Teacher Workshop Curriculum

UNDERSTANDING AND LEARNING ABOUT STUDENT HEALTH

Written by Corinna Rea, MD with help from Marina Catallozzi, MD

UNDERSTANDING AND LEARNING ABOUT STUDENTS HEALTH

Teacher Workshop Curriculum Outline:
Goal: To increase teachers comfort with common topics of adolescent health. Workshop Five: Eating DisordersHealthy Weights, Healthy Attitudes Definition of anorexia nervosa and bulimia nervosa Epidemiology of eating disorders in the US What causes eating disorders? Common complications Warning signs and what to do Treatment and Outcomes

Lesson Plan: Eating Disorders:

Healthy Weights, Healthy Attitudes
Goal: To develop an understanding of what eating disorders are as well as common warning signs and consequences. Introduction: Brief introduction of yourself and teachers. Briefly review lesson plan outline. (5 minutes) Definition of eating disorders: (10 minutes) Read cases and ask whether teachers have ever encountered similar scenarios. Review definitions of anorexia nervosa and bulimia nervosa. --Key points: *Anorexia nervosa is characterized by self-starvation and excessive weight loss *Bulimia nervosa is characterized by a secretive cycle of binge eating followed by purging or other compensatory strategy *People with anorexia and bulimia both experience extreme dissatisfaction with their body shape and weight Demographics of eating disorders nationally: (5 minutes) --Key Points *As many as 10 million females have an eating disorder such as anorexia or bulimia *Bulimia is more common than anorexia, but anorexia has a higher mortality rate *Eating disorders usually begin at a young age, and men and women can both suffer. In fact, we are seeing increased rates in males and in non-Caucasian populations *There are two peaks: around 14 years old and 18 years old What Causes Eating Disorders: (5 minutes) --Key points *Unclear, but likely a combination of genetics, social pressure and psychological factors *Often a way to gain a sense of control *Even young children can be concerned about weight *Eating disorders often co-occur with other mental illnesses Complications of Eating Disorders (5 minutes) --Key points *Many medical problems may arise from eating disorders, including bone thinning, heart problems and early death *Emphasize: eating disorders are dangerous and should be managed by health professionals *Highest mortality rate (most deaths) of ANY psychiatric illness Diagnosing and Treating Eating Disorders (10 minutes) *Eating disorders may present with several warning signs *Teachers can play a key role in diagnosing eating disorders *An interdisciplinary team should treat patients, including doctors, dieticians and mental health professionals *Eating disorders are very hard to treat with high rates of recurrence, but the earlier theyre identified the better

EXAMPLE CASES
Jennifer is a 14-year-old female who is sent to the school nurse because she fainted during gym class. She has lost 20 pounds over the past 6 months. When the nurse asks about the weight loss, Jennifer states that she is "fat" and avoids looking at herself in the mirror. She also complains that she constantly feels bloated and has constipation. She is an excellent straight-A student. She currently weighs 85 pounds, and she stopped menstruating 6 months ago when she began losing weight. Emily is a 17-year-old female who goes to her doctor after vomiting blood. After further questioning, the girl admits she has been self-inducing vomiting to control her weight for the past two years. She initially started vomiting at a friends suggestion after eating an entire pizza. She now vomits three to five times per week after an uncontrollable eating binge (four slices of pizza, one pint of ice cream, half a box of cookies). She tearfully reports that she may have injured her throat with her fingernail last night, and says she feels very guilty about her actions. Emily also drinks alcohol and smokes cigarettes two to three times per week. She has not lost any weight despite her purging.

WHAT ARE EATING DISORDERS?

An eating disorder is when a person experiences severe disturbances in eating behavior, such as extreme reduction of food intake or overeating, or feelings of intense distress or concern about body weight or shape. A person with an eating disorder may have started out just eating smaller or larger amounts of food than usual, but at some point, the urge to eat less or more spirals out of control. People with eating disorders are usually SECRETIVE about their eating, purging or lack of eating.

There are two main kinds of eating disorders: Anorexia Nervosa and Bulimia Nervosa. Anorexia Nervosa has four diagnostic criteria: 1. Refusal to maintain weight within a normal range for height and age (less than 85 percent of expected body weight). 2. Intense fear of weight gain despite being underweight. 3. Severe body image disturbance in which body image is the predominant measure of self-worth with denial of the severity of the illness. 4. In girls who have gone through puberty and have their period, absence of the menstrual cycle for greater than three cycles.

 There are two subtypes of anorexia nervosa: restricting and binge eating/purging. People with the restricting subtype restrict their food intake to lose weight. People with the binge/purge subtype engage in binge eating or purging behavior (eg vomiting, laxatives). Either subtype may also use compulsive exercise to reduce their weight. So, someone with anorexia may induce vomiting and still be

considered anorexic (NOT bulimic) if he/she is 15 percent below ideal body weight.

WHAT ARE EATING DISORDERS?

Bulimia Nervosa diagnostic criteria: 1. Recurrent episodes of binge eating accompanied by a feeling of a lack of control. 2. Repeated behaviors to make up for eating normal or increased amounts of food to prevent weight gain (vomiting, laxatives, fasting, excessive exercising). 3. The binge eating and inappropriate compensatory behaviors occur at least twice a week for three months. 4. Dissatisfaction with body shape and weight. There are two subtypes of bulimia nervosa: purging and nonpurging type: In the purging type, the person regularly engages in self-induced vomiting or misuses laxatives/diuretics. In the nonpurging type, the person uses other strategies such as excessive exercise or fasting.

FAST FACTS ABOUT EATING DISORDERS

In the United States, as many as 10 million females have an eating disorder such as anorexia or bulimia. One in 100 American women suffer from anorexia. Two to three in 100 American women suffer from bulimia. Women are much more likely than males to develop an eating disorder, but men can have eating disorders. An estimated 5 to 15 percent of people with anorexia or bulimia are male. There are two peaks in the onset of anorexia nervosa, at age 14 (thought to be related to puberty) and 18 (thought to be due to the transition to college), though patients may present from late childhood through adulthood. The median age of onset for bulimia is 18 years.

For females between 15 and 24 years old who suffer from anorexia nervosa, the mortality rate associated with the illness is 12 times higher than the death rate of ALL other causes of death. Anorexia nervosa has the highest early death rate of any mental illness, up to 20 percent. Most people with eating disorders never receive mental health care. Almost 50% of people with eating disorders meet the criteria for depression. NIMH, National Eating Disorders Association, ANAD

WHAT CAUSES EATING DISORDERS?

It is unclear why eating disorders occur, but is likely related to the interaction of numerous factors (psychological, biological, family, environmental etc). An individual may experience decreased self-esteem or self-control because of pre-disposing factors and use dieting or weight loss to gain a sense of control. Our culture also projects unrealistic images of ideal bodies in magazines and on television, and encourages women to try and achieve this ideal.
Over one-half of teenage girls and nearly one-third of teenage boys use unhealthy weight control behaviors such as skipping meals, fasting, smoking cigarettes, vomiting, and taking laxatives. 42% of 1st-3rd grade girls want to be thinner and 81% of 10 year olds are afraid of being fat. 46% of 9-11 year-olds are sometimes or very often on diets.

Several factors have been associated with the development of eating disorders: Dieting history Childhood preoccupation with a thin body and social pressure Sports in which leanness is emphasized or in which scoring is subjective (ballet, running, gymnastics) Some studies suggest a role for genetics Psychiatric problems are common in patients with eating disorders, including depression, anxiety disorders, obsessive-compulsive disorder, and substance abuse Family stress Neurotransmitter imbalance

 Predisposing factors that make a person more vulnerable to developing an eating disorder:

Female sex Family history of eating disorders Perfectionist personality (type A) Low self-esteem Feelings of inadequacy or lack of control in life Depression, anxiety, anger, or loneliness Troubled personal relationships Difficulty expressing emotions and feelings History of being teased or ridiculed based on size or weight History of physical or sexual abuse Cultural pressures that glorify thinness and place value on obtaining the perfect body

COMPLICATIONS OF EATING DISORDERS Many medical complications can occur from starvation or persistent purging: Osteopenia (bone thinning), fractures Slowed growth Heart problems (slow heart rate, low blood pressure, heart beat irregularities) Abdominal problems (nausea, bloating, constipation) Dry skin, brittle hair and nails Growth of fine hair all over body Abnormal salts in the body Dental erosion and enlarged salivary glands Inflammation and possible rupture of the esophagus from frequent vomiting Infertility with amenorrhea (no period) (anorexia) Liver and kidney problems Low body temperature Seizures Early death

DIAGNOSING EATING DISORDERS

As

teachers, you may be able to play a key role in the diagnosis of an eating disorder.
The following are possible warning signs of anorexia and bulimia: Unnatural concern about body weight (even if the person is not overweight) Dramatic weight loss (anorexia) Obsession with calories, fat grams and food Use of any medicines to keep from gaining weight (diet pills, laxatives, water pills) Consistent excuses to avoid mealtimes or situations involving food. Excessive, rigid exercise regimen--despite weather, fatigue, illness, or injury, the need to burn off calories taken in Withdrawal from usual friends and activities Evidence of binge eating (disappearance of large amounts of food, empty wrappers and containers) Evidence of purging behaviors, including frequent trips to the bathroom after meals, signs and/or smells of vomiting, presence of wrappers or packages of laxatives or diuretics Unusual swelling of the cheeks or jaw area Calluses on the back of the hands and knuckles from self-induced vomiting Discoloration or staining of the teeth

 If you suspect one of your students has an eating disorder, you should first speak privately with the student. Select a time to talk when you will not feel rushed. In a direct but nonjudgmental manner, tell the student what you have observed that concerns you. Allow the student to respond, and if he/she tells you about personal problems, listen carefully and empathetically. It is not your job to diagnose or provide therapy, but you may be able to help the student recognize his/her problems and realize that there are resources that can help. Focus on your desire for the student to feel healthy and perform well, not on weight or right and wrong. Remember that people can rarely overcome eating disorders by themselves. Stop the conversation if no progress is being made or the student is growing too upset.

If you continue to be concerned, contact the students family and the school nurse to discuss your concerns. It is very important that the student see a doctor as soon as possible for a medical evaluation.

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TREATING EATING DISORDERS

An interdisciplinary team should treat eating disorders, including a physician, dietician, and mental health professional. Physicians must rule out other causes for the symptoms, and monitor immediate and long-term medical complications. Dieticians educate patients about healthy eating behaviors and help anorexic patients regain weight through a controlled regimen. Mental health professionals provide counseling to the patient and the patients family. They try to help the patient recognize thoughts and feelings leading to disordered eating and to develop more adaptive thoughts and coping strategies. **A note on refeeding syndrome: This is a potentially fatal condition resulting from rapid changes in fluids and electrolytes when malnourished patients are refed. Hence, patients must be monitored very closely during the refeeding process. Patients who are severely malnourished or experiencing significant medical complications may need to be admitted to the hospital for treatment.

Eating disorders are very difficult to treat. Only 50 percent of patients with anorexia nervosa will have a good outcome. 30 percent of patients with bulimia nervosa continue to engage in binging and purging behaviors after 10 years of follow-up. Young women with anorexia nervosa are 10 times more likely to die than age-matched controls, either from complications of their eating disorder, or from suicide. Outcomes

are better the earlier the disease is identified, so if you suspect an eating disorder, seek help!!!!

For more information, please contact one of the following organizations:

National Institute of Mental Health (NIMH), NIH, HHS Phone: (866) 615-NIMH (6464) Internet Address: http://www.nimh.nih.gov National Mental Health Information Center, SAMHSA, HHS Phone: (800) 789-2647 Internet Address: http://mentalhealth.samhsa.gov Academy for Eating Disorders Phone: (847) 498-4274 Internet Address: http://www.aedweb.org National Association of Anorexia Nervosa and Associated Disorders Phone: (847) 831-3438 Internet Address: http://www.anad.org National Eating Disorders Association Phone: (800) 931-2237 Internet Address: http://www.nationaleatingdisorders.org