PART II: Not just a Girl’s Disease: Treating Boys

with Eating Disorders a Dietitian’s Perspective on Food and Feelings

Megan Kniskern, MS, RD, CEDRD Nutrition and Culinary Services Director

Outline

• Prevalence

• Perpetuating Factors

• Dietary Obstacles

• The Nutrition Language

• Dietary Support

• Treatment

Prevalence in Boys and Males

• Large national study – 25% of diagnosable cases of eating pathology occurred in males (Hudson, et al, 2007)

• 25% of pre-adolescent AN are male (Bryant-Waugh & Lask, 2002)

• National Institute of Mental Health suggest that about 1 million men and boys suffer with ED

• 10% of diagnosed ED are male (APA)

• We see more like 15-20%

Primary Perpetuating Factors for AN in Boys

• To prevent further ridicule for being overweight • To enhance one’s ability in sporting events

– Males are 3x more likely to be trying to gain weight • To prevent medical issues experienced by their

fathers, for example cardiac issues • To enhance gay relationships.(Andersen et al., 2000)

Trauma

• Bullying, teasing, competition, conflict particular as it relates to the body teaches males to shun dependence, less emotional support, complicates emotional intimacy (Levant,

2006).

• Boys with ED’s often have a history of being teased as a child (Fichter and Krenn, 2003)

• Bullying impacts exercising / participation in sports and social events

Biological, Medical and Nutritional Factors

• With boys, less weight loss secondary to B/P compared to females may put them at more acute risk

• Being overweight as a child is very common in eating disordered males (APA Practice Guidelines, 2006)

• Nearly 16% of boys thought they were overweight when only 5% actually were (Kjelsas, 2003)

• Delayed maturation in boys increases the risk for ED’s (APA Practice Guidelines, 2006)

– Delayed maturation in boys has been linked to poor body image, decreased acceptance from peers, greater problems with mother and father, increase in depressive symptoms (Disordered Eating Among Adolescent Boys, 2004)

Males and Boys: Nutrition

• Don’t connect to the medical because the secondary consequences aren’t as evident – menstrual cycle, not developing sexual characteristics, not having children, hair loss, etc.

• Weight loss can be quick and require minimal effort

• Hypermetabolic – need more calories to maintain weight and even more to restore

• Skinny – means different things

• Less food “cravings”

• Language of food is different

• Boys approach food differently socially

C o n n e c t i o n b e g i n s h e re …

• When it comes to connecting ED behaviors to emotions or motivations, boys struggle to understand what this means.

• There is a lack of connection to Nutrition Education

– “I never do that.”

– “I don’t know.”

• The language needs to be different

– Boys eat differently – “I ate a whole pizza with friends once.”

• Not about “weight” but about “size” and appearance

– Some may be trying to gain muscle

• “Purging” and weight control behaviors are usually through excessive exercise and restricting specific foods.

N u t r i t i o n A s s e s s m e n t

Female Assessment

• Do you weigh daily?

• Do you ever purge?

• What is your exercise regimen?

• 24 hour food recall

• What do you eat during a binge?

• What foods do you dislike, are there foods you “fear”?

• Why do you fear those foods?

Male Assessment

• How would you describe your body? Is there anything about your body you would change?

• Do you ever throw-up?

• What type of exercise do you do? Do you play sports with friends?

• Do you take any supplements? Protein powders or shakes?

N u t r i t i o n A s s e s s m e n t

• Where do you get your nutrition information?

• How are family meals eaten in your home?

– Do you grocery shop?

– Do you know how to cook?

• What are the eating patterns of your mom & dad?

• Go through different meal scenarios and ask how they may handle those foods/meals:

– School lunch, breakfast, weekends, snack at a friends’ house, etc.

• Most won’t identify any food aversions or “fears” until faced with a meal that is difficult.

P h y s i c a l a n d P h y s i o l o g i c a l M a r ke r s

• Weight and Growth tracking

– Adol males use growth chart, not BMI!

– IBWR = 25th- 85th percentile for BMI for age and gender

• >85th percentile – overweight (CDC)

• >95th percentile – obese (CDC)

• <5th percentile – underweight (CDC)

– Measure height every 4 weeks

• Adjust IBWR

P h y s i c a l a n d P h y s i o l o g i c a l M a r ke r s

• Lean Body Mass vs Fat Mass

– 18 yo: Boys 17% BF and Girls 27.8% BF (Laurson, 2011)

– Boys peak at age 11, girls continue to increase

– Adult Avg: Males 17-19 and Females 22-25

• Testosterone levels – can be low

• Fluid and electrolyte balance – monitor fluid manipulation

• Injuries, stress fractures, osteopenia/osteoporosis

ACE Bod y Fat % Chart

Description

Women

Men

Essential fat

10-13%

2-5%

Athletes

14-20%

5-13%

Fitness

21-24%

14-1?16

Average

25-31%

18-24%

Obese

32%+

25%+

ROS EWOOD.

ARIZONA ·CI\LIFORNIA

M u s c l e D y s m o r p h i a

• Body builders – “bigorexia” - Body focused and distorted – muscularity, long hours in the gym, meticulous diet and ergogenic aids – High protein, Supplements (powders, shakes, bars), anabolic steroids – Forbes article in April 2013; $32 billion revenue in 2012 with

projected $60 billion by 2021 (Nutritional Business Journal)

• Plastic surgery to create “muscular look” • Self-conscious of body, avoid social situations

Pearson, 2014

S u p p l e m e n t s

• Anabolic steroids are illegal and banned from sports (int’l) – Long term damage: infertility, “feminization” in men, liver damage,

depression, anger (roid rage) • Gamma-Hydroxybutyric Acid (GHB) – CNS depressant

– Promoted as alternative for AS in building muscle, seizures, respiratory depression, coma, dealth

– 2001 FDA made it illegal • Creatine – found in meat and fish, stored in our muscles and produces ATP

– Promoted to increase strength and power – 1,700 research articles and found the main benefit is to enhance

sprint work during swimming, running, and cycling • Protein/Amino Acids – whey, glutamine and arginine • The FDA does NOT regulate these products! • Chocolate milk (low fat) for recovery beverage (4:1)

Pearson, 2014; Pritchett, 2012; Spaccarotella, 2011

Herbal Supplements

• $5 billion annually on herbal supplements

• DNA barcoding to blind test 44 herbal products, 12 companies (Newmaster, et.al, 2013)

– Created standard reference materials (SRM) of 100 herbs

– 59% contained items not listed on labels

– Product substitution occurred in 30 of the 44 products

– Fillers: rice, soybean and wheat (allergens)

– 1/3 had no trace of the plant advertised on the bottle

Influencing Teens Why I Got Started I have been chubby pretty much my whole life. When high school hit, everyone shot up and got thin, guys started bulking for football and other sports, but I stayed the same "kid" who was addicted to food, especially candy. I continued to gain weight, but no height, until finally I began to mature my junior year. Still, I ate only junk, lots of candy, and never anything healthy. The summer before my senior year, I reached an all time high weight of around 175 pounds. There was a back to school pool party, and I was embarrassed to take my shirt off because of the other guys and mainly because I didn't want the girls to see me like that. Every day I would wake up, look in the mirror and say to myself "Is this how I really have to look?" My little brother would tease me and call me "fatty." He was of course joking but I took it seriously since I was so self-conscious. I then decided to make a change. Then I got hooked! I made it a point to read as many articles a day as I could. This is where Bodybuilding.com helped too. It offered me the best insights, best supplement prices, and motivation to keep going!

Athlete Dietary Concerns…

• Male AN associated with athletics 45%, females 9% (Braun, 1999)

• CHO restrictive – ↑ CHO (55-70%) • Calorie restrictive – cardiovascular risk ↑, endocrine system

↓ (growth hormone, muscle repair), immune function ↓, thyroid function ↓, loss of menstruation (LBM, bone health)

• LBM – low body wt, dehydration, diuretics, supplements • Weight or physique focused – wrestling, body building,

jockey, boxing, cycling, swimming, etc. – Purging, bingeing, restriction, and fluid manipulation

• Chronic injury or inability to recover in a reasonable time frame – fear of being honest

• Overall body image awareness intensified

Awareness in Athletics

• Coaches and trainers have a powerful presence • National Athletic Trainers’ Association (NATA) - changing

approaches to weight loss and weight maintenance – Avoid “ideal” physique, balance of nutrients, adequate calories

(NATA, 2011) • NCAA 2001 Body Composition Issues Checklist

– Disordered eating can be “contagious” – Weigh-ins and body comps rarely needed – Promote healthy weights and values are individualized

• Texas Tech Athletic Department – No comparing body wt or compositions – Values should not be posted – Very low LBM percentages should not be the goal

Nutrition Support - Athletes

• Nutrition approach:

Endurance: 1.2-1.5g/kg, Strength: 1.3-1.8g/kg protein

Dietary Support & Interventions

• Get out of the office if you can – play basketball, go for a walk, or allow doodling

• What are the motivations to change

– Play a sport, be with friends, self-confidence, girls, etc.

• Eat with them

• Use comparisons they can connect to

• 3 meals/3 snacks – high kcal/kg

– Use food not supplements; incorporate variety

• Monitor labs

– Adequate calcium and vitamin D

Dietary Support Continued

• RDA for protein:

– 9-13yrs 0.95kcal/kg/d, 14-18yrs 0.85kcal/kg/d

• Kcal: 1200kcal/d and increase by 200kcal every 48 hrs (females/IP) – 2-3# wt gain/wk

– This is being challenged as “too slow” due to initial weight loss and no concerns with refeeding syndrome (Garber, et. al, 2011)

• Food allergies or intolerances – seen much less with males

Co-morbidity

• Autism Spectrum Disorder

• Substance Abuse

• Oppositional Defiant Disorder / Conduct D/O

• Attention Deficit Hyperactivity Disorder

• Tourette’s Syndrome

• Anxiety

• Depression

• ASD

Dietary Support

– Aversions; textures, additives

– Structure; consistent meal times, reliability

• OCD

– Structure, textures, food ritual support

• Substance Abuse

– Food cravings, detox food support, education

• ADHD

– Elimination diet, low sugar, simple carbs

Challenges with Families with ED

• Lack sense of urgency

– Boys don’t “present” as always looking “sick”

• Misinformed about ED / lack of ED education

– Distortions come in all shapes, sizes and genders

• Fearful to be blamed

– Parent’s own eating patterns can have a significant influence and/or fears they may need to change as well

• Inconvenienced by ED and treatment needs

• Not involved

– Most often see mom, very little dad involvement

• Mental Health Issues

Male Case Study #1

• 15 yo, white male, originally in tx at 20 yo, college student (excelled), wrestling scholarship – ED began at 16 on wrestling team in high school, was very successful and got a scholarship

• Initial admit: Restrict/Binge/Purge/Weighing all related to sport and pressure for success – d/c slightly overweight

• IP →PHP→IOP→OP →IOP →PHP →IOP

• Re-admit: Restrict/Exercise purging – very resistant to nutrition support and many food fears, more denial

– Tattoos, piercings, very extreme – Enmeshment with mom

• D/C within IBWR – BMI 23

Male Case Study #2

• 16 yo white male, IP: 69”, 105.8#, IBWR 127-164; had lost 53# in 6 months – Restored 21.8# at a rate of 0.36#/day; 3235kcal/day upon d/c to IOP

• Restriction, food rituals, fear of contamination, body image distortion, fear of wt gain, fatigue, heart palpitations, anemia, GERD, unintentional vomiting, dizziness, constipation, dehydration, nausea, poor memory

• Reported always being the “fat kid”, finished last running, food was “best friend” but now it is my “worst enemy”

• Isolation, baggy clothes, depression, move to US from UK, care for sick mother

Questions & Answers

References/resources supporting the information in this presentation are

available upon request

Megan.Kniskern@rosewoodranch.com

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