MNT in Eating Disorders

The Ideal Body ImageMedia promotionSocial acceptanceInfluence and stress on young individuals

Food: More Than Just NutrientsLinked to personal emotionsComfortRelease of natural opioidsReward

Eating Disorders (APA Diagnoses)Anorexia nervosaBulimia nervosaEating disorder not otherwise specified (EDNOS)Binge eating disorder (BED)Schebendach in Krause, 12th ed., p. 564)

Genetic Link?Identical twins have a higher chance of eating disordersFraternal twins are less likely

Profile of AnorexiaUsually occurs between the ages of 12-18Typically white femaleLifetime prevalence among women is .3 to 3.7%, depending on criteria used5%-10% are maleMiddle-upper socioeconomic classOften coexists with other psychiatric disorders: major depression or dysthymia (50-75%), anxiety disorders, OCD (40%)5-20% mortality rate, mostly from heart failure or arrhythmias

Schebendach in Krause, 12th Ed, p 564

Anorexia Nervosa: Psychological FeaturesPerfectionismHarm avoidanceFeelings of ineffectivenessInflexible thinkingOverly restrained emotional expressionLimited social spontaneitySchebendach in Krause, 12th Ed., p. 564

Anorexia NervosaFood ritualsCuts food in small piecesRearranges food on plateEliminates foods gradually300-600 calories a dayDiet pop, sugarless gumProlonged exercisePreoccupation with foodCooks for othersHungry, but refuses to eat

Diagnostic CriteriaAmerican Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria are the standard

AN APA Diagnostic CriteriaWeight

AN Diagnostic CriteriaWeight deficit is necessary (

Related Psych Disorders in ANDepression: May be due, in part, to the psychological stress of starvationObsessive-compulsive disorder: may be exacerbated by malnutritionComorbid personality disorders: poor impulse control, substance abuse, mood swings, and suicide tendencies

Prevalence of ANMore prevalent in industrialized countries that idealize a thin body type although expected to become more widely distributedLifetime prevalence among women is .5% to 3.7%, depending on criteria usedPrevalence among men is one tenth of that among womenSchebendach in Krause, 12th edition, p. 564

Risk Periods for Anorexia NervosaAge 14 puberty, high schoolAge 18 college, full time jobs

Pathophysiology of ANPhysical and psychological consequences of malnutrition

Pathophysiology of ANDepleted fat stores; muscle wastingAmenorrheaCheilosisPostural hypotension; dehydration or edemaBradycardia; hypothermia Sleep disturbances

Pathophysiology of AN: OsteopeniaReduced bone mineral densityMay result in vertebral compression, fracturesCaused by estrogen deficiency, elevated glucocorticoid levels, malnutrition, reduced body massAffects males and females

Pathophysiology of ANLow body temperature/cold intoleranceLower metabolism: low thyroid hormoneBone marrow hypoplasia (50% of AN patients) results in leukopenia, anemia, thrombocytopenia

Pathophysiology of AN: Cardiovascular Decreased heart rate

Pathophysiology of ANIron deficiency anemiaIncreased infectionsDry skin, hairYellow skin due to hypercarotenemiaDesquamation, hair loss, alopeciaHirsutismLanugo: fine body hairs

Pathophysiology of AN: GIBloating, abnormal fullness after eatingConstipationDigestive enzymes low

Pathophysiology of ANElectrolyte imbalance heart failure, deathLow intake potassiumLoss in vomiting, diureticsRefeeding syndrome: electrolyte imbalances caused by too-rapid refeeding

Bulimia NervosaAn illness characterized by repeated episodes of binge eating followed by inappropriate compensatory methods Purging, including self-induced vomiting or misuse of laxatives, diuretics, or enemasNon-purging including fasting or engaging in excessive exercise

Bulimia Nervosa APA CriteriaCharacterized by recurrent episodes of binge/purge eatingAverage 2 binges/purge cycles/weekUncontrollable eating during bingePurge regularly: vomiting, laxatives, diuretics, strict dieting, fasting, vigorous exerciseContinues at least 2x/wk for 3 monthsAmerican Psychological Association. DSM-IV-TR, ed 4, Washington DC, 2000

Bulimia Nervosa PrevalenceLifetime prevalence of BN among young adult women is 1% to 3%Rate of occurrence in males is 10% of that in femalesRarely seen in childhoodSchebenbach, in Krause, 12th edition, p. 565

Bulimia Nervosa Prevalence5% of college women 20% of college women exhibit symptoms (Sx)50% of those with anorexia nervosa develop bulimia nervosaGorging and purging/vomitingSusceptible populationsathletes, actors, dancers, wrestlers, runners

Profile of BulimiaYoung (usually female) adults (college students)May be predisposed to becoming overweightUsually at or slightly above normal weight Tried frequent weight-reduction diets as a teenImpulsiveOften goes undiagnosed

Profile of Bulimia NervosaOther psychological disorders, including major depression, dysthymia, anxiety disorders, personality disorders, substance abuseLow self esteemGuiltPreoccupied with foodRecognize behavior is abnormal

Binge DefinitionEating, in a discrete period of time (e.g., within any 2-hour period) an amount of food that is definitely larger than most people would eat under similar circumstancesA sense of lack of control over eating during the episode

BingeRelieves stressCommon binge foods:High carbohydrate, high fatConvenience foodsCakes, cookies, ice creamSoft, easier to purgeHigh food bills

PurgeLaxatives, enemasAct on large intestine90% of calories are absorbed in small intestineDamages large intestine constipation

VomitingMost commonly used compensatory behavior (80%-90% of BN)33-75% of calories still absorbedFingers down throat Damaged knucklesSyrup of IpecacToxic to heart, liver, kidneysPoison if taken repeatedly

VomitingTeethStomach acid erodes enamelPain, decay

DiureticsWater lossElectrolyte lossNO fat loss!

Hypergymnasia: Excessive ExerciseCompulsive exercise: that which significantly interferes with life activitiesOccurs at inappropriate times or in inappropriate settingsContinues despite injury or other medical complications

Symptoms of BNUsually normal weight and secretive in behaviorScarring of the dorsum of the hand used to stimulate the gag reflex, known as Russells SignParotid gland enlargementErosion of dental enamel with increased dental caries resulting from gastric acid in the mouth

Pathophysiology of BN: VomitingDehydrationAlkalosisHypokalemiaSore throat, esophagitis, mild hematemesisAbdominal pain

Pathophysiology of BN: VomitingSubconjunctival hemorrhageMallory-Weiss esophageal tearsEsophageal ruptures (rare)Acute gastric dilatation or ruptureSalivary gland infections

Pathophysiology of BN: Laxative AbuseDehydrationElevation of serum aldosterone and vasopressin levelsRectal bleedingIntestinal atonyAbdominal cramps

Pathophysiology of BN: Diuretic AbuseDehydrationHypokalemia

Pathophysiology of BNCardiac arrhythmias related to electrolyte and acid-base imbalance caused by vomiting, laxative, and diuretic abuseIpecac may cause irreversible myocardial damage and sudden deathMenstrual irregularities

Vicious Cycle of Bulimia

Eating Disorder Not Otherwise Specified (EDNOS)A diagnostic category for eating disorders that fail to meet full criteria for either anorexia nervosa or bulimia nervosaMay have partial symptoms of either AN or BNFor example, all criteria for AN may be met except patient has regular menses OR significant weight loss but wt still in normal range

Physical Manifestations of Eating Disorders

Treatment of Eating Disorders

AN: Treatment NutritionIncrease food intake to raise the BMRPrevent further weight lossRestore appropriate food habitsUltimately weight gainSome weight restoration and treatment of malnutrition may make psychotherapy more effective

AN: TreatmentPsychologicalCognitive behavior therapyDetermine underlying emotional problemsReject the sense of accomplishment associated with weight lossFamily therapy, support group

Nutrition Assessment in Eating Disorders

Assessment of Intake in Eating DisordersCalories compared with DRIEvaluate macronutrient mix (carbohydrate, protein, fat)Evaluate micronutrient intake compared with DRIEstimate fluids and compare with needsEvaluate alcohol, caffeine, drugs, dietary supplements

Dietary Intake in ANGenerally inadequate caloric intake,

Dietary Intake in BNHighly variable; in one study mean intake of 4446 kcals; 44% overeating, 19% undereatingWhen not binge eating may follow a low fat diet

Eating Behavior in AN/BNUnusual or ritualistic behaviorsUnusual food combinationsNontraditional utensilsExcessive spices, vinegar, lemon juice, noncaloric sweetenersMeal spacing, length of time allocated for a mealBN: may eat quicklyAN: may eat in excessively slow manner

AN/BN Eating AttitudesFood aversionsSafe foodsMagical thinkingBinge trigger foodsIdeas on appropriate amounts of foodMisconception that purging eliminates all calories from a binge episode

Lab AssessmentVisceral proteins: generally normal in ANLipids: elevated cholesterol and abnormal lipid profile; may be due to hepatic dysfunction, decreased bile acid secretion, hypothalamic dysfunction, eating patternsDoes not warrant prescription of low fat, low cholesterol dietReassess after weight restored

Lab AssessmentSerum glucose: low due to lack of precursors for gluconeogenesis and productionLow T3 syndrome: low levels of active form of thyroid hormone; resolves with refeeding

Vitamin-Mineral AbnormalitiesHypercarotenemia: in AN restrictors; mobilization of lipid stores, catabolic changes, metabolic stress; normalizes with rehabDeficiency diseases rare in AN, possibly due to use of supplements, catabolic state, use of nutrient-dense foodsOsteopenia and osteoporosis are common

Metabolic ChangesAN: low metabolic rates (REE 62-70% of expected, or 700-1000 kcals)Refeeding causes increases in REEElevated diet-induced thermogenesis (DIT) and REE may require high calorie prescriptions in nutritional rehabBN: unpredictable metabolic rateHelpful to measure REE using indirect calorimetry

Anthropometric AssessmentAN patients meet criteria for marasmus (depleted adipose and somatic protein stores but intact visceral proteins)Body composition: underwater weighing or DEXA; BIA of questionable validitySkinfolds from 4 sites (triceps, biceps, subscapular, suprailiac crest)MAMC

Body Weight AssessmentGoal weight determined by various methods (NCHS growth tables to age 18)Daily preprandial early morning weight in hospitalGowned weight on the same scale once a week in outpatient (pt should void and urine specific gravity checked or patient examined to determine if bladder is full)

Management of Eating DisordersMultidisciplinary team including physicians, nutritionists, psychotherapistsMay include inpatient medical or psychiatric hospitalization, partial hospitalization and residential treatment, intensive outpatient, or outpatient programs

Treatment GoalsAN: weight gain and correction of malnutrition disorders; normalization of eating patterns and behaviorsBN: weight maintenance in the short term even if patient is overweight until eating habits are stabilized

Factors Affecting Weight Gain in ANFluid balancePolyuria seen in starvationEdema from starvation or refeedingHydration ratio in tissuesMetabolic rateResting energy expenditurePostprandial energy expenditure

Factors Affecting Weight Gain in ANEnergy cost of tissue gainedLean body massAdipose tissuePrevious obesityPhysical activity

Nutritional Care in ANOften require hospitalization to begin refeedingSome require enteral feedings, but most can be rehabbed with oral feedingsGoal is increase in energy intake with weight gainEnergy intake must be increased gradually while minimizing caloric expenditure

Nutritional Care in ANInitial calorie prescriptions 1000-1600 kcals, or 30-40 kcals/kgIncrease 100 to 200 kcals q 2-3 days; may be as high as 70-100 kcal/kg/dayHospitalized patients: goal is 2-3 lb/weekOutpatients: 1 pound/weekAPA Practice Guidelines for the Treatment of Eating Disorders, January, 2006

Refeeding SyndromeRefeeding malnourished patients with AN can result in life-threatening hypophosphatemia, cardiac arrhythmia, and deliriumMay be precipitated by high-calorie feeding regimensPatients weighing less than 70% desirable body weight at greatest riskSerum phos, mg, K+, calcium must be closely monitored and supplements provided as needed

Energy Needs in AN70-100 kcals/kg may be needed for continued weight gain (depends on REE and type of tissue gained)AN more physically active than controls; require kcals for weight maintenanceMay require 3000-4000 kcals/day later in wt restoration (males 4000-4500)

Energy Needs in ANIf unsuccessful in weight gain, evaluate for discarding food, vomiting, exercising, increased motor activity, metabolic resistanceUse indirect calorimetry in fasting and post-prandial stateOnce at goal rate, 40-60 kcals/kg should promote wt maintenance and continued growth and development in adolescents

Macronutrient MixFat intake of 25%-30% of calories is recommended as added fat or less obvious sources (whole milk or peanut butter)Protein: 15%-20% of calories; RDA for age and sex in grams/kg of IBW; high biological value sources; vegetarian diets should be discouraged during rehabCarbohydrate: 50%-55%; include sources of insoluble fiber to relieve constipation

MicronutrientsVitamin-mineral supplements: may have increased need in anabolism; 100% RDA multivitamin with minerals (iron may constipation)Encourage calcium-rich foods and Vitamin D

MNT in ANEarly treatment: caloric intake usually low, can be provided in 3 meals per day; snacking may relieve some physical discomfortLater treatment: as caloric prescription increases, snacks become unavoidableDefined formula liquid supplements may be helpful; patients may be more willing to accept them than large volumes of food

MNT in BNImmediate goal interruption of the binge and purge cycle with weight maintenanceRarely hospitalized except for electrolyte disturbances

Energy Needs in BNMay be hypocaloric; poor correlation between predicted and actual REEMeasured REE preferable; provide calories at 120%-130% measured REESigns of low metabolism: history of chronic dieting, low T3 level, cold intoleranceIn presence of low metabolism, provide 1500-1600 kcals/day) or determine average calories/day based on current intake

Energy Needs in BNMonitor anthropometric status and adjust caloric prescription for weight maintenanceAvoid weight reduction diets until eating patterns and body weight are stabilizedMay be on low-calorie intakes for longer periods than anorectic patients

Monitoring of BN PatientsBingeing, purging, restrained intake impair recognition of hunger and satiety cuesMany patients with BN are afraid to eat early in the day as they might binge laterMay digress from meal plan after a binge, attempting to compensate

Macronutrients in BNProtein: 15-20% of calories; meet RD in g/kg IBW; HBV sourcesCarbohydrate: 50%-55% of calories; encourage insoluble fiberFat: 25%-30% of caloriesProvide source of essential fatty acidsMVI: multivitamin with minerals

Cognitive Behavioral TherapyStructured psychotherapeutic method alters attitudes and problem behaviorsIdentifies and replaces negative, inaccurate thoughtsTypically a 20-week intervention thatEstablishes a regular eating patternEvaluates and changes beliefs about shape and weightPrevents relapse

Female Athlete Triad

Three ComponentsEating disorderLack of menstrual periodsOsteoporosisBones like 60-year-oldCaused by low estrogenOften irreversibleEarly warning: stress fracturesAlso meet criteria for EDNOS

Female Athlete TriadFemale athletes participating in appearance-based and endurance sportsSeen in 15% swimmers, 62% gymnasts, and 32% of all other sport

Female Athlete TriadPerformance thinness: the commonly held belief that achieving a lower weight and percentage of body fat will enhance performanceAppearance thinness: trend to reward thinner athletes in adjudicated sports such as gymnastics and figure skating

Treatment for Female Athlete TriadReduce preoccupation with food, weight, and body fatIncrease meals and snacks graduallyRebuild body to healthy weightEstablish regular mensesDecrease training

Binge-Eating Disorder (Compulsive Overeating)Complex and serious eating disorderOccurs in ~30% -50% of subjects in weight control programs (40% are males)More common with obese individuals with history of restrictive dieting~50% exhibit clinical depressionNot preoccupied with body shapeOnset adolescence or early 20s

Binge Eating Disorder Diagnostic Criteria (APA)Recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of BNAt least 2x week over 6 month periodDistress, disgust, guilt, depression

Binge-Eating Disorder (Compulsive Overeating)Eat more rapidly than usualEat until uncomfortableEat when not hungryCannot control bingesEmbarrassed, guilty after binge

Binge Eating ProcessPreconditionTrigger phaseMaintenance phaseEnding phasePost-binge phase (consequences)

Characteristics of a Binge-EaterConsider self as hungrier than normalIsolate self to eat large quantitiesTriggered by stress, depression, anxiety, loneliness, anger, frustrationUsually binge on junk foodsEat without regards to biological needFood is used to reduce stress, provide feeling of power and well-being

Treatment for Binge-EatingLearn to eat in response to hungerLearn to eat in moderationAvoid restrictive diets which can intensify problemsIncrease activity

Treatment for Binge-EatingIncrease self-acceptance and improved body imageAddress hidden emotionsOvereaters AnonymousAntidepressants

BaryophobiaThe fear of becoming heavyChildren are given a low-fat, restricted diet in hopes to ward off obesity or heart diseaseDetrimental to children; affect growth and developmentSelf-imposed restrictive diets by young adults to avoid obesityLack of appropriate nutrition information

Treatment for BaryophobiaNutrition educationNutrition required for proper growthAppropriateness of sweets and fats in the diet

Childhood Eating DisordersDSM criteria not appropriate in young childrenCases of AN reported in children as young as 8 years oldBN rare in childhoodC/o nausea, abdominal pain, difficulty swallowing, concerns about weight, shape, and body fatness

Five Warning Signs of Childhood Eating DisorderDecreasing weight goalIncreasing criticism of the bodyIncreasing social isolationDisruption of menstruationReports of purging in the context of dieting

Eating Disorders in Dietetics StudentsThere is some evidence that the prevalence of disordered eating is higher in dietetics students than in other majors, though the research has been mixed

Eating Disorders in UG College StudentsWorobey and Schoenfeld surveyed 165 undergraduate women (mean age 21.6+4.9 years and 46 men (22.4+6.6 years) from dietetics, exercise science, dance, psychology, and biology/nursing Worobey J, Schoenfeld D. Eating disordered behavior in dietetics students and students in other majors. JADA 1999;99:1100-1102

Eating Disorders in UG College Students Nursing/biology majors had significantly higher BMI and weightDietetics students scored highest on Cognitive concerns and binge/purge behaviorWorobey J, Schoenfeld D. Eating disordered behavior in dietetics students and students in other majors. JADA 1999;99:1100-1102

Eating Disorders in College StudentsDietetics and dance majors scored highest on Life InterferenceDance students scored highest on Excessive Exercise

Worobey J, Schoenfeld D. Eating disordered behavior in dietetics students and students in other majors. JADA 1999;99:1100-1102

Eating Disorders in College StudentsFredenberg et al surveyed 5 groups of students in DPD dietetics, CP dietetics, non-food home economics curricula, college basketball or volleyball programs, and sororitiesFredenberg JP, Berglund PT, Dieken HA. Incidence of eating disorders among selected female university students. J Am Diet Assoc 1996;96:64-65.

Eating Disorders in College StudentsFredenberg and colleagues found no significant differences among the groups of college women surveyed in EAT scores (Eating Attitude Test.)However, 17.7% of DPD students had EAT scores symptomatic of eating disorders compared with 3.3% and 2.9%, respectively for CP and home economics students (NS)This was lower than in a previous study (24%) (Drake et al, JADA, 1989)Worobey J, Schoenfeld D. Eating disordered behavior in dietetics students and students in other majors. JADA 1999;99:1100-1102

PrognosisMortality has declined for AN from 10% to 2%.20% to 30% will have a lifelong struggle with foodBulimics may need long-term counseling to correct underlying philosophies and beliefs.Family counseling is useful for both AN and bulimia.High relapse rate after treatment

Topics for Nutrition EducationImpact of malnutrition on growth and developmentImpact of malnutrition on behaviorSet-point theoryMetabolic adaptation to dietingRestrained eating and disinhibitionCauses of bingeing and purgingWhat does weight gain mean?Modified from Schebendach J, Nussbaum MP: Nutrition management in Adolescents with eating disorders. Adoles Med: State Art Rev 3 (3): 556, 1992.

Topics for Nutrition Education contdImpact of exercise on caloric expenditureIneffectiveness of vomiting, laxatives, and diuretics in long-term weight controlPortion controlFood exchange systemSocial dining and holiday diningFood Guide PyramidHunger and satiety cuesInterpreting food labelsNutrition misinformationModified from Schebendach J, Nussbaum MP: Nutrition management in Adolescents with eating disorders. Adoles Med: State Art Rev 3 (3): 556, 1992.

Dying To Be ThinNormal to be concerned about diet, health, and body weightWeight normally fluctuates Treat physical and emotional problems earlyDiscourage restrictive dietsCorrect misconception about foodsThin is not necessary better

SummaryNutritional intervention supports psychologic strategy