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Nutrition Therapy for Clients with Disordered Eating By: Megan Holt, MPH, RD.

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1 Nutrition Therapy for Clients with Disordered Eating By: Megan Holt, MPH, RD

2 REVIEW OF ED CRITERIA for AN (DSM-IV) Refusal to maintain body weight at or above a minimally normal weight for age and height (or failure to make expected weight gain during period of growth) Refusal to maintain body weight at or above a minimally normal weight for age and height (or failure to make expected weight gain during period of growth) Intense fear of gaining weight or becoming fat, even though underweight. Intense fear of gaining weight or becoming fat, even though underweight. 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. 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. In postmenarchal females, amenorrhea ie, the absence of at least three consecutive cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone administration.) In postmenarchal females, amenorrhea ie, the absence of at least three consecutive cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone administration.) Specify type: Specify type: Restricting Type: During the current episode of AN, the person has not regularly engaged in binge-eating or purging behavior Restricting Type: During the current episode of AN, the person has not regularly engaged in binge-eating or purging behavior Binge-Eating/Purging Type: During the current episode of AN, the person has regularly engaged in binge-eating or purging behavior Binge-Eating/Purging Type: During the current episode of AN, the person has regularly engaged in binge-eating or purging behavior

3 REVIEW OF ED CRITERIA for BN (DSM-IV) Recurrent episodes of binge eating characterized by both of the following:(1) Eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is larger than most would eat during a similar period of time and under similar circumstances.(2) A sense of lack of control over eating during the episode Recurrent episodes of binge eating characterized by both of the following:(1) Eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is larger than most would eat during a similar period of time and under similar circumstances.(2) A sense of lack of control over eating during the episode Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas or other medications, fasting or excessive exercise. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas or other medications, fasting or excessive exercise. The binge eating and compensatory behaviors both occur, on average, at least twice/week for 3 months. The binge eating and compensatory behaviors both occur, on average, at least twice/week for 3 months. Self-evaluation is unduly influenced by body shape and weight. Self-evaluation is unduly influenced by body shape and weight. The disturbance does not occur exclusively during episodes of AN. The disturbance does not occur exclusively during episodes of AN. Specify type: Specify type: Purging type: During the current episode of BN, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas. Purging type: During the current episode of BN, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas. Nonpurging type: During the current episode of BN, the person has used 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. Nonpurging type: During the current episode of BN, the person has used 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.

4 REVIEW OF ED CRITERIA for ED-NOS (DSM-IV) For females, all AN criteria are met except that the individual has regular menses. For females, all AN criteria are met except that the individual has regular menses. All AN criteria are met except that, despite significant weight loss the current weight is in the normal range. All AN criteria are met except that, despite significant weight loss the current weight is in the normal range. All BN criteria are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for duration of less than 3 months. All BN criteria are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for duration of less than 3 months. The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (eg, self- induced vomiting after the consumption of two cookies). The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (eg, self- induced vomiting after the consumption of two cookies). Repeatedly chewing and spitting out, but not swallowing, large amounts of food. Repeatedly chewing and spitting out, but not swallowing, large amounts of food. Binge-eating disorder (falls under DSM-IV for now): recurrent episodes of binge eating in the absence of inappropriate compensatory behaviors characteristic of BN. Binge-eating disorder (falls under DSM-IV for now): recurrent episodes of binge eating in the absence of inappropriate compensatory behaviors characteristic of BN.

5 AN: Pathophysiology Depleted fat stores; muscle wasting Depleted fat stores; muscle wasting Amenorrhea Amenorrhea Cheilosis Cheilosis Postural hypotension; dehydration or edema Postural hypotension; dehydration or edema Sleep disturbances Sleep disturbances Low body temperature/cold intolerance Low body temperature/cold intolerance Lower metabolism: low thyroid hormone Lower metabolism: low thyroid hormone Bone marrow hypoplasia (50% of AN patients) results in leukopenia, anemia, thrombocytopenia Iron deficiency anemia Increased infections Dry skin, hair and hair loss Yellow skin due to hypercarotenemia Lanugo: fine body hairs

6 AN: Pathophysiology Osteopenia/Osteoporosis Reduced bone mineral density Reduced bone mineral density May result in vertebral compression, fractures May result in vertebral compression, fractures Caused by estrogen deficiency, elevated glucocorticoid levels, malnutrition, reduced body mass Caused by estrogen deficiency, elevated glucocorticoid levels, malnutrition, reduced body mass Affects males and females Affects males and females T-Score

7 AN: Pathophysiology GI GI Bloating, abnormal Bloating, abnormal fullness fullness after eating Constipation Constipation Diarrhea Diarrhea Digestive enzymes low (i.e. lactase) Digestive enzymes low (i.e. lactase)

8 AN: Pathophysiology Cardiovascular Cardiovascular Decreased heart rate <60 bpm Decreased heart rate <60 bpm Fatigue, fainting Fatigue, fainting Decreased blood pressure <70 mm/Hg systolic; orthostatic hypotension Decreased blood pressure <70 mm/Hg systolic; orthostatic hypotension Reduction in heart mass Reduction in heart mass Mitral valve prolapse related to hypovolemia or cardiomyopathy Mitral valve prolapse related to hypovolemia or cardiomyopathy Death from CHF Death from CHF Electrolyte imbalance → heart failure, death Electrolyte imbalance → heart failure, death Low intake potassium Low intake potassium Loss in vomiting, diuretics Loss in vomiting, diuretics Refeeding syndrome: electrolyte imbalances caused by rapid refeeding Refeeding syndrome: electrolyte imbalances caused by rapid refeeding

9 BN: Pathophysiology Vomiting Vomiting Dehydration Dehydration Alkalosis Alkalosis Hypokalemia (low potassium) Hypokalemia (low potassium) Sore throat, esophagitis, mild hematemesis Sore throat, esophagitis, mild hematemesis Abdominal pain Abdominal pain Subconjunctival hemorrhage Subconjunctival hemorrhage Esophageal tears/ruptures (rare) Esophageal tears/ruptures (rare) Acute gastric dilatation or rupture Acute gastric dilatation or rupture Salivary gland infections Salivary gland infections Cardiac arrhythmias related to electrolyte and acid-base imbalance caused by vomiting, laxative, and diuretic abuse Cardiac arrhythmias related to electrolyte and acid-base imbalance caused by vomiting, laxative, and diuretic abuse Ipecac may cause irreversible myocardial damage and sudden death Ipecac may cause irreversible myocardial damage and sudden death Menstrual irregularities Menstrual irregularities

10 BN: Pathophysiology Laxative Abuse Laxative Abuse Dehydration Dehydration Elevation of serum aldosterone and vasopressin levels Elevation of serum aldosterone and vasopressin levels Rectal bleeding Rectal bleeding Intestinal atony Intestinal atony Abdominal cramps Abdominal cramps Diuretic Abuse Diuretic Abuse Dehydration Dehydration Hypokalemia Hypokalemia

11 Role of the dietitian in a treatment team and goals of nutrition therapy AN: weight gain/prevention of further loss and correction of malnutrition induced disorders; normalization of eating patterns and behaviors AN: weight gain/prevention of further loss and correction of malnutrition induced disorders; normalization of eating patterns and behaviors BN: weight maintenance in the short term even if patient is overweight until eating habits are stabilized BN: weight maintenance in the short term even if patient is overweight until eating habits are stabilized Increase food intake to raise the BMR (basal metabolic rate) Increase food intake to raise the BMR (basal metabolic rate) Some weight restoration and treatment of malnutrition may make Some weight restoration and treatment of malnutrition may make psychotherapy more effective due to improved cognition (Nutritional intervention must support psychological strategy)

12 Role of the dietitian in a treatment team and goals of nutrition therapy Often require hospitalization to begin refeeding Often require hospitalization to begin refeeding Some require enteral feedings, but most can be Some require enteral feedings, but most can be rehabbed with oral feedings Goal is increase in energy intake with weight gain Goal is increase in energy intake with weight gain Energy intake must be increased gradually while Energy intake must be increased gradually while minimizing caloric expenditure Hospitalized patients: goal is 2-3 lb/week Hospitalized patients: goal is 2-3 lb/week Outpatients: 1 pound/week Outpatients: 1 pound/week (APA Practice Guidelines for the Treatment of Eating Disorders, January, 2006)

13 Part I: Nutrition Assessment Calories compared with DRI (dietary reference intake) Calories compared with DRI (dietary reference intake) Evaluate macronutrient mix (carbohydrate, protein, fat) Evaluate macronutrient mix (carbohydrate, protein, fat) Evaluate micronutrient intake compared with DRI Evaluate micronutrient intake compared with DRI Estimate fluids and compare with needs Estimate fluids and compare with needs Evaluate alcohol, caffeine, drugs, dietary supplements Evaluate alcohol, caffeine, drugs, dietary supplements (www.usda.gov) for DRI’s (The Eating Disorders Clinical Pocket Guide by Jessica Setnick)

14 Pertinent medical history Ex: diabetes, hypertension, high cholesterol, kidney disease, etc. Ex: diabetes, hypertension, high cholesterol, kidney disease, etc. Pertinent family history (parents, siblings) ED, heart disease, etc. ED, heart disease, etc. Eating habits, weight and stature, relationship with food Eating habits, weight and stature, relationship with food Nutrition Assessment

15 Height (verify- particularly in adolescents) (verify- particularly in adolescents) ED history bingeing, purging, relationship bingeing, purging, relationship with food/shape/exercise with food/shape/exercise Weight history lifetime highest, lifetime highest, lowest during ED Conditions around extreme weights Conditions around extreme weights

16 Nutrition Assessment Current ED behaviors How often does the client How often does the client weight at home? Binge Binge Purge (33-75% kcals still absorbed) Purge (33-75% kcals still absorbed) Fluid intake Fluid intake (caffeinated and decaf)

17 Food Rituals Eating foods in certain orders (ex: veggies first) Eating foods in certain orders (ex: veggies first) Excessive chewing (or counting chews) Excessive chewing (or counting chews) Rearranging food on a plate (ex: 8 peas) Rearranging food on a plate (ex: 8 peas) Eating finger foods with fork and knife Eating finger foods with fork and knife Wiping fork after each use Wiping fork after each use Not allowing foods to touch Not allowing foods to touch One food per meal (ex: blueberries) One food per meal (ex: blueberries)

18 Nutrition Assessment Medical changes related to ED Constipation, diarrhea, Constipation, diarrhea, lactose intolerance, dental problems, bone health? Last period and when Last period and when stopped if amenorrhea Medications and supplements BCP, calcium, MVI, herbal supplements, miralax, etc. BCP, calcium, MVI, herbal supplements, miralax, etc.

19 Nutrition Assessment Methods to suppress hunger Gum, diet soda/products, Gum, diet soda/products, coffee, condiments Vegetarianism How long? Does this coincide with start of ED? How long? Does this coincide with start of ED? Honoring vegetarianism and level of care (later) Honoring vegetarianism and level of care (later) Food Allergies? Gluten Gluten Lactose Lactose Other? Other?

20 Nutrition Assessment Blood values and nutritional significance: Albumin Albumin Total protein Total protein Blood Urea Nitrogen (BUN) Blood Urea Nitrogen (BUN) Creatinine Creatinine Mangnesium Mangnesium Phosphorus Phosphorus Sodium Sodium Potassium Potassium Hemoglobin/Hematocrit Hemoglobin/Hematocrit Estradiol Estradiol Frequency of blood draws?

21 Food Journal (see sample food journal) Keeps for three days prior to visit Keeps for three days prior to visit Continues until eating and B/P stable Continues until eating and B/P stable More useful with clients that are new More useful with clients that are new to treatment/little knowledge of nutrition No judgment!!!! No judgment!!!!

22 Plan of Care MVI/Supplement recommendations Calcium: Needs 1200mg/day Calcium: Needs 1200mg/day Supplementation: mg/day Supplementation: mg/day Calcium Carbonate most common Calcium Carbonate most common MVI with Vitamin D MVI with Vitamin D

23 Plan of Care MVI/Supplement recommendations Iron: Needs 15-18mg/day Iron: Needs 15-18mg/day Supplementation: 50-60mg twice daily Supplementation: 50-60mg twice daily Frequent complaints: constipation, nausea Frequent complaints: constipation, nausea Vitamin C, meat protein (heme iron) increases absorption Vitamin C, meat protein (heme iron) increases absorption Caffeine and phytates inhibit absorption Caffeine and phytates inhibit absorption Other supplements per MD (ex: B12) Other supplements per MD (ex: B12)

24 What’s wrong with this picture? Break up into groups Break up into groups Look at the 3 different sample menus Look at the 3 different sample menus How would you make this day more balanced? How would you make this day more balanced?

25 Mindful Eating! Synonymous words: Synonymous words: Intuitive eating Intuitive eating Conscious eating Conscious eating Thoughtful eating Thoughtful eating Characteristics of: Characteristics of: Being connected and present Being connected and present Awareness Awareness Respecting body Respecting body Being in-tune with physical hunger and fullness cues Being in-tune with physical hunger and fullness cues Being non-judgmental Being non-judgmental

26 Mindful Eating Practice Take your time (slow down!) Take your time (slow down!) Use timer Use timer Put utensils down Put utensils down Push plate away Push plate away Use your 4 senses Use your 4 senses Limit distractions Limit distractions Set environment to be calm Set environment to be calm Meditation or prayer Meditation or prayer

27 Body Cues How to distinguish between emotional and physical hunger and fullness How to distinguish between emotional and physical hunger and fullness Use Hunger Scale (on food journal) Use Hunger Scale (on food journal) Use inquiry Use inquiry When did I eat last? When did I eat last? Did I have a balanced meal or snack? Did I have a balanced meal or snack? Was I fully satisfied when I finished? Was I fully satisfied when I finished? Are there any particular emotions present? Are there any particular emotions present?

28 Part II:Meal Planning Estimating needs for AN kcals/kg body weight ( kcals daily to start) kcals/kg body weight ( kcals daily to start) kcal increases 2 times weekly kcal increases 2 times weekly kcals/kg ultimately, with weight restoration goal of 1-2 lbs weekly (outpatient) or 2-3 lbs weekly (inpatient) kcals/kg ultimately, with weight restoration goal of 1-2 lbs weekly (outpatient) or 2-3 lbs weekly (inpatient) Fluids 30-40ml/kg body weight or 64oz Fluids 30-40ml/kg body weight or 64oz (APA Practice Guidelines for Treatment of ED’s 2006)

29 Determining Goal Weight CDC Growth Charts (adolescents) CDC Growth Charts (adolescents)http://www.cdc.gov/GROWTHCHARTS/ Hamwi Equation: Hamwi Equation: Hamwi Formula for Men 106 lbs for first 5 feet + 6 lbs for each inch over 5 feet (med. frame) Small frame (- 10%), Large frame (+ 10%) Hamwi Formula for Women 100 lbs for first 5 feet + 5 lbs for each inch over 5 feet (med. frame) Small frame (- 10%), Large frame (+ 10%) Hamwi Formula for Women 100 lbs for first 5 feet + 5 lbs for each inch over 5 feet (med. frame) Small frame (- 10%), Large frame (+ 10%) Past History/ menstruation Past History/ menstruation Genetics: parents build and eating habits Genetics: parents build and eating habits

30 Meal Planning-AN 3 meals and 3 snacks 3 meals and 3 snacks Liquids and use of supplements Liquids and use of supplements May need reglan due to delayed May need reglan due to delayed gastric emptying for comfort gastric emptying for comfort

31 Meal Planning-BN Estimating needs for BN: kcals/kg body weight, depending kcals/kg body weight, depending on current intake and exercise on current intake and exercise Primary goal: interuption of B/P Primary goal: interuption of B/P Initial prescription typically around 1500 kcals Initial prescription typically around 1500 kcals Adjust for weight maintenance, and avoid weight Adjust for weight maintenance, and avoid weight reduction diet until eating is stable reduction diet until eating is stable Expect impairment of hunger/satiety signals Expect impairment of hunger/satiety signals Ex: 5 ft 4 in., 128 lbs (58kg)= kcals Ex: 5 ft 4 in., 128 lbs (58kg)= kcals (APA Practice Guidelines for Treatment of ED’s 2006)

32 Meal Planning: Macronutrients 50-55% carbohydrate (25-30g fiber) 50-55% carbohydrate (25-30g fiber) 15-20% protein ( g/kg body wt) 15-20% protein ( g/kg body wt) 25-30% fat (less than 10% total kcals 25-30% fat (less than 10% total kcals from saturated/trans fatty acids) from saturated/trans fatty acids)

33 Exchange System Exchanges versus Calories More flexible than Calorie counting More flexible than Calorie counting Emphasizes balance and moderation Emphasizes balance and moderation Incorporates evidence based suggestions Incorporates evidence based suggestions for macronutrients from ADA and AHA for macronutrients from ADA and AHA

34 Exchange System Grains/Starches 6-11 Grains/Starches 6-11 Milk/Dairy 3-4 Milk/Dairy 3-4 Fruit 2-4 Fruit 2-4 Vegetables 3-5 Vegetables 3-5 Protein/Meat 4-6 Protein/Meat 4-6 Fats 4-6 Fats 4-6 Above guidelines may Above guidelines may not be adequate for weight restoration!! restoration!! See sample exchange See sample exchangelists

35 Exchange System Starches/Grains: 15g Carb, 3g protein, 0-1g fat, Starches/Grains: 15g Carb, 3g protein, 0-1g fat, 80 kcals Dairy/Milk: 12g Carb, 8g protein, 0-3g fat, 100 kcals Dairy/Milk: 12g Carb, 8g protein, 0-3g fat, 100 kcals Fruit: 15g Carb, 0g fat/protein, 60 kcals Fruit: 15g Carb, 0g fat/protein, 60 kcals Veggies: 5g Carb, 0-2g protein, 0g fat, 25 kcals Veggies: 5g Carb, 0-2g protein, 0g fat, 25 kcals Meat/Protein (lean): 0 Carb, 7g protein, 0-3g fat, 45 kcals Meat/Protein (lean): 0 Carb, 7g protein, 0-3g fat, 45 kcals Fats: 0g Carb, 0g protein, Fats: 0g Carb, 0g protein, 5g fat, 45 kcals

36 Measuring food Discouraged!! Discouraged!!Exceptions: First time with a new food and very distorted view of portions First time with a new food and very distorted view of portions New to treatment/meal planning New to treatment/meal planning Assure client that exchanges consider balance and quality of diet Assure client that exchanges consider balance and quality of diet GOAL: NORMALIZE EATING GOAL: NORMALIZE EATINGNO!!!!

37 Portion Distortion Woman's fist or baseball - a serving of vegetables or fruit Woman's fist or baseball - a serving of vegetables or fruit A rounded handful - about one half cup cooked or raw veggies or cut fruit, a piece of fruit, or ½ cup of cooked rice or pasta - this is a good measure for a snack serving, such as chips or pretzels A rounded handful - about one half cup cooked or raw veggies or cut fruit, a piece of fruit, or ½ cup of cooked rice or pasta - this is a good measure for a snack serving, such as chips or pretzels Deck of cards - a serving of meat, fish or poultry or the palm of your hand (don't count your fingers!) – ex: one chicken breast, ¼ pound hamburger patty Deck of cards - a serving of meat, fish or poultry or the palm of your hand (don't count your fingers!) – ex: one chicken breast, ¼ pound hamburger patty Golf ball or large egg - one quarter cup of dried fruit or nuts Golf ball or large egg - one quarter cup of dried fruit or nuts Tennis ball - about one half cup of ice cream Tennis ball - about one half cup of ice cream Computer mouse - about the size of a small baked potato Computer mouse - about the size of a small baked potato Compact disc - about the size of one serving of pancake or small waffle Compact disc - about the size of one serving of pancake or small waffle Thumb tip - about one teaspoon of peanut butter Thumb tip - about one teaspoon of peanut butter Six dice - a serving of cheese Six dice - a serving of cheese Check book - a serving of fish (approximately 3 oz.) Check book - a serving of fish (approximately 3 oz.)

38 No Weighing! Ask client to refrain from weighing at home Weight 1-2/week with practitioner, less if stable (ex: normal wt BN) Blind weight: challenge client to focus on other measures of health and remind them of past experiences with weighing (i.e. triggers ED behaviors)

39 What’s the point?

40 Where does exercise fit in? Restrict with AN until eating improves and client reaches 90% ideal body weight Restrict with AN until eating improves and client reaches 90% ideal body weight With normal weight BN, wait for improvement in B/P With normal weight BN, wait for improvement in B/P Monitor client for compensatory exercise (trading vomiting for exercise) Monitor client for compensatory exercise (trading vomiting for exercise) Explain rationale and caution against exercising on purging days due to electrolyte disturbance Explain rationale and caution against exercising on purging days due to electrolyte disturbance Start with mindful activity: yoga Start with mindful activity: yoga Weight bearing exercise and osteoporosis Weight bearing exercise and osteoporosis

41 Female Athlete Triad Characterized by disordered eating, amenorrhea, and osteoporosis. Characterized by disordered eating, amenorrhea, and osteoporosis. 50% of these athletes may have bone mineral densities that are 1 standard deviation below normal for age. 50% of these athletes may have bone mineral densities that are 1 standard deviation below normal for age. Requires exercise restriction. Requires exercise restriction. Coaches must de-emphasize weight and are cautioned to stop weighing athletes continually/focus on strength and mental conditioning. Coaches must de-emphasize weight and are cautioned to stop weighing athletes continually/focus on strength and mental conditioning. Some highly motivated and competitive athletes may correct their eating disorder if they are told that malnutrition will affect their performance. Some highly motivated and competitive athletes may correct their eating disorder if they are told that malnutrition will affect their performance.

42 Meal Planning Using Exchange System Case Study see assessment form, see assessment form, sample meal plan and sample menus

43 Vegetarianism and Considerations Duration of vegetarianism Duration of vegetarianism and motivation Minor/Adult Minor/Adult Lacto-ovo? Vegan? Lacto-ovo? Vegan? Level of care Level of care Able to meet needs Able to meet needs through other foods?

44 Food Allergies Often used in service of ED and learned in higher LOC Often used in service of ED and learned in higher LOC Verify if feasible (parents, allergist) and if accommodating allergy will limit progress Verify if feasible (parents, allergist) and if accommodating allergy will limit progress Ex: gluten, nuts, mayo Ex: gluten, nuts, mayo Offer alternatives Ex: for lactose intolerance offer lactaid tablet, lactaid milk, soy milk/yogurt Ex: for lactose intolerance offer lactaid tablet, lactaid milk, soy milk/yogurt Play detective! If it sounds fishy, it probably is! Ex: pt states gluten intolerant, but eats oatmeal/bran muffins Ex: pt states gluten intolerant, but eats oatmeal/bran muffins GOAL: help to normalize eating and making peace with fear foods!

45 HAES Model: Health at Every Size Health enhancement—attention to emotional, physical and spiritual well- being without focus on weight loss or achieving a specific “ideal weight” Health enhancement—attention to emotional, physical and spiritual well- being without focus on weight loss or achieving a specific “ideal weight” Size and self-acceptance—respect and appreciation for the wonderful diversity of body shapes and sizes (including one's own!), rather than the pursuit of an idealized weight or shape Size and self-acceptance—respect and appreciation for the wonderful diversity of body shapes and sizes (including one's own!), rather than the pursuit of an idealized weight or shape The pleasure of eating well—eating based on internal cues of hunger, satiety, and appetite, rather than on external food plans or diets The pleasure of eating well—eating based on internal cues of hunger, satiety, and appetite, rather than on external food plans or diets The joy of movement—encouraging all physical activities for the associated pleasure and health benefits, rather than following a specific routine of regimented exercise for the primary purpose of weight loss The joy of movement—encouraging all physical activities for the associated pleasure and health benefits, rather than following a specific routine of regimented exercise for the primary purpose of weight loss An end to weight bias—recognition that body shape, size and/or weight are not evidence of any particular way of eating, level of physical activity, personality, psychological issue or moral character An end to weight bias—recognition that body shape, size and/or weight are not evidence of any particular way of eating, level of physical activity, personality, psychological issue or moral character Confirmation that there is beauty and worth in EVERYbody Confirmation that there is beauty and worth in EVERYbody

46 Nutrition Education Topics Calcium intake and Osteoporosis Calcium intake and Osteoporosis Set Point Theory (Key’s Study) Set Point Theory (Key’s Study) Danger of Fad Diets Danger of Fad Diets Function of Foods: Carbohydrate, Fat, Protein Function of Foods: Carbohydrate, Fat, Protein Changes to Expect with Refeeding (constipation, bloating, fullness) Changes to Expect with Refeeding (constipation, bloating, fullness) Moderate vs. Compulsive/Compensatory Exercise Moderate vs. Compulsive/Compensatory Exercise HAES model (Health at Every Size) HAES model (Health at Every Size) Laxative Abuse Laxative Abuse Consequences of Malnutrition Consequences of Malnutrition (Client ready handouts can be found in Winning the War Within)

47 Questions? Thank you!


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