May
31
Family Care an Anorexia Option
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The Weekend Australian
Health editor Adam Cresswell | May 31, 2008
IT took a while for Sydney mother Jan to realise something wasn’t quite right with her daughter Ashleigh, then aged 13 1/2.
At that stage weighing 62 kilograms, Ashleigh was sensitive about her weight - which was perfectly healthy, but towards the upper end of the normal range. Ashleigh mentioned to Jan (not their real names) that she wanted to shed a bit of the “puppy fat” that was making her unhappy.
For the next couple of months, until about October 2006, all seemed to be going well. Ashleigh continued to eat well, was sporty, healthy and - so it seemed - happy. Her mother noticed a bit of weight had come off, but nothing to cause concern.
Slowly, that changed.
“I started to notice that she was making different choices about food,” says Jan. “There was always an excuse - ‘No, I don’t want a salad sandwich, I’ll just have the salad without the bread’.”
So began a near year-long ordeal during which mother and daughter consulted their GP, then waited weeks to see a psychologist and dietitian, before Ashleigh was finally taken to the eating disorders unit at the Children’s Hospital at Westmead, Sydney.
At the time of her admission, Ashleigh had lost over 20kg. Her periods had ceased eight months earlier. Her hair was falling out, and was being replaced by a soft fuzz similar to that on baby’s heads. Her teeth were brittle and chipping, her skin was breaking out and she had dark circles under her eyes.
Whereas a normal heartbeat would have been somewhere between 60 and 70 beats per minute, Ashleigh’s scarcely rose above 42.
“They had to tube her immediately, and put her under heat lamps for three to four days,” her mother recalls. “She was tubed for a week.”
Anorexia nervosa is a lethal disease that kills 20 per cent of those affected - a higher mortality rate than for either depression or schizophrenia.
There is a paucity of research comparing different treatments for anorexia, but there is a push in Australia to widen the availability for a treatment method that has the most research evidence to back it up.
Called the Maudsley Approach, it is suitable for people who have had anorexia for less than three years. Contrary to previous treatment protocols - many of which have involved hospitalising the patient when they become dangerously ill, effectively separating them from their families for weeks on end - the Maudsley Approach puts parents in the front line by teaching them how to handle the problem at home.
Once patients are well enough to leave hospital if they initially required inpatient treatment, phase one of the three-stage treatment focuses on weight restoration. A therapist works with the family, emphasising to the anorexic patient the severe health dangers associated with starvation, and coaching the parents on how to insist the child eats.
Siblings are also involved to be a support for the patient.
Once the adolescent has accepted the need to eat and weight is returning, the treatment moves into phase two, when the therapist and parents help the child take more control over their own eating, gradually trusting them to take more meals unsupervised. Phase three starts when the adolescent can maintain their weight above 95 per cent of their ideal weight, and is aimed at establishing a healthy identity.
The three phases usually take one year.
Trial results show between 60 and 70 per cent of adolescent patients have recovered by the end of the year-long treatment, while 75 to 90 per cent have regained their normal weight five years later.
The method is not without its critics, who say not all parents are able to give up work in order to supervise children all day. They also question the effect on siblings of being sidelined, and having nightly dinnertime confrontations - sometimes including, as in Ashleigh’s case, threats of suicide - played out nightly near or in front of them.
One of the main international advocates of the approach, Daniel le Grange from the University of Chicago - who helped develop it further after it was first developed at the Maudsley Hospital in London, where he once worked - has been in Australia for the past several weeks, briefing health workers on how the program works and what training is required.
The program is non-drug-based and has negligible commercial links. The main outlay for parents and health workers is a text book on what to do, costing about $20 and $50 respectively. It has now been adapted for treatment of bulimia, which is more common than anorexia but does not have such serious outcomes.
After a slow takeup by a handful of centres in Sydney and Melbourne, and a few in Victoria, availability of the Maudsley Approach for anorexia may soon widen more rapidly thanks to a more enthusiastic backing from NSW Health.
For many families, it’s a better option than some in-patient treatment programs, which can be extremely expensive and which in some cases have forced families to sell their homes to finance it.
Even so, it’s not for the faint-hearted.
Jan remembers her daughter “screaming, arguing, (and) my husband and I sitting on either side of her at the table so she couldn’t escape. We would be at the table for three hours so she would eat something - not one night, but night after night after night.”
Le Grange concedes the program can be “gruelling”, but counters criticism that it’s not a realistic option for those parents who can’t afford to take several weeks off work to give the sick child the care and supervision required.
“If parents don’t have that luxury, we can look for grandparents or aunts,” le Grange says. “You just have to be creative as clinicians.”
The only other reason why someone might not be suitable, says le Grange, other than having anorexia for more than three years, is that they are too sick. The cut-off is if someone is below 75 per cent of their healthy weight, a category that covers about 20 per cent of patients presenting with anorexia.
Stephen Touyz, professor of clinical psychology at the University of Sydney, and co-director of the Peter Beumont Centre for Eating Disorders at the Wesley Private Hospital, says the Maudsley Approach received the top rating of any treatment for anorexia from Britain’s National Institute for Health and Clinical Excellence, which assesses the cost-effectiveness of therapies for the UK’s National Health Service.
Touyz, who is working on a tool that will allow doctors to grade a patient’s anorexia by severity - much as cancers are currently graded from one to four - says the strength of Maudsley is that it encourages early intervention in anorexia.
“The message is: if you think your child has anorexia, you want to get in early, and treat it early,” he says. “Because if it becomes chronic, it’s very hard to treat … and Maudsley does have highly successful outcomes.”
Ashleigh, meanwhile, has stabilised her weight at 52kg. Jan, who says she would recommend the Maudsley Approach to others, says the next milestone will be when Ashleigh’s periods restart, which the doctors think could be within three months if she can keep her weight up.
“It’s not a quick fix. But we’re absolutely stronger as a family. We always were strong.”
May
31
Obesity Epidemic Exaggerated: Report
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Hysteria over fat children inflated
The Weekend Australian
Adam Cresswell, Health editor | May 31, 2008
AUSTRALIA’S childhood obesity epidemic has been “exaggerated” and government-led national prevention efforts may be misdirected, with childhood obesity only increasing in lower-income families.
Controversial new research into childhood obesity rates has called into question whether the millions of dollars allocated by the federal Government for obesity prevention programs should be targeted to the highest-risk groups, rather than focused at the general population.
The findings, based on measurements taken from thousands of Australian children in two nationally representative samples in 2000 and 2006, found that the growth in childhood obesity overall has slowed to a crawl, and the only statistically significant increases are now among boys and girls from low-income homes.
The overall obesity rate rose only slightly, from 6 per cent in 2000 to 6.8 per cent in 2006 - an increase researchers said was not statistically significant.
Among low-income boys, obesity almost doubled from 5.4 per cent in 2000 to 9.3 per cent in 2006. The increase for wealthier children was much less, rising from 4.9 per cent to 6.8 per cent among middle-income boys and from 3.7 per cent to 4.9 per cent for the wealthiest.
Among low-income girls, the obesity rate increased from 3.9per cent in 2000 to 6.8 per cent in 2006, whereas the rate stayed flat at 5.5 per cent for middle-income girls, and increased from 2.4 per cent to 3.9per cent among high-income girls.
Australia’s health ministers in 2003 labelled obesity “an epidemic”. In this month’s budget, the Government said it would spend $62 million under its National Preventative Health Strategy to fight obesity, including nearly $13 million to fund a kitchen garden program in 190 schools nationally.
But Jenny O’Dea, associate professor of child health research at the University of Sydney, willtell a Nutrition Australia conference next month that obesity in children “has not increased overall” between 2000 and 2006.
In comments that have already drawn fire from some other obesity experts, Professor O’Dea told The Weekend Australian there was “no doubt that it (childhood obesity) has been exaggerated”.
“Some kids are more at risk than others, and that’s where the prevention efforts need to go,” she said.
Last night, Health Minister Nicola Roxon said obesity was “a significant challenge in health and a cause of several major chronic diseases - and will remain a priority for the Rudd Government”.
The findings are based on two studies using nationally representative samples, one conducted in 2000 and based on 4500 primary and high school children, and a further study of 6000 children in 2006. Although the overall rate of childhood obesity rose only marginally, further analysis showed a significant rise among children from lower socio-economic families.
Professor O’Dea said there had been “an assumption that all of our children are at risk of obesity and ill-health”.
“This latest data shows that’s not really true - there’s something protective about high income and middle income, and the real risk has been in low-income children,” Professor O’Dea said. “They (other experts) have to look at the evidence, and they are refusing to do it.
“I’m not saying there’s no risk in other children. I’m just saying if there’s going to be a focus (on prevention), you get a bigger bang for your buck by focusing on these disadvantaged groups.”
Last week, a US study found there had been “no significant increase” in the prevalence of obesity in American children and teenagers from 1999 to 2006, contrary to figures from prior years. The study, published in the prestigious Journal of the American Medical Association, found obesity rates varied by racial group, being higher for non-Hispanic black and Mexican- American girls than for non-Hispanic white girls.
Professor O’Dea said her Australian data showed the rate of obesity was 25 per cent among Pacific Islander children, 18 per cent among Middle Eastern children and 10 per cent among Aboriginal children.
“It’s politically incorrect to point the finger of risk at social class. But when you have the data sitting in front of you, it’s very clear - it’s not an issue of prejudice, it’s an issue of social justice.
“There’s a lot of money to be made out of childhood obesity, and … I think that’s where a lot of the hysteria comes from.”
The head of at least one school in an affluent part of inner-eastern Sydney yesterday agreed the obesity problem was neither as ubiquitous nor as uniform as sometimes supposed. Gabrielle McAnespie, principal of St Charles’s Primary School in Waverley, said: “This is my 28th year in teaching, and over that period of time I can’t say I have noticed an increase (in childhood obesity).”
Jan Wright, director of the Child and Youth Interdisciplinary Research Centre at the University of Wollongong, agreed the problem had been exaggerated and dramatised, and said prevention programs needed to focus on improving neighbourhoods with poor facilities, rather than blaming individuals.
“In one Victorian primary school, overweight children were singled out and told to do laps of the oval - which were known within the school as ‘fat laps’,” Professor Wright said.
Ian Caterson, director of the Institute of Obesity, Nutrition and Exercise at Sydney University, said it “would be encouraging if it’s true” that childhood obesity had levelled off.
“I would like to see a bit more data,” Professor Caterson said.
But he said focusing on obesity only, and ignoring the lesser category of overweight, meant the problem was understated.
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