weight loss - case study
by Kate Harrod-Wild Paediatric Dietitian Wrexham Maelor Hospital
Phyllis was referred to the adult eating disorder service just before her 15th birthday. The referral was rejected by the adult service as she was less than 16 years and so was passed on to the paediatric dietetic service. We have no funding for eating disorders, but will pro- vide an initial assessment of current nutritional intake. The referral was for ongoing abdominal pain, possibly due to constipation, gastritis or psychological in origin.
On her initial visit, Phyllis was aged 15 years and one month. She attended with her mother, but did not want her mother to come into the consultation. The history given was that she had lost approximately four stone in weight over a period of about a year, about half of it with a slimming club. At this first visit, her weight was 70.8kg, at a height of 167.5cms giving a body mass index (BMI) of 25.2 – so she had been considerably overweight. However, she was now very anxious about eating and was terrified she would regain the weight she had lost. From her diet history her daily intake consisted of in excess of 20 cups of tea with skimmed milk plus one to two pieces of toast with margarine. This was causing consid- erable tension at home – she was having frequent rows with her mum. When asked how she felt about eating she became tearful – but still didn’t want her mum to come in. She felt very frightened of food and very frightened of regaining the weight. There were limited options for treat- ment available as our child and adolescent mental health service was unlikely to accept a referral due to the fact that she had a normal BMI. In any case, on questioning, she didn’t have all the features of a classic eating disor- der; she had appropriate body image and, despite a very low intake, she didn’t seem particularly concerned about avoiding fat and had not recently become vegetarian, although she had never liked meat. In addition, although she was very articulate, she hated school and was clearly not in the high achieving bracket.
Feeling guilty about eating
We talked about how she felt about slightly increas- ing her food intake. She agreed, but was worried that this would lead to bingeing. However, when asked to explain how she would define bingeing, she described it as eating a piece of cake and feeling guilty afterwards. On nego- tiation she agreed to have a yoghurt at breakfast time, a jacket potato and tuna when she came home from school and cheese with her toast later on. She was not happy to eat at school as she felt too self conscious. We discussed the possibility of a referral to psychology if her anxiety/very low food intake continued and she was open to this option. With her permission, as I showed Phyllis out, I outlined the plan to her mother. In view of her very low intake, I asked her to attend a week later. Phyllis imme- diately looked more relaxed and happier. She attended this appointment and every subsequent one with her father. She was sometimes having toast at breakfast. Lunch was fruit and she had toast or a sandwich and soup when
NHDmag.com June '10 - issue 55
Kate Harrod-Wild is a paediatric dietitian with over 15 years experience of working with children in acute and community settings. Kate has also written and spoken extensively on child nutrition.
Weight loss and disordered eating behaviour
she came home, plus a sandwich or beans on toast later on. This was confirmed when she was re-weighed, as her weight had increased to 71.4kg. Her boyfriend was appar- ently pleased as had never seen her eat before! Phyllis was keen to have a structured meal plan and I understood her need to have a framework to feel ‘safe’ when eating. A plan was given for 1,200-1,500kcals per day to avoid ‘frightening’ her – with the understanding that it would need to change according to her weight. She was seen again in another week, still relaxed and she had eaten a biscuit! She felt nervous but had eaten it anyway. She wasn’t weighed at her request.
Weight Aware UK. Nutritional Health & Dietetics Magazine. Portrait 131mm H x 93mm W. June 2010. Version 1.
Phyllis was then not seen for about a month over the Christmas period. When she attended again she had had a bit of a setback. She was bored over Christmas and argued with her boyfriend who was going into the army imminently. She also wanted to join the army, so we discussed the need to stabilise her eating and weight to achieve this goal; she understood that she would not be accepted into the army with unresolved weight and eating issues.
Separating food from emotions
Her weight was down to 70.4kg, which was unsurprising
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