1. Great Ormond Street Hospital & Institute of Child Health Nutritional issues in children and adolescents with eating disorders Dasha Nicholls Feeding and Eating Disorders Service, GOSH

2. Great Ormond Street Hospital & Institute of Child Health Issues Refeeding BMI/defining malnutrition Bone health Healthy diets for children and adolescents Impact on the brain

3. Great Ormond Street Hospital & Institute of Child Health Refeeding I Increasing preference for outpatient treatment over inpatient treatment of AN Debate about criteria for admission and where to admit paediatric ward for primarily medical concerns unit skilled in normalising eating behaviour. This means determining medical condition risks of refeeding.

5. Great Ormond Street Hospital & Institute of Child Health Medical stability Guidelines are based on % weight for height (=%BMI) – arbitrary? pulse BP (often not using child cuffs or norms), temperature Are there better practical ways of assessing medical risk or metabolic instability in children?

6. Great Ormond Street Hospital & Institute of Child Health Refeeding II When is it dangerous to refeed on an outpatient basis, even if medically stable? Factors to consider are absolute %BMI, rate of weight loss, current intake UK less conservative approach to admission for the initial phase of refeeding. How great is the risk of refeeding in reality?

7. Great Ormond Street Hospital & Institute of Child Health Refeeding III Energy requirements of adolescents in puberty are greatly increased. How can we best determine energy needs? Calculating energy requirements during growth is a problem based on nutritional status, age or developmental stage? Indirect calorimetry has been used in the clinical management of adolescents, to measure energy expenditure. What is the added value of this?

8. Great Ormond Street Hospital & Institute of Child Health Refeeding IV How much does it matter what we feed younger patients in the early stages of nutritional rehabilitation? Risks of limited range Merits of food over nutritional supplements

9. Great Ormond Street Hospital & Institute of Child Health The great weight gain debate

10. Great Ormond Street Hospital & Institute of Child Health Defining malnutrition In adults, concern around BMI 13 Is such a guideline is available for children in terms of severity of malnutrition below the 85% BMI level? Guidelines suggest 75% BMI as admission criteria 67% equivalent to adult BMI of 13

11. Great Ormond Street Hospital & Institute of Child Health BMI vs body composition Children have very different fat mass/fat free mass ratios at different developmental stages. Are there other parameters that might better define stages of malnutrition than BMI/other weight for height measures? Measures of body fat also flawed in children

12. Great Ormond Street Hospital & Institute of Child Health BMI vs % fat in boys

13. Great Ormond Street Hospital & Institute of Child Health Malnutrition II How helpful is it to specify types of malnutrition e.g. energy deficiency versus protein deficiency? Given how different children lose weight (e.g. slow/fast, drink excess, excess excerise with normal diet, cut out fat but not protein etc) does this have implications for morbidity, refeeding, prognosis, and speed of weight gain

14. Great Ormond Street Hospital & Institute of Child Health Defining malnutrition III When current definitions do not apply Adaptation to low caloric intake history of failure to thrive or long standing food restriction (e.g. restrictive eating pattern or child raised in famine conditions) Some ethnic groups, particularly from the Asian subcontinent. Both groups may present with ‘acute on chronic’ low weight. Should we have different criteria in these populations?

15. Great Ormond Street Hospital & Institute of Child Health Onset of menses (longitudinal data 1° amen. girls)

16. Great Ormond Street Hospital & Institute of Child Health Bone health and prevention of osteoporosis Nutritional rehabilitation is the treatment of choice, but how can we maximise bone accretion during the vital years?

17. BONE DENSITYBONE DENSITY 406020 Peak Bone Mass # AGE Bone accretion and loss

18. Bone density 60% of bone accretion occurs during puberty GENESGENDERRACE SEX HORMONES GROWTH HORMONE CORTISOL EXERCISE WEIGHTNUTRITION (INC.CALCIUM)

19. Great Ormond Street Hospital & Institute of Child Health Healthy diets for children and adolescents Dieting Up to 18 X relative risk for development of eating disorders How important are micronutrient changes (such as zinc) in the onset of problem eating Could some sorts dieting be higher risk than others? What sort of ‘normal’ diet should we be aiming for, in your view?

20. Great Ormond Street Hospital & Institute of Child Health Healthy diets for children and adolescents II Are there nutritional cultures that are not in the interests of young people, ‘healthy’ foods, low fat foods vegetarian diets? Could attempts to address the obesity epidemic be inadvertently giving unhelpful nutritional advice for children?

21. Great Ormond Street Hospital & Institute of Child Health J “Last year J changed schools and it did not go very smoothly – J found it difficult to settle down. J is an extremely bright child and in the area where we live there are quite a few underachievers. J would often help them as the teachers we talked to refused to believe that J was bored. In October J was diagnosed with vertigo. This went on for a couple of months on and off and the doctor said that in an older person he would have said it was stress. For a week before Christmas it seemed to be getting better, but then J needed to have a tonsillectomy. After the operation J got shingles.”

22. Great Ormond Street Hospital & Institute of Child Health “Shortly after this J started eating strangely, reading the packets of food, and refusing to eat things that were high in fat. The GP was not interested. Then J started getting faddy about food, changing from vegetarian to couscous then to diet foods and gradually the weight began to drop off. My daughter kept going to the GP about how worried she was but it was not until J had lost a lot of weight that they were sent to see a psychologist. J eats minute amounts at a time. When getting a drink J will not just walk to the fridge, but will tiptoe and does not stop moving. There are rituals for doing certain things and given the chance J would be exercising the whole time.”

23. Great Ormond Street Hospital & Institute of Child Health Vegetarianism Associated with more dieting, higher ED scores, vomiting and laxative use Klopp J AM Diet Assoc 2003; Gilbody IJED 1999; Neumark-Sztainer 1997;

24. Great Ormond Street Hospital & Institute of Child Health BCS70 Waves at 10, 16 and 30 years ?Data at 16 yrs Cohort 18,664 30 yr data recently made available

25. Great Ormond Street Hospital & Institute of Child Health Vegetarianism Answered “Are you vegetarian?” n = 6228 Of those 229 vegetarian (4.6%) 6% of girls - Chi squared p < 0.000

26. Great Ormond Street Hospital & Institute of Child Health

27. Great Ormond Street Hospital & Institute of Child Health Weight status and vegetarianism BMI at 16 not significant different between vegetarians vs non-vegetarians (20.9 vs 21.3) although absolute weight was lower (56.6 vs 58.9 kg) height was lower (1.66 vs 1.69 m p <0.00) Of total sample 122 (2.1%) were below 2SDS for BMI. Lowest 9.9 Not related to veg status but numbers too low

28. Great Ormond Street Hospital & Institute of Child Health Self report of ED at age 30 18,664 in sample 11,095 responded to Q 116 reported AN 107 reported BN 15 both 106 AN only 92 BN only

31. Great Ormond Street Hospital & Institute of Child Health Impact on the brain AN causes cortical atrophy not fully reversed with weight gain, Related to high cortisol levels Abnormalities of cognitive function have also been found not always possible to differentiate cause and effect. What do we know about the impact of malnutrition on the developing brain?