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Topic 9. Eat more or less? Discussion #3. Discussion One - Maria - too little food: Maria is a 15-year-old female seen by her pediatrician and nutritionist for rapid weight loss. Nutrition-Focused Physical Findings Maria's parents say that for the last 7 months, she began asking her mother to cook "healthier", along with eating smaller portions and skipping some meals. At first, they thought it was "normal for her age" and allowed her to lose weight, they even congratulated her on being "healthier and thinner". However, her mom knows she is losing too much weight and is very concerned. She does not know how to motivate her to eat. Maria is currently obsessed with the calories she eats. For example, Maria decided that she does not want to eat more than 800 cal/day. Her parents do not understand this obsession with counting calories. They came to the clinic because Maria has reduced her food intake to only apples and water for the past month. She has lost about 25 pounds (from 115 to 90 pounds (21% weight loss) in the last 7 months. The Nutritionist takes Maria's height and weight; she is 5 feet 4 inches and weighs 90 pounds. She then compares it to Maria's last visit, in one year she grew 2 inches (was 5 feet 2 inches) and lost 30 pounds (was 120 pounds). The nutritionist decides to compare Maria's past body mass index for age percentiles charts to see her development over time and notes that for most of Maria life she was in the 75th percentile, as of a year ago she was in the 25th percentile and today's visit she is way below the 5th percentile. Chief complaint by her parents: Maria's father is particularly concerned because her grades have worsened. The school is sending her parents emails about Maria's behavioral changes in school claiming she no longer engages in her classes, they ask her parents to help get Maria to participate more in class. Overall, her father worries about his outstanding girl losing her way. Her Inother on the other hand is worried about her health because Maria stopped getting her menstruation for the past 3 months. Maria's mother states: "she has lost too much weight... Why? We eat every day! Every day is battle with her and food. What do I do?" Social History: Maria's parents were separated about four years ago. The father re-married approximately 4 years ago. Mary lives with her mother and younger brother (10 years old). She spends alternative weekends with her father and part of every holiday. Today's consultation Maria's mother describes Maria's body type and personality to the doctor and Maria comments on her own body type, revealing her frustration and social emotional feeling with her weight. The mother points out that as a child Maria was a "puggy" a pleasingly overweight girl. They have noticed that Maria, who has always been a cheerful, happy, and docile child, is more irritable, getting angry frequently and for no apparent reason and tends to lock herself in her room. As a child she was never very communicative and always was reserved in saying how she feels. Maria at this point of the consultation speaks out and states "I was not a pleasantly plump girl", I was a 'cow'! My mom loves to feed me, she does not understand how easy it is to gain weight and how hard it is to lose weight. For a year and a half, I have tried several times to lose weight, but I always fail. My boyfriend who loves me pointed out how fat I was and unhealthy. I knew I had to tell my mom what to feed me. She does not understand. My boyfriend understands me. I decided the only way to start losing weight was to take it seriously and I started by vomiting after eating. One of my girlfriends was kind enough to give me that advice. After a while she told me I would lose my appetite and it worked. I no longer must vomit after eating. Today I am naturally not that hungry and I almost look good. My weight goal is 83 pounds, that would be healthy. Geez, look at howfat my thighs are!" The pediatrician and nutritionist ask Maria": Does she take laxatives? Denies. How often do you think about food? Maria responds "Not often. I just keep a record of my calories and weigh myself three times a day. I am starting to exercise every day hoping to get to 2 hours of cardio every day." How often do you go to the bathroom to poo? "once every three days- maybe four. Isn't that exciting"? Symptoms include: Dizziness, hair loss, lack of concentration. She is very sad and anxious. She says she sleeps well. Maria has never complained of anything or has been diagnosed with anything before today's consult.. DISCUSS 1. What kind of eating disorder does Maria have? 2. What is Maria BMI? 3. How would you address Mary's situation to start treatment? 4. Are there any other questions you would ask Maria and/or parents