Water Loading Before Appointments

In my previous blog I discussed falsifying weight by wearing weights.  This time I would like to discuss a much more common circumstance in which a patient falsifies their weight by trying to drink a lot of water before they are weighed.  Often this is done because they know their weight is down (since they have been secretly restricting or exercising), or they are afraid their weight is down and are anxious that the doctor or parents not find out.

Although it seemed unlikely that a person could drink enough to make a great deal of difference to a single weight, we have had a patient urinate off ten pounds of fluid (!) as she went from our office to the hospital, where she was being admitted for medical instability.

Wearing Weights

I remember the first time a patient of ours was “caught” wearing weights.  I was examining her with her mother and a young resident pediatrician in the room.  I noticed that her weight was up, but she looked terrible!  So I thought to myself: back to basics, re-examine her carefully in case you have missed some physical sign, maybe she has grown in height and weight has not caught up…..so I repeated her physical exam with an eye to re-assessing her pubertal development.  

I asked her to lie down on the exam table and that’s when I saw it:  a large, hard lump in her vaginal area.  I immediately had her sit up and she began to cry, which made the young resident (who had also seen it and was scared for her) begin to cry.  It turns out to have been her father’s coin collection.  She had carefully taped those coins to her inner thighs, each week a few more, to make up for what she thought was her approximate weight loss plus some.  She and her mother had driven two hours to see us each week, the young girl sitting on what had to have been a very painful lump.

Recently, while responding to a struggling parent who had posed a specific concern on the F.E.A.S.T. website, I used the word “remission.” Another mother on the forum responded that she did not like my use of the word “remission” since she preferred to think her daughter’s illness was not chronic. Until that moment it had not occurred to me that this question of chronicity was a controversial one for some parents.

Ken Nunn, neuro-anatomist, eating disorder specialist and great thinker, wrote an important chapter called “The Sensitivities that Heal and the Sensitivities that Hinder” in Drs Lask and Bryant-Waugh’s Eating Disorders in Childhood and Adolescence 3rd Edition. In it he called childhood anorexia nervosa a “malignant disease of children with parents usually trying to do more than could be expected of any parent...”

I got off the phone with a college student health doctor last week with the sinking feeling that I get when I have not been able to convey the rationale for what we do here at Kartini Clinic.

Let me give you some background: college-aged youth with an eating disorder who graduate from our Day Treatment Program and return to college face many hurdles to remaining in good remission. We long ago learned that we are not able to manage them from afar and therefore make every effort to help the family arrange college-based or local community care. In general, we have not found a team composed of a “therapist, nutritionist and doctor” to be very helpful when an eating disorder has been severe enough to have required an in-patient and/or DTU stay. But few colleges offer anything else. Further, our patients have come through a family-based program here that emphasizes parents do not cause and children do not choose to have an eating disorder, and that anorexia nervosa is a brain disorder. If their new therapist at college believes differently (say, that AN is caused by exposure to the media or by unresolved conflicts related to their family of origin, or fears of maturity, etc) this can be very disorienting.

By Julie K. O'Toole MD, MPH

I have decided occasionally to write about topics that may be of more interest to practicing physicians and other providers confronted with difficult or unusual cases related to disordered eating. This is one of those topics.

Food phobia of childhood, primarily seen in pre- or early pubertal children, was first described as such by Bryan Lask (pediatric psychiatrist) and Rachel Bryant-Waugh (psychologist) in the early 1990’s as a result of their work at Great Ormond Street Children’s Hospital in London. To my knowledge, with the exception of one article reporting work with a single young boy, food phobia has not been discussed as an entity in the American pediatric literature except under the general title “dysphagia” where it is likely to come to the attention primarily of pediatric gastroenterologists and otolaryngologists. In the adult literature it is usually referred to as “choking phobia”. More recently Dr. Lask has chosen to refer to it again as “functional dysphagia,” although we at the Kartini Clinic for Disordered Eating prefer the more intuitive “food phobia.” In our experience, pediatricians report they are often at a loss about what to do with these challenging patients. We are grateful to Drs. Lask and Bryant-Waugh for calling attention to this condition. Click here for the full article.

This morning I was reading a mother’s cry for help on Laura Collins' blog “Around the Dinner Table." The scared mother spoke of her 10 year old daughter’s struggle and her own ambivalence about what to do. There were many supportive responses from other parents and although I have a lot to say on this subject, I did not chime in for fear of sounding self-promoting. Yet the very young child is Kartini Clinic’s special area of expertise. So I will take this opportunity to speak to this population in the hope that parents who are searching for help may find this information useful.

Fasten your seat belt.

Determining ideal body weight in children who suffer from anorexia nervosa is complex. Pediatric patients cannot be treated like “little adults”. An example of this principle is the way medication is dosed in childhood. The right dose of an antibiotic for a newborn is different than the right dose for a two year old or for a 14 year old. And so it is for setting “weight goals” in pediatric eating disorder patients.

Bear with me then, because this is not simple. And not only is it not simple, but it is even more complicated and fraught with “special cases” than the following summary would indicate. Yet, I believe, parents can use it as a general guide.

Reporting on a new article

I just reviewed an article which should help us answer the question: how much will my young daughter with anorexia nervosa need to weigh in order to grow normally again and to get a period?

First a few jargon words to know:

Menarche = the first menstrual period
Amenorrhea = no menstrual periods
Primary amenorrhea = never had a menstrual period
Premenarcheal = before menarche
Linear growth = growth in height

Ingemar Swenne of the Uppsala University Children’s Hospital published an article in the 2008 journal Hormone Research. To my reading the article looked carefully done with results relevant to young girls with anorexia nervosa. For that reason I decided to review the salient points for among our readership who may be interested in the subject.

I have recently received some feedback about our food plan that impels me to add a few details. The food plan has been the backbone of treatment at the Kartini Clinic for many years, but there are some things you should know about it.

1. It was developed to enable families to feed their children without resort to counting calories or exchanges. The child chooses among real food items that have been counted already (by us). Many different food choices are available.

2. Within the confines of the food plan parents can cook traditional American food, if that is what their family likes, or Chinese food or Indian food or Russian food or German food, nouvelle-cuisine, French food, Japanese food…you get the picture.

Most of you will have heard me say that weight restoration is the cornerstone of treatment in childhood anorexia nervosa, without which you get nothing. It makes sense, you say? And yet we still get children referred to us who have been in hospital or residential centers and were discharged well below a restored weight—or even discharged weighing less than when they entered! How can that be? We gnash our teeth.

In my opinion it is a reflection of the general reluctance to accept that medical, not psychological interventions, must come first. A child must be weight-restored before medication, social support, psychotherapy, cognitive restructuring, etc. can have a fighting chance of working. This reluctance to acknowledge the physiological takes many forms, depending on the stage of treatment for the child.