. It is important to consider what can be done to maintain familiar healthy
family rituals around eating and meals, while at the same time supporting a loved one struggling with
an eating disorder. This is not easy to do!
One important thing to remember is that the eating disorder should not be allowed to “run the house”.
This might look like favourite foods no longer being allowed at the table or in the house, different rules
for different members, altering family rituals around eating and meals to accommodate the eating
disorder. A second important thing to remember is that the eating disorder does not get to make
decisions around safety. If your son or daughter has not taken care of their health consider whether they
or those around them are at risk when involved in some activities such as driving a car or baby sitting.
Remember that starvation changes how people think, feel and behave. Family meals can provide
an opportunity to monitor how your loved one is managing this aspect of their health so that safety
decisions can be made.
Many parents with the best of intentions end up
supporting the eating disorder rather than their son or
daughter, particularly at mealtimes.
Turn meals back into family time:
1.Talk to your kids about their day. Talk about things unrelated to dieting, calories, weight or shape.
2.Turn off the television.
3.Start out with a relaxing, pleasant atmosphere- lights, music, table place settings etc.
4.Don’t nag, police, prompt or bribe your loved one to eat.
5.Enjoy your own meal.
6.Serve your traditional family foods from all food groups including those enjoyed by everyone.
The eating disorder shouldn’t get to decide what everyone eats.
7.Don’t use family times to scold, nag or fight.
8.Everyone gets a turn to talk.
Don’t Say
Do Say
Don’t you think you’ve had enough?
How are your doing with that?
Is that what the staff said?
What can I do to support you?
Is that on your meal plan?
What’s going to be most helpful?
Satter (2005)
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Preparing for an Eating Disorder Hospitalization:
Information for Families
Treatment: It is important to remember that your loved one will typically not benefit from therapy
unless they are medically stable. It is equally important to remember that a hospitalization stay is often
just the beginning of the recovery process and not a comprehensive eating disorder `fix’. Sometimes
more than one admission is required.
Medical Stabilization:
General community hospitals admit to medically stabilize. That means they admit the person to
Emergency, Pediatrics or General Medicine, to reduce imminent medical risk. Most often they do
not have the expertise to provide specialized eating disorder care. It is important to remember that
the job of the staff during this admission is to take care of the MEDICAL needs of your loved one.
Their job is to keep your loved one alive. Stays typically are short and can range from 2-8 days
Medical and Psychiatric Stabilization:
Sometimes a loved one is both at risk physically AND psychiatrically; for example they may be
very underweight and suicidal. In this case both mental health AND medical emergent care may
be required. This care is often hard to access. The job of the staff is to stabilize the mental and
physical health of your loved one so that they can go on to more comprehensive care. These
programs will not typically have staff with eating disorder expertise, but the staff is experienced in
managing general psychiatric and medical concerns. Stays typically are short and can range from
1-4 weeks.
Specialized Eating Disorder Care:
Hospital programs that provide specialized comprehensive care are typically scarce and as a result
often have long waiting lists. Sites may offer inpatient beds, partial or day hospital programming
and/or outpatient services. These programs have trained eating disorder staff with specialized
expertise.
Inpatient:
Admissions aim to restore and maintain medical stability through 24 hour medical monitoring.
Treatment encourages a resumption of more normalized eating, may include supervised alternatives
to solid food intake, safe withdrawal from laxatives, supervised meals for reduction of purging
behaviors or medical monitoring for other complications. Individuals who have struggled to eat
anything might be appropriate. Referrals are typically through physicians and admissions are
typically made based on the level of illness severity of those currently awaiting admission. Clients
may be uninterested in or uncertain about recovery. Stays can vary in length from 2- 6 months.
Day Hospital:
These are programs where individuals are no longer at imminent medical risk, can go home in the
evenings, eat some foods on their own without needing supervision but are struggling to maintain
their activities of daily living. Motivation for change, readiness for change and deeper issues
at the core of the eating disorder can begin to be addressed. Treatment might include: group,
individual and/or family therapy; nutrition assessments and counselling; activity groups; medication
review; meal planning and support; medication treatment and team consultations. Clients are
usually with peers. Admissions are typically made with a physician’s referral and completion of
a comprehensive multi-disciplinary assessment. Clients may have mixed feelings about recovery.
Stays can vary in length from 2-12 months.
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Outpatient:
These programs are offered to those at all stages of change i.e. those just beginning, in the middle
of or completing their recovery process. Clients must be medically stable. Motivational issues
are often addressed but so too are some of the deeper issues underlying the eating disorder.
Most often, services include group, individual and/or family therapy; nutrition assessments and
counselling. Admissions can be based on a physician’s referral or clients, in some programs,
may refer themselves. There is often a 2-6 month wait for admission but once admitted clients can
typically remain for as long as they are motivated, attend their appointments and find the treatment
beneficial. Clients can be both certain and uncertain about recovery. Stays can vary in length from
1-7yrs.
Leaving the Hospital
Support
Leaving the hospital is usually very scary for families. Having had the support of professionals, and
some respite for even a brief while, families are often anxious about being left alone to once again
manage the eating disorder full time at home. It is important that you seek support for yourself
and for you as a couple if appropriate. This may occur through formal supportive services (See
“Resources for Patients and Families” Sheet) or through friends and family.
Follow-up Plan
Ensuring there is a follow-up plan in place for your son/daughter before they are sent home is
important. This may involve follow-up appointments with your family doctor, and/or referrals to
other more specialized providers and programs. If your family doctor has not been involved
to date, now is a good time to update him/her about the status of your loved ones’ health and
establish a follow-up plan.
Re-admissions
Having everyone understand the terms and conditions that would lead to a readmission is also
critical should things decline once again. Understand what the `criteria’ are. Examples include
fainting, not eating anything for days/weeks or suicidality. Decide where you will go a relapse
occur.
Remember, the aim at all times is to provide compassionate care
that maintains the dignity of your loved one while reducing
the imminent risk to their life.
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Eating Disorder Resources for Patients & Families
Websites
Central West Eating Disorder Program (CWEDP)
www.cwedp.ca
Danielle’s Place www.daniellesplace.org
Sheena’s Place
www.sheenasplace.org
Homewood Health Centre
www.homewood.org
National Eating Disorders Information Centre (NEDIC)
www.nedic.ca
Something Fishy Website
www.somthing-fishy.org
National Institute of Mental Health (NIMH)
www.mentalhealth.com
Canadian Mental Health Association (CMHA)
www.cmha.ca
Canada’s Food Guide www.hc-sc.gc.ca/fn-an/food-guide-aliment/index_e.html
Support Centres
Danielle’s Place- Burlington
Sheena’s Place- Toronto
EDAC- Waterloo
(905) 333-5548
(416) 927-8900
(519) 745-4875
Finding a Private Practitioner
National Eating Disorders Information Centre
v Information and Resources
v Service Provider Search Directory
www.nedic.ca
1-866-633-4220
(416) 340-4156
Specialized Treatment Contacts – CWEDP Sites
Trellis Mental Health and Developmental Services (serving Waterloo Region and Wellington County)
General Intake
(519) 821-3582
1-800-471-1732
Credit Valley Hospital, Mississauga
(905) 813-4505
Halton Healthcare Services, Oakville Trafalgar Memorial Hospital
(905) 815-5127
William Osler Health Centre, Brampton Civic Hospital
(905) 453-1160
Coalitions/Prevention
Body Image Coalition of Peel
v Directory/Resources and Services www.bodyimagecoalition.org
(905) 791-7800 ext. 2063
Eating Disorders Awareness Coalition of Waterloo Region
v Directory/ Resources and Services
Wellington-Dufferin-Guelph Eating Disorders Coalition
About Kids Health
BodySense: Promoting Positive Body Image in Sport
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www.edacwr.com
(519) 745-4875
April Gates
(519) 824-1010 (ext. 2292)
www.aboutkidshealth.ca/thestudentbody/
www.bodysense.ca
127
FAMILY PSYCHOEDUCATION GROUP
PURPOSE
The group is intended for family members of individuals suffering from eating disorders, such
as bulimia nervosa, anorexia nervosa and binge eating not otherwise specified (binge eating
disorder). Its goal is to increase understanding of the nature and treatment of eating disorders
and to offer suggestions about how to cope with the behavioral and emotional issues they
engender.
WHO CAN PARTICIPATE?
Those eligible to participate include parents, siblings (age 16 and over), partner/spouse,
boyfriend/girlfriend, concerned relatives, and where relevant, close friends of the individual
with the eating disorder. Family members may participate regardless of whether the
person with the eating disorder is currently receiving treatment, and regardless of that
individual’s age. Please note that this program is for family members and significant others
only. Individuals with eating disorders are not eligible to participate in this particular
group. On occasion, a limited number of professionals may be present to observe the
Family Psychoeducation Group for ongoing professional development. Group facilitators
will introduce observers at the beginning of the day. Observers adhere to the practice of
confidentiality.
FORMAT
The group consists of a full day session from 9:00 am to 4:00 pm. It typically occurs on a
Saturday. The group format will be both educational and supportive.
CONTENT
The group will be facilitated by members of the Credit Valley Hospital Eating Disorders Team.
They will provide information on the development and maintenance of eating disorders, the
regulation of body weight and the consequences of dieting, and the nature of treatment and
recovery. The group facilitators will also recommend strategies for assisting and supporting
recovery, and will address questions from audience members.
REFERRAL TO THE PROGRAM
To register, call The Credit Valley Hospital Eating Disorders Program at (905) 813-4505.
Participants must provide their name, address, date of birth, phone number and health card
number. For further information please contact (905) 813-4505.
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OUR HISTORY
Over 13 years ago, Sheena Carpenter lost her battle with anorexia and bulimia. Sheena’s
Place resulted from this tragedy and through the dedication of our founders and supporters
we have been able to honour Sheena’s memory and serve thousands of other individuals and
families affected by eating disorders.
WHO WE ARE
Sheena’s Place is a community-based centre offering hope and support services to people
affected by eating disorders. Since our incorporation in 1994 we have been committed to
providing tangible help to individuals and families for whom resources are scarce to none.
Sheena’s Place is centrally located in a welcoming house in downtown Toronto.
OUR SERVICES
All those who participate in our programs do so by self-referral and there is no cost.
We offer over 50 different groups at any one time in four main areas:
Support
Body Image
Expressive Art
Skill Building
Sharing feelings & strategies in an informal setting
Heightening awareness about feelings towards the body
Exploring various art materials as a form of expression
Offering new ways of coping or making changes
Sheena’s Place also has an extensive lending library on eating disorders and related issues.
HOW TO FIND OUT MORE
You can drop in to have a tour, learn about the agency, the nature of our services or arrange
an individual information interview to ask more specific questions and get help in finding the
right group for you.
For appointments call 416 – 927-8900 or drop in on Wednesdays from 11 a.m. to 1 p.m.
For more program information please visit our website: www.sheenasplace.org or visit our
centre. 87 Spadina Road, Toronto, Ontario M5R 2T1 416 927-8900
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Physician Support
“I think family doctors have a tremendous ability to manage their
patients with eating disorders. They often just need direction,
encouragement and support.”
Dr. Colleen Flynn, MD FRCPC
Previously Medical Director
Eating Disorder Program
Credit Valley Hospital
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Support Resources for Primary Care Providers
• C
ontact our support service if you are uncertain about issues related to assessment,
diagnosis and ongoing management
• C
onnect your patient and his/her family with the CWEDP Treatment Program and/
or local Support Centre within their community as a first step (See `Family and
Patient Resources’ and `Physicians: Connections and Links’ sheets). Doing so will
facilitate referrals to alternate levels of care and transitioning back to community
care following acute admissions. Families can receive support through both types
of Centres
heck www.cwedp.ca- professional resource section for service and binder
• C
updates or to download referral forms or access Physician Q & A Forum contact
905-815-5124 for a password.
CWEDP PHYSICIAN SUPPORT
Please feel free to use the support services below- they have been established to
assist you.
Phone Support/General Inquiry
905-815-5124
Please provide your name, question, patient age and return phone
number. Your call will be forwarded to a local expert and returned within
24 hours.
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Physicians: Eating Disorder Connections and Links
Local Connections: CWEDP Sites
Trellis Mental Health and Developmental Services
Waterloo Region and Wellington County
General Intake
(519) 821-3582
1-800-471-1732
Credit Valley Hospital, Mississauga
Halton Healthcare Services, Oakville Trafalgar Memorial Hospital
(905) 813-4505
(905) 815-5127
William Osler Health Centre, Brampton Civic Hospital
(905) 453-1160
Acute Connections: Physician to Physician
Children and Adolescents
Adults
The Hospital for Sick Children
Adolescent Medical Physician-On Call
Locating Tel (416) 813- 7500
Toronto General Hospital
Dr. Blake Woodside-Director,
Inpatient Program
Tel (416) 340-4445
McMaster Children’s Hospital
Dr. Sheri Findlay- Medical Director,
Adolescent Eating Disorder Program
Tel (905) 512-2100 x 75644
Credit Valley Hospital
Dr. Randy Staab
Tel (905) 813-4505
London Health Science Centre
Dr. Jennifer Couturier- Physician Leader,
Eating Disorder Program
Tel (519) 685-8500 x 57422
Ottawa General Hospital
Dr. Hany Bissada-Head,
Eating Disorder Program
Tel (613)-737-8042
Children’s Hospital of Eastern Ontario
(CHEO)-(Ottawa)
Dr. Wendy Spettigue-Psychiatric Director,
Eating Disorder Program
Tel (613) 737-7600
Homewood Health Centre
April Gates-Program Coordinator
Tel (519) 824-1010 x2292
Websites:
APA Best Practice Guidelines for the Treatment of Patients with Eating Disorders:
http://www.psych.org/psych_pract/treatg/pg/EatingDisorders3ePG_04-28-06.pdf
APA: Treating Eating Disorders; a Quick Reference Guide
http://www.psych.org/psych_pract/treatg/pg/EatingDisorders3ePG_04-28-06.pdf
Canada’s Food Guide –
http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index_e.html
Growth Charts http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/charts.htm
Health and Welfare Canada- BMI Calculator
http://www.hc-sc.gc.ca/fn-an/nutrition/weights-poids/guide-ld-adult/bmi_chart_java-
graph_imc_java_e.html
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Supplemental Resources
“We must learn the virtue of patience [until our patients],
freed from the shackles of anorexia or bulimia nervosa can
[learn to be] their own valuable and unique selves, at which point
we… should quietly withdraw and leave them to it”
Beaumont, Russell and Touyz, 1995
taken from Treating Eating Disorders: Ethical, Legal; and Personal Issues (1998).
Edited by Walter Vandereycken and Pierre J.V. Beumont
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Contact us for further information or to order additional copies of
Putting Eating Disorders
on the Radar
of
Primary Care Providers
Please contact either of the following or go to the CWEDP website (www.cwedp.ca)
CWEDP Regional Office
Central West Eating Disorders Program
Ph: 905-815-5124
Fax: 905-815-5076
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143
References
Addiction Counselling Services of Peel (Peel Memorial Hospital), the Integrated Addiction Recovery Model.
Alleyne, J. (2006) Athlete’s @ Risk: Prevention and Treatment of Eating Disorders. Presentation made to CWEDP
June 23, 2006.
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV),
published by the American Psychiatric Association, Washington D.C.; 1994.
American Psychiatric Association, Practice Guidelines for the Treatment of Patients with Eating Disorders, Third
Edition published by the American Psychiatric Association, Washington D.C; 2006.
American Psychiatric Association, Treating Eating Disorders: A Quick Reference Guide based on Practice
Guidelines for the Treatment of Patients with Eating Disorders, Third Edition published by the American Psychiatric
Association, Washington D.C; 2006.
Giordano, S. (2005). Risk and supervised exercise: the example of anorexia to illustrate a new ethical issue in the
traditional debates of medical ethics. Journal of Medical Ethics 31, 15-20.
Health and Welfare Canada (1988), Promoting Healthy Weights: A discussion paper, Minister of Supply and
Services Canada: Ottawa Ontario.
Honey, A.; Clarke, S.; Halse, C.; Kohn, M.; Madden, S. (2006). The influence of siblings on the experience of AN
for adolescent girls. European Eating Disorder Review 14 (5), 315-322.
Johnson, C, Initial consultation for patients with bulimia and anorexia nervosa. In D.M. Garner & P.E. Garfinkel
(Eds.), Handbook of Psychotherapy for Anorexia and Bulimia (19-51). New York: Guilford Press; 1985.
Klump, K.; Wonderlich, S.; Lehoux, P.; Bulik, C. (2002) Does environment matter? A review of non-shared
environment and eating disorders. International Journal of Eating Disorders, 31(2) 118-135.
McGough, S. (2004) Exercise Addiction and Eating Disorders. McLean in the News. FitnessManagement.com (July).
Maine, M. Father Hunger Carlsbad, CA Gurze Books; 1991.
Mehler, PS.; Anderson, AE. Eating Disorders: A Guide to Medical and Complications. Baltimore, MD: Johns
Hopkins University Press; 2000.
National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and
Health Promotion (2000). Individual Growth Charts. http://www.cdc.gov/growthcharts.
Northern Health, Prince George Eating Disorders Clinic (2006) Physician’s Resource Package.
Prochaska, J. O., DiClemente, C. C., and Norcross, J. C., (1992) In search of how people change: Applications to
addictive behaviors. American Psychologist, 47, 1102-1114.
Root, M; and Fallon, P. Guidelines for Family Members Who Want to Help a Family Member Recover (1983)
Satter, E. Your Child’s Weight: Helping without harming (birth through adolescence) Madison Wisconsin, Kelcy
Press; 2005.
Shroff, H.; Reba, L.; et al., (2006) Features Associated with Excessive Exercise in Women with Eating Disorders.
International Journal of Eating Disorders, 39, 454-461.
Silber, T.J., D’Angelo, L.J. (1991). The role of the primary care physician in the diagnosis and management of
anorexia nervosa The Academy of Psychosomatic Medicine, 32, 221-225.
Society for Adolescent Medicine, Eating Disorders in Adolescents: Position paper of the Society for Adolescent
medicine. Journal of Adolescent Health 33, 496-503
Weiner, R. G. Working with physicians toward the goal of primary and secondary prevention. In Piran, N.;
Levine, M.P., Steiner-Adar, C. (1999) Preventing Eating Disorders: A handbook of special challenges. 285-303.
Philadelphia, P.A. Taylor and Francis.
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Resource Evaluation
Please help us to refine this resource package so that it provides maximal practical assistance by
completing the following brief questionnaire after you have had the opportunity to use it. Answer the
following questions and send it back to us either by fax (905-815-5076) or by snail mail (CWEDP 700
Dorval Dr. 6th Floor Oakville, Ont. L6K 3V3).
1.How did you receive your copy of the Resource Binder and DVD?
Received through an educational session (e.g. workshop; grand rounds presentation)
Received from colleague
Requested through CWEDP Website
Other 2. Please let us know about your practice?
Family Physician
Clinical Nurse Practitioner
Pediatrician
Psychiatrist
Other Please Specify: 3. Which items or sections in the binder were most helpful to you?
4. Which sections within the DVD were the most helpful?
5. Which items/sections were the least helpful to you?
6. Which items were most helpful for your patient(s)?
7. Which items were most helpful for your patients’ family members?
see over
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8. What do you feel is missing?
9. How many patients/clients do you see a year do you see with a diagnosis of an
eating disorder?
patients/clients
10. How many more patients/clients do you suspect having an eating disorder in
addition to those who already have a diagnosis of an eating disorder?
patients/clients
11. Has the information in this binder made you think differently about the number
of individuals you suspect may have an eating disorder?
Yes No
Not Sure
12. Has the information in this binder made you think differently about how you
would treat those you suspect may have an eating disorder?
Yes No
Not Sure
13. My confidence and comfort in identifying eating disorders in my practice has
not improved at all
improved somewhat
14. I would be interested in receiving binder updates?
improved significantly
Yes
No
My e-mail address is My fax number is My Phone number is My mailing address is 15. Other Comments or feedback?
Thank you in advance for providing your feedback. Please feel free to check out
the CWEDP Website at www.cwedp.ca.
148
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