Update Beitler Case Study

Body Dysmorphia Related to Gender
Dysphoria in Adolescents: An Eating Disorder

Case Study
Kara Beitler
Body
Dysmorphia
• The preoccupation with one or more
“flaws” within one’s physical
appearance, that may not be present.
• Behaviors include mirror checking,

skin picking, reassurance seeking https://www.istockphoto.com/illustrations/body-dysmorphia
etc.
Disordered Eating
(DE) Behaviors
• The term used to describe a range of irregular eating
behaviors – that may or may not warrant an eating
disorder (ED) diagnosis.
• Examples:
• Frequent dieting/preoccupation with food
• Rigid rituals and routines
• Guilt or shame with eating
Disordered Eating (DE) Behaviors
https://www.verywellhealth.com/disordered-eating-5095720
Eating Disorders (EDs)
• Eating Disorders (EDs) are both mental and physical
illness that are diagnosed based on specific criteria.
• Diagnostic and Statistical Manual of Mental

Disorders, 5th Edition (DSM -5)
Eating Disorders (EDs)
• Types of EDs include:
• Anorexia Nervosa (AN)
• Bulimia Nervosa (BN)
• Binge Eating Disorder (BED)
• Other Specified Feeding or Eating Disorder
(OSFED)
• Avoidant Restrictive Food Intake Disorder
(ARFID)
Anorexia Nervosa (AN)
• AN is characterized by:
• Dramatic weight loss
• Difficulty maintaining weight for
height, age, and stature.
• Calorie restriction
• Excessive exercise
• AN signs and symptoms:
• Dressing in layers to hide weight loss or to stay warm
• Denying feeling hungry
• Complains of constipation, abdominal pain, lethargy,
etc.
• Cooking for others, but not eating it.
• Refuses to eat certain foods, restricting whole
categories and choosing restrictive diets (i.e
vegetarian, vegan, etc).
• Diagnostic Criteria:
• Restriction of energy intake relative to age, sex,
developmental trajectory, and physical health
requirements.
• Intense fear of gaining weight
• Disturbance in the way in which one’s body is shaped
or experienced.
Medical Nutrition Therapy
Goals/Intervention: Anorexia
Nervosa.
• Calculate estimated energy needs using
gender-based equations and monitor energy
and macronutrient intake to meet body
composition and health goals.
• Have a client-centered, collaborative
approach to counsel patients and caregivers
on food selection.
• Use goal setting to create eating patterns that
aid in nutrition rehabilitation.
Important Definitions:
Sex: Classification of people as male, female, or intersex based
on combinations of physical characteristics.
Gender Identity: A person’s internal sense of being man or boy,

women or girl, sometimes a blend of both or neither. This does
not necessarily have to correspond to the sex assigned at birth.
Gender Pronouns: Pronouns are used for one to identify

themselves apart from their given name (ex. She/her/hers,
He/His/Him, They/Them/Theirs)
Important Definitions:
Transgender: “Umbrella” term used to describe a full range of
people whose gender identity and/or gender do not conform with
what was assigned at birth.
Male to Female (MtF): Individuals whose assigned sex at birth

was male and have changed, are changing, or wish to change
their body to be more feminine.
Hormone Therapy: Using hormones for gender affirming

purposes to either masculinize or feminize a person to align the
person’s physical characteristic to his or her gender identify.
Gender Dysphoria
• Discomfort or distress that a person
experiences because of a “discrepancy”
between their gender identity and sex
assigned at birth.
• Body dissatisfaction
Dietary Consideration for
Transgender Patients
• Depends on what stage of transition patient is in:
• Hormone replacement, on puberty blockers, etc.
• Effects of hormone therapy

• Changes in body composition, altered laboratory
values, other metabolic factors.
Risk for EDs: Transgender
Population
• At higher risk for:
• Disordered eating
• Unhealthy weight control behaviors
• Body Dysphoria
• Body Dissatisfaction
• As of 2020, 10.5% of transgender men, and 8.1%
of transgender women have been diagnosed with
EDs
• With AN
• 4.2% of transgender men
• 4.1% of transgender women
EDs: Transgender
Population
• Societies body image ideals
• Femininity = thinness
• Masculinity = muscular
• Strive for thinness could manifest in DE

or ED.
• Unhealthy relationship with exercise and
food.
Clinical Considerations for
Transgender Patients
• RDs must provide appropriate, patient-centered, and
compassionate care.
• It is important to create a welcoming environment:
• Be aware of misconceptions, biases, stereotypes
• Ensure use of inclusive, gender-neutral language that
allows for self-identification
• Ask gender-neutral questions or ask for pronouns.
Nutrition Field: Areas for
Growth within
Transgender Population
• Little research has been done on nutrition assessment methods/
interventions within this population.
• Assessment methods can gendered

• Growth charts (boys and girls), gender-based energy predictive
equations, body fat %
• There is a need for a gender-affirmative approach.

Introduction to patient
Complains Of
• Mood Swings
Admission Diagnosis • Recently denied from
residential treatment
Patient • Suicidal Ideations, facility for ED in Chicago
• 15 years old Anorexia Nervosa r/t suicidal ideations.
(Restrictive Type) and
• Female (Assigned Male at body dysmorphia
Birth – AMAB)
• Pronouns: She/Her/Hers
Patient Assessment
• Height: 159.3 cm
• Weight: 47.14 kg  103 lbs
• Usual Body Weight (UBW): 60.5 kg  133 lbs

• 78% UBW
• Weight loss: Patient reported 20 lbs weight loss (22% BW) in 3 mo.
• Past Medical History (PMH):

• Prior suicide attempt with multiple hospitalizations
• Self harming behaviors
• Major depressive disorder
• Anxiety
• Gender dysphoria
• Male puberty
• Anorexia Nervosa
Medications
Name Type of Medication
Buspar Anti-Anxiety
Zoloft Anti-Depressant
Vitamin D Vitamin
Multivitamin Vitamin
Nutrition
Values:
Related Lab
Values Creatinine 0.5 (L)
Protein 6.5 (L)
Aspartate
transaminase (AST)
- 18 (L)
Alkaline
Phosphatase (ALP)
83 (L)
Reported Intakes/Diet
History
Patient follows a Vegan Diet.
Breakfast (5 am – 7 am): Toast w/ Other foods include - Hummus
jelly and black coffee sandwich, veggie burger etc.
Lunch (11 am – 12:30 pm): Patient reports calorie counting

Peanut butter and jelly sandwich, and aiming to eat 800 kcal/day
applesauce, and almond milk
Dinner (4-5 pm): Peanut butter Patient reports sometimes

and jelly sandwich, apple sauce, sleeping in to avoid eating
and almond milk breakfast.
Calculating Patient’s Estimated
Needs
Calculating Patient’s Estimated
Needs
• Energy: 2120 total calories/day : 45 total calories/kg/day (RDA 15-18 yo M)
• (45 x 47.1 kg) = 2120 kcal/day
• Protein: 42 grams/day : 0.9 total grams/kg/day (RDA 15-18 yo M)

• (0.9 x 47.1 kg) = 42 grams/day
• Fluids: 2355-2826 mL/day : 50-60 total fluid mL/day (RDA 15-18 yo M)

• (50 x 47.1 kg) = 2355 mL/day
• (60 x 47.1 kg) = 2826 mL/day
• Used admit BW (47.1 kg) used for kcal, protein, and fluids.
Age (years) Calories (kcal/kg) Protein (g/kg) Fluid (mL/kg)
15-18 Male 45 0.9 50-60
Nutrition Diagnosis
• Inadequate oral intake
• Disordered eating pattern
• Underweight
• Unsupported beliefs/attitudes about
food – or nutrition related topics.
Nutrition Diagnosis
Statement
Disordered eating pattern RT restriction secondary to
body dysmorphia AEB Anorexia Nervosa restrictive
type, pt calorie counting, reports eating 800 kcal/day,
pt reports sometimes sleeping in so they can skip
breakfast, pt reported not eating when they feel
hungry, and pt reported intentional weight loss of 13.4
kg (22% BW) in 3 mos.
Interventions
Our Recommendations: Handouts Provided:
Diet education
General Healthful
Vegetarian Nutrition
Weight restoration
Therapy (NCM)
Building meals
Meal Planning and
with a variety of
Eating Guidelines
food
(NCM)
Goal setting
Monitoring and
Evaluation
While the patient was impatient - Monitor:
• Patient intakes of meals
• 25% of meals before individualized meal plan
• 85% of meals after individualized meals sent
• Weight changes
• Behaviors/attitudes towards food.
After the Anderson Center – Patient is receiving specialized ED care.

Summary
No censuses on nutrition recommendations for the transgender population
Thus, RDs must use clinical decision making to determine an individualized nutrition care
plan – especially in EDs in minority populations (transgender population).
• Hormone therapy/puberty blockers
• Puberty inconsistent with gender identity
Nutrition Prescription based on:

• Biological sex for gender-based energy predictive equations
• Male puberty
Intervention based on:

• Gender neutral education materials
Thank you!
Do You Have Any Questions?
References
Anorexia nervosa. National Eating Disorders Association (NEDA). Updated 2022. Accessed
September 18, 2022.
https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia
Etudo, M. (2021, April). What is disordered eating? Very Well Health.

https://www.verywellhealth.com/disordered-eating-5095720
Evaluation and Diagnosis. National Eating Disorders (NEDA). Updated 2022. Accessed 9/27.
https://www.nationaleatingdisorders.org/evaluation-and-diagnosis
McClain, Z., & Peebles, R. (2016). Body image and eating disorders among lesbian, gay, bisexual, and
transgender youth. Pediatric Clinics of North America, 63(6), 1079–1090.
https://doi.org/10.1016/j.pcl.2016.07.008
Nagata, J. M., Ganson, K. T., & Austin, S. B. (2020). Emerging trends in eating disorders among sexual
and gender minorities. Current Opinion in Psychiatry, 33(6), 562–567.
https://doi.org/10.1097/YCO.0000000000000645
References
Orthorexia. National Eating Disorders Association. Updated 2022. Accessed September 17, 2022.
https://www.nationaleatingdisorders.org/learn/by-eating-disorder/other/orthorexia
Ozier, A. D., Henry, B. W., & American Dietetic Association (2011). Position of the American Dietetic
Association: Nutrition intervention in the treatment of eating disorders. Journal of the American
Dietetic Association, 111(8), 1236–1241. https://doi.org/10.1016/j.jada.2011.06.016
Rahman, R., & Linsenmeyer, W. R. (2019). Caring for transgender patients and clients: Nutrition-
related clinical and psychosocial considerations. Journal of the Academy of Nutrition and
Dietetics, 119(5), 727–732. https://doi.org/10.1016/j.jand.2018.03.006
Rozga, M., Linsenmeyer, W., Cantwell Wood, J., Darst, V., & Gradwell, E. K. (2020). Hormone therapy,
health outcomes and the role of nutrition in transgender individuals: A scoping review. Clinical
Nutrition ESPEN, 40, 42.
Substance Abuse and Mental Health Services Administration. DSM-5 Changes: Implications for Child
Serious Emotional Disturbance [Internet]. Rockville (MD): Substance Abuse and Mental Health
Services Administration (US); 2016 Jun. Table 23, DSM-IV to DSM-5 Body Dysmorphic Disorder
Comparison. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t19/

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Body Dysmorphia Related to Gender

Dysphoria in Adolescents: An Eating Disorder

• Behaviors include mirror checking,

• Diagnostic and Statistical Manual of Mental

Gender Identity: A person’s internal sense of being man or boy,

Gender Pronouns: Pronouns are used for one to identify

Male to Female (MtF): Individuals whose assigned sex at birth

Hormone Therapy: Using hormones for gender affirming

• Effects of hormone therapy

• Strive for thinness could manifest in DE

• Assessment methods can gendered

• There is a need for a gender-affirmative approach.

• Usual Body Weight (UBW): 60.5 kg  133 lbs

• Past Medical History (PMH):

Protein 6.5 (L)

Lunch (11 am – 12:30 pm): Patient reports calorie counting

Dinner (4-5 pm): Peanut butter Patient reports sometimes

• Protein: 42 grams/day : 0.9 total grams/kg/day (RDA 15-18 yo M)

• Fluids: 2355-2826 mL/day : 50-60 total fluid mL/day (RDA 15-18 yo M)

After the Anderson Center – Patient is receiving specialized ED care.

Nutrition Prescription based on:

Intervention based on:

Etudo, M. (2021, April). What is disordered eating? Very Well Health.

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