Nutrition Therapy for Clients with
Disordered Eating
By: Megan Holt, MPH, RD
REVIEW OF ED CRITERIA for AN (DSM-IV)

Refusal to maintain body weight at or above a minimally normal weight
for age and height (or failure to make expected weight gain during period
of growth)

Intense fear of gaining weight or becoming fat, even though underweight.

Disturbance in the way in which one's body weight or shape is
experienced, undue influence of body weight or shape on self-evaluation,
or denial of the seriousness of the current low body weight.


In postmenarchal females, amenorrhea ie, the absence of at least three
consecutive cycles. (A woman is considered to have amenorrhea if her
periods occur only following hormone administration.)
Specify type:

Restricting Type: During the current episode of AN, the person has
not regularly engaged in binge-eating or purging behavior

Binge-Eating/Purging Type: During the current episode of AN, the
person has regularly engaged in binge-eating or purging behavior
REVIEW OF ED CRITERIA for BN (DSM-IV)





Recurrent episodes of binge eating characterized by both of the following:(1)
Eating, in a discrete period of time (eg, within any 2-hour period), an amount
of food that is larger than most would eat during a similar period of time and
under similar circumstances.(2) A sense of lack of control over eating during
the episode
Recurrent inappropriate compensatory behavior in order to prevent weight
gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas
or other medications, fasting or excessive exercise.
The binge eating and compensatory behaviors both occur, on average, at
least twice/week for 3 months.
Self-evaluation is unduly influenced by body shape and weight.
The disturbance does not occur exclusively during episodes of AN.
Specify type:

Purging type: During the current episode of BN, the person has regularly
engaged in self-induced vomiting or the misuse of laxatives, diuretics or
enemas.

Nonpurging type: During the current episode of BN, the person has used
inappropriate compensatory behaviors, such as fasting or excessive exercise,
but has not regularly engaged in self-induced vomiting or the misuse of
laxatives, diuretics or enemas.
REVIEW OF ED CRITERIA for ED-NOS (DSM-IV)






For females, all AN criteria are met except that the individual has regular
menses.
All AN criteria are met except that, despite significant weight loss the
current weight is in the normal range.
All BN criteria are met except that the binge eating and inappropriate
compensatory mechanisms occur at a frequency of less than twice a
week or for duration of less than 3 months.
The regular use of inappropriate compensatory behavior by an individual
of normal body weight after eating small amounts of food (eg, selfinduced vomiting after the consumption of two cookies).
Repeatedly chewing and spitting out, but not swallowing, large amounts
of food.
Binge-eating disorder (falls under DSM-IV for now): recurrent episodes of
binge eating in the absence of inappropriate compensatory behaviors
characteristic of BN.
AN: Pathophysiology







Depleted fat stores; muscle
wasting
Amenorrhea
Cheilosis
Postural hypotension; dehydration
or edema
Sleep disturbances
Low body temperature/cold
intolerance
Lower metabolism: low thyroid
hormone






Bone marrow hypoplasia (50% of
AN patients)
results in leukopenia, anemia,
thrombocytopenia
Iron deficiency anemia
Increased infections
Dry skin, hair and hair loss
Yellow skin due to
hypercarotenemia
Lanugo: fine body hairs
AN: Pathophysiology
T-Score
Osteopenia/Osteoporosis

Reduced bone mineral density

May result in vertebral
compression, fractures

Caused by estrogen deficiency,
elevated glucocorticoid levels,
malnutrition, reduced body mass

Affects males and females
AN: Pathophysiology
GI





Bloating, abnormal
fullness
after eating
Constipation
Diarrhea
Digestive enzymes low (i.e.
lactase)
AN: Pathophysiology
Cardiovascular
 Decreased heart rate <60 bpm




Decreased blood pressure <70 mm/Hg systolic; orthostatic
hypotension
Reduction in heart mass
Mitral valve prolapse related to hypovolemia or cardiomyopathy


Fatigue, fainting
Death from CHF
Electrolyte imbalance → heart failure, death



Low intake potassium
Loss in vomiting, diuretics
Refeeding syndrome: electrolyte imbalances caused by rapid refeeding
BN: Pathophysiology












Vomiting
Dehydration
Alkalosis
Hypokalemia (low potassium)
Sore throat, esophagitis, mild hematemesis
Abdominal pain
Subconjunctival hemorrhage
Esophageal tears/ruptures (rare)
Acute gastric dilatation or rupture
Salivary gland infections
Cardiac arrhythmias related to electrolyte and acid-base imbalance caused
by vomiting, laxative, and diuretic abuse
Ipecac may cause irreversible myocardial damage and sudden death
Menstrual irregularities
BN: Pathophysiology
Laxative Abuse







Dehydration
Elevation of serum aldosterone and vasopressin levels
Rectal bleeding
Intestinal atony
Abdominal cramps
Diuretic Abuse
Dehydration
Hypokalemia
Role of the dietitian in a treatment team and
goals of nutrition therapy




AN: weight gain/prevention of further loss and correction of
malnutrition induced disorders; normalization of eating patterns and
behaviors
BN: weight maintenance in the short term even if patient is
overweight until eating habits are stabilized
Increase food intake to raise the BMR (basal metabolic rate)
Some weight restoration and treatment of malnutrition may make
psychotherapy more effective due to improved cognition
(Nutritional intervention must support psychological strategy)
Role of the dietitian in a treatment team and
goals of nutrition therapy






Often require hospitalization to begin refeeding
Some require enteral feedings, but most can be
rehabbed with oral feedings
Goal is increase in energy intake with weight gain
Energy intake must be increased gradually while
minimizing caloric expenditure
Hospitalized patients: goal is 2-3 lb/week
Outpatients: 1 pound/week
(APA Practice Guidelines for the Treatment
of Eating Disorders, January, 2006)
Part I: Nutrition Assessment





Calories compared with DRI
(dietary reference intake)
Evaluate macronutrient mix
(carbohydrate, protein, fat)
Evaluate micronutrient intake
compared with DRI
Estimate fluids and compare
with needs
Evaluate alcohol, caffeine,
drugs, dietary supplements
(www.usda.gov) for DRI’s
(The Eating Disorders Clinical Pocket
Guide by Jessica Setnick)
Nutrition Assessment

Pertinent medical history
Ex: diabetes, hypertension, high cholesterol, kidney
disease, etc .

Pertinent family history (parents, siblings)
ED, heart disease, etc.
Eating habits, weight and stature, relationship with food

Nutrition Assessment
Height
 (verify- particularly in adolescents)
ED history
 bingeing, purging, relationship
 with food/shape/exercise
Weight history
 lifetime highest,
lowest during ED
 Conditions around extreme weights
Nutrition Assessment
Current ED behaviors
 How often does the client
weight at home?
 Binge
 Purge (33-75% kcals still absorbed)
 Fluid intake
(caffeinated and decaf)
Food Rituals







Eating foods in certain orders
(ex: veggies first)
Excessive chewing (or
counting chews)
Rearranging food on a plate
(ex: 8 peas)
Eating finger foods with fork
and knife
Wiping fork after each use
Not allowing foods to touch
One food per meal (ex:
blueberries)
Nutrition Assessment
Medical changes related to ED
 Constipation, diarrhea,
lactose intolerance, dental
problems, bone health?
 Last period and when
stopped if amenorrhea
Medications and
supplements
 BCP, calcium, MVI, herbal
supplements, miralax, etc.
Nutrition
Assessment
Methods to suppress hunger
 Gum, diet soda/products,
coffee, condiments
Vegetarianism
 How long? Does this coincide with start of ED?
 Honoring vegetarianism and level of care (later)
Food Allergies?
 Gluten
 Lactose
 Other?
Nutrition Assessment
Blood values and nutritional significance:
 Albumin
 Total protein
 Blood Urea Nitrogen (BUN)
 Creatinine
 Mangnesium
 Phosphorus
 Sodium
 Potassium
 Hemoglobin/Hematocrit
 Estradiol
Frequency of blood draws?
Food Journal
(see sample food journal)
 Keeps for three days prior to visit
 Continues until eating and B/P stable
 More useful with clients that are new
to treatment/little knowledge of nutrition
 No judgment!!!!
Plan of Care
MVI/Supplement recommendations




Calcium: Needs 1200mg/day
Supplementation: 500-1000mg/day
Calcium Carbonate most common
MVI with Vitamin D
Plan of Care
MVI/Supplement recommendations






Iron: Needs 15-18mg/day
Supplementation: 50-60mg twice daily
Frequent complaints: constipation, nausea
Vitamin C, meat protein (heme iron) increases absorption
Caffeine and phytates inhibit absorption
Other supplements per MD (ex: B12)
What’s wrong with this picture?



Break up into groups
Look at the 3 different sample menus
How would you make this day more
balanced?
Mindful Eating!

Synonymous words:




Intuitive eating
Conscious eating
Thoughtful eating
Characteristics of:





Being connected and present
Awareness
Respecting body
Being in-tune with physical hunger and fullness cues
Being non-judgmental
Mindful Eating Practice

Take your time (slow down!)







Use timer
Put utensils down
Push plate away
Use your 4 senses
Limit distractions
Set environment to be calm
Meditation or prayer
Body Cues

How to distinguish between emotional and
physical hunger and fullness


Use Hunger Scale (on food journal)
Use inquiry
When did I eat last?
 Did I have a balanced meal or snack?
 Was I fully satisfied when I finished?
 Are there any particular emotions present?

Part II:Meal Planning
Estimating needs for AN
 30-40 kcals/kg body weight (1200-1600kcals
daily to start)
 200-300 kcal increases 2 times weekly
 70-100 kcals/kg ultimately, with weight
restoration goal of 1-2 lbs weekly (outpatient) or
2-3 lbs weekly (inpatient)
 Fluids 30-40ml/kg body weight or 64oz
(APA Practice Guidelines for
Treatment of ED’s 2006)
Determining Goal Weight

CDC Growth Charts (adolescents)

http://www.cdc.gov/GROWTHCHARTS/
Hamwi Equation:
Hamwi Formula for Men
106 lbs for first 5 feet + 6 lbs for each inch over 5 feet (med. frame)
Small frame (- 10%), Large frame (+ 10%)
Hamwi Formula for Women
100 lbs for first 5 feet + 5 lbs for each inch over 5 feet (med. frame)
Small frame (- 10%), Large frame (+ 10%)


Past History/ menstruation
Genetics: parents build and eating habits
Meal Planning-AN



3 meals and 3 snacks
Liquids and use of supplements
May need reglan due to delayed
gastric emptying for comfort
Meal Planning-BN
Estimating needs for BN:
 25-35 kcals/kg body weight, depending
on current intake and exercise
 Primary goal: interuption of B/P
 Initial prescription typically around 1500 kcals
 Adjust for weight maintenance, and avoid weight
reduction diet until eating is stable
 Expect impairment of hunger/satiety signals

Ex: 5 ft 4 in., 128 lbs (58kg)=1450-2030 kcals
(APA Practice Guidelines for Treatment of ED’s 2006)
Meal Planning: Macronutrients
50-55% carbohydrate (25-30g fiber)
 15-20% protein (0.8-1.0g/kg body wt)
 25-30% fat (less than 10% total kcals
from saturated/trans fatty acids)
www.mypyramid.gov
www.eatright.org
www.americanheart.org

Exchange System
Exchanges versus Calories
 More flexible than Calorie counting
 Emphasizes balance and moderation
 Incorporates evidence based suggestions
for macronutrients from ADA and AHA
www.diabetes.org
Exchange System








Grains/Starches 6-11
Milk/Dairy 3-4
Fruit 2-4
Vegetables 3-5
Protein/Meat 4-6
Fats 4-6
Above guidelines may
not be adequate for weight
restoration!!
See sample exchange
lists
Exchange System






Starches/Grains: 15g
Carb, 3g protein, 0-1g
fat,
80 kcals
Dairy/Milk: 12g Carb, 8g
protein, 0-3g fat, 100
kcals
Fruit: 15g Carb, 0g
fat/protein, 60 kcals
Veggies: 5g Carb, 0-2g
protein, 0g fat, 25 kcals
Meat/Protein (lean): 0
Carb, 7g protein, 0-3g
fat, 45 kcals
Fats: 0g Carb, 0g
protein,
5g fat, 45 kcals
Measuring food
Discouraged!!
Exceptions:
 First time with a new food and
very distorted view of portions
 New to treatment/meal
planning
 Assure client that exchanges
consider balance and quality of
diet
 GOAL: NORMALIZE EATING

NO!!!!
Portion Distortion










Woman's fist or baseball - a serving of vegetables or fruit
A rounded handful - about one half cup cooked or raw veggies or
cut fruit, a piece of fruit, or ½ cup of cooked rice or pasta - this is a
good measure for a snack serving, such as chips or pretzels
Deck of cards - a serving of meat, fish or poultry or the palm of your
hand (don't count your fingers!) – ex: one chicken breast, ¼ pound
hamburger patty
Golf ball or large egg - one quarter cup of dried fruit or nuts
Tennis ball - about one half cup of ice cream
Computer mouse - about the size of a small baked potato
Compact disc - about the size of one serving of pancake or small
waffle
Thumb tip - about one teaspoon of peanut butter
Six dice - a serving of cheese
Check book - a serving of fish (approximately 3 oz.)
No Weighing!



Ask client to refrain from
weighing at home
Weight 1-2/week with
practitioner, less if stable
(ex: normal wt BN)
Blind weight: challenge client
to focus on other measures of
health and remind them of past
experiences with weighing (i.e.
triggers ED behaviors)
What’s the point?
Where does exercise fit in?






Restrict with AN until eating
improves and client reaches
90% ideal body weight
With normal weight BN, wait
for improvement in B/P
Monitor client for
compensatory exercise
(trading vomiting for exercise)
Explain rationale and caution
against exercising on purging
days due to electrolyte
disturbance
Start with mindful activity: yoga
Weight bearing exercise and
osteoporosis
Female Athlete Triad





Characterized by disordered eating,
amenorrhea, and osteoporosis.
50% of these athletes may have
bone mineral densities that are 1
standard deviation below normal for
age.
Requires exercise restriction.
Coaches must de-emphasize weight
and are cautioned to stop weighing
athletes continually/focus on
strength and mental conditioning.
Some highly motivated and
competitive athletes may correct
their eating disorder if they are told
that malnutrition will affect their
performance.
Meal Planning Using
Exchange System
Case Study
 see assessment form,
sample meal plan
and sample menus
Vegetarianism and Considerations





Duration of vegetarianism
and motivation
Minor/Adult
Lacto-ovo? Vegan?
Level of care
Able to meet needs
through other foods?
Food Allergies
Often used in service of ED and
learned in higher LOC

Verify if feasible (parents, allergist)
and if accommodating allergy will
limit progress

Ex: gluten, nuts, mayo
Offer alternatives

Ex: for lactose intolerance offer lactaid
tablet, lactaid milk, soy milk/yogurt
Play detective! If it sounds fishy, it
probably is!

Ex: pt states gluten intolerant, but eats
oatmeal/bran muffins
GOAL: help to normalize eating and
making peace with fear foods!

HAES Model: Health at Every Size






Health enhancement—attention to emotional, physical and spiritual wellbeing without focus on weight loss or achieving a specific “ideal weight”
Size and self-acceptance—respect and appreciation for the wonderful
diversity of body shapes and sizes (including one's own!), rather than the
pursuit of an idealized weight or shape
The pleasure of eating well—eating based on internal cues of hunger,
satiety, and appetite, rather than on external food plans or diets
The joy of movement—encouraging all physical activities for the associated
pleasure and health benefits, rather than following a specific routine of
regimented exercise for the primary purpose of weight loss
An end to weight bias—recognition that body shape, size and/or weight are
not evidence of any particular way of eating, level of physical activity,
personality, psychological issue or moral character
Confirmation that there is beauty and worth in EVERYbody
Nutrition Education Topics









Calcium intake and Osteoporosis
Set Point Theory (Key’s Study)
Danger of Fad Diets
Function of Foods: Carbohydrate, Fat, Protein
Changes to Expect with Refeeding (constipation, bloating, fullness)
Moderate vs. Compulsive/Compensatory Exercise
HAES model (Health at Every Size)
Laxative Abuse
Consequences of Malnutrition
(Client ready handouts can be found in Winning the War Within)
Questions?
Thank you!