Nutritional Aspects of
Eating Disorders
Glenda McPherson, MA, RD
Clinical Dietitian, Unity Health System
February 29, 2008
Nutrition program purpose
• Identify treatment team members and their roles.
• Discuss cycles of eating disorders as they relate to
nutrition treatment.
• Explain specific tasks of nutritionist on treatment team.
• Increase understanding of food-related behaviors from
individual point of view.
• Explain rationale for nutrition treatment approaches.
• Give examples of treatment strategies.
• Identify signs of recovery.
Eating disorder treatment team
Team must be multidimensional and must address
• biochemistry
• physiology
• psychological issues
• behaviors
Eating disorder treatment team
To change food-related behavior permanently the
following aspects must be addressed concurrently:
•
•
•
•
Medical
Nutritional
Pharmacological
Psychological
Cycles in eating disorders
•
•
•
•
•
Family
Individual
Environment, culture
Stressors
Behaviors
Cultural
Message
1.
2.
3.
4.
5.
Individual with
Eating Disorder
Be attractive
Be successful
Be thin
Be strong
Be muscular
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Separation anxiety
Difficulty with intimacy
Appearance-based Self Esteem
Poor assertiveness
Perfectionist
Maturity fears
Mood disorders
Anxiety disorders
Impulsive
Harm avoidance
External Stressors
1.
2.
3.
4.
5.
6.
7.
8.
Puberty
College
Divorce
Death
Rejection
Comments
Bullying/teasing
Traumatic events
Family
Power struggles
Parental conflicts
Poor conflict resolution skills
Parent-child boundary difficulties
Over value external appearances
Parental anxiety/mood disorder
1.
2.
3.
4.
5.
6.
Cycles in Eating Disorders
Biology
1.
2.
Genetics
Neurotransmitters
1. Dieting
2. Exercising
3. Purging
4. Deception
5. Binge eating
6. Restriction
7. Night eating
Conscious Fears
1.
2.
3.
4.
Gaining weight
Being fat
Being weak
Being out-of-control
Consequences of Behaviors
Adapted From:
Dan W. Reiff and K. Kim Lampson Reiff. © 1985.
Behaviors
1. Illusion of power and control
2. Social withdrawal
3. Emotional Anesthesia
4. Eating disorder identity
5. False autonomy
Power Struggle
6. Malnutrition
7. Poor eating habits
If treatment initiated here
8. Alienation from family
by self or others
9. Delayed psychological and social maturity
Role of the nutritionist
Provide nutrition therapy:
• education
• cognitive behavioral therapy
• family therapy
• health belief model
Level of involvement depends on team, division of
responsibilities within the team, dietitian’s background
or experience.
With Maudsley Approach, nutritionist acts as a
consultant to the family, as needed by the family.
Goals of the nutritionist
• Guide the individual or family in developing a healthy
relationship with food to
normalize eating patterns.
maintain a healthy/stable weight range.
• Communicate with team members throughout the
process.
Tasks of the nutritionist
Educate individual and family about normal and abnormal
• food intake patterns.
• hunger patterns.
• somatic sensations resulting from above.
Dieting and bingeing are the norm—
disordered eating
Chronic Dieters
Binge Eaters
Overeaters
Dysfunctional
Eating
Occasional Dieters
Eating Disorders
Normal Eating
Optimal (normal), “healthy” eating
• Promotes clear thinking and mood stability.
• Fosters healthy relationships in family, work, school,
community. Thoughts of eating, food, and weight 10–
15% of day.
• Nurtures food health, vibrant energy, and healthy growth
and development. Stable weight results expressing
genetics and (appropriate) environment.
Reference: Berg, F. (2001) Afraid to Eat: Children and Teens in Weight Crisis.
Optimal, “healthy” eating
(continued)
• Includes eating at regular times and regulation
mostly by internal signals of hunger, appetite
and fullness/satiety.
• Enhances feelings of well-being. Involves eating
for nourishment, energy, health, pleasure, social
reasons. After eating, you feel good!
• Reflects food choices that are varied, moderate
in amounts, and balanced in nutrient
composition.
Reference: Berg, F. (2001) Afraid to Eat: Children and Teens in Weight Crisis.
Disordered/dysfunctional eating
• Irregular and chaotic eating patterns
(fasting, bingeing, dieting, skipping meals;
undereating or overeating); feel bad after
eating.
• Feeling fatigued, irritable, moody, chilled,
less able to concentrate, and increasingly
self-absorbed; thoughts of food, eating,
weight 20 to 65% or more.
Reference: Berg, F. (2001) Afraid to Eat: Children and Teens in Weight Crisis.
Case 1
•
•
•
•
•
Female
15 years old
Lost 15 pounds in less than two months
Star middle distance runner on track team
Same eating pattern for two months
Typical Food Intake Pattern
Time of Day
Food Eaten or Exercise Done
6:15–7:00 a.m.
7:00–7:15 a.m.
10:00 a.m.
1 c. skim milk
1 1/2 c. Special K
Pushups and crunches, 50–100 each
2 c. water
Bagel, apple, Diet Coke
Gummy bears, 2 c. water
Track practice
2 oz. chicken, 1 c. fast-food yogurt
200 crunches
1 c. salad, fast-food dressing, Diet Coke
Apple
12:00 noon–12:20 p.m.
2:00 p.m.
3:00–5:00 p.m.
6:30–7:45 p.m.
7:45–8:00 p.m.
9:00 p.m.
Missing nutrients
•
•
•
•
•
•
Carbohydrates
Protein
Essential fat
Vitamins
Minerals
Water
Most commonly eliminated foods
•
•
•
•
•
•
Red meat
Fats and foods containing fat
Desserts
High-quality protein especially if vegetarian
Breads (complex carbohydrates)
High-sugar foods—juices
Effects of restriction
• Obsession with food and eating
• Tendency to binge eat in some cases
• Increase in oral behavior: chewing gum, drinking water
or diet soda
• Intensification of negative body image
• Breakdown of natural mechanisms for determining
hunger and satiety
• Physical problems: constipation, light-headedness,
feeling cold
• Lowered metabolic rate
• Rituals
Typical hunger pattern for person
with anorexia nervosa
• Wants to feel hungry all the time.
• Hunger = control.
• Intense hunger needs to be present to
legitimize eating.
• Eating to fullness and to the slightest
stomach expansion is frightening.
Typical hunger pattern
Person who has anorexia nervosa
Compared with a person who has recovered
10
Intense Hunger
9
8
Moderately
Intense Hunger
7
ANOREXIA
NERVOSA
6
5
Moderate Hunger
4
NORMAL
3
Minimal Hunger
2
1
No Hunger
0
6 7 8
9 10 11 12
AM
Time (one day in hours)
1
2
3
4
5
6
PM
7
8
9
10 11
12
1
2
3
4
5
6
AM
Adapted from Reiff, D. W. & Reiff, K. K. (1991) Eating Disorders:
The Health Professional’s Guide to the Process of Recovery.
Biochemical changes
Food intake
Carbohydrate
Serotonin
Depression
OC thoughts
Gastroparesis
Tasks of the nutritionist
Assist individual in understanding connection
between emotions and behaviors enabling her
or him to nourish the body and deal with
emotions separately.
Nutrition therapists access
feelings by
•
•
•
•
Getting to know the person.
Teaching the language of feelings.
Listening.
Teaching that “fat” is not a feeling and decode its
feelings.
• Helping to identify feelings.
• Exploring the correlation between use of food
and dealing with feelings.
One helpful technique
is food journals
Journals are used to:
• empower—identify and describe patterns;
self-assessment.
• develop confidence in food.
• identify hunger/fullness patterns; challenge false
beliefs.
• identify cognitive distortions.
• be a private communication between
nutritionist/therapist and child and are not to be
monitored by parents.
Journals are not typically used with initial phases of the
Maudsley Approach.
Dietary treatment for anorexia
nervosa
• Cease weight loss.
• Establish regular eating: every 3 to 4 hours.
• Establish meal plans.
Gradually increase calorie levels depending on
individual’s needs and treatment model being used.
Consider likes/dislikes.
Include protein, carbohydrate, fat.
• Maintain adequate hydration.
• Eliminate diet foods, caffeine.
• Use supplements if necessary and only during initial
stages of treatment.
Processing in anorexia nervosa
• Help individual process food fears and other
distortions.
Cognitive behavior therapy
• Explain the physiology of starvation.
• Work to identify and accept internal cues and
respond appropriately.
• Help patient process gradual increases in
weight.
• Help to legitimize eating.
Tips for parents/caretakers
• Provide food to support treatment plan as communicated
by individual.
• Individual determines how much and whether to eat
unless she or he is in initial stage of Maudsley Approach,
in which case parent(s) decide.
• Avoid talk and questioning about food (e.g., “What did
you eat at school today?”).
• Avoid talk about body size or weight of self or others!
Focus on feelings and other matters.
• Sit down together for meals as often as possible; insist
on sitting during family meal.
• Avoid power struggles with individual about eating
disorders.
Case 2
•
•
•
•
Female
17 years old
Normal weight
Started acting
Typical food intake pattern
6:00 a.m.
1 grapefruit
12:00 noon 1 apple, ½ bagel, 1 nonfat yogurt
7:00 p.m.
4 c. salad greens
10:00–10:30 p.m.
1 brownie, 1 granola bar, 1 bagel, 2 c. dry
cereal, 1 bag chocolate chip cookies, 1 box
animal crackers, ½ coffee cake, 1 pt. ice
cream
Afterward
Guilt
Typical hunger and food intake pattern
Person who has bulimia nervosa
10
Intense Hunger
Continuous
binge
9
8
One
diet
pop
Moderately
Intense Hunger
7
Celery &
carrot
sticks
6
Gum
5
Moderate Hunger
4
3
Minimal Hunger
2
Large
salad
Gum
Several cups
coffee over
one hour
Binge
Two
cups
coffee
Three
hard
candies
Ice
Gum
cubes
One
cup
Three
coffee
hard Salad
candies
Gum
2 cups coffee
over ½ hour
and one apple
Binge
Purge followed by
drinking one diet pop
and chewing one
package gum
Purges followed by
drinking one diet
pop and chewing
one package gum
1
No Hunger
0
6 7 8
9 10 11 12
AM
Time (one day in hours)
1
2
3
4
5
6
7
PM
8
9
10 11
12
1
2
3
4
5
6
AM
Adapted from Reiff, D. W. & Reiff, K. K. (1991) Eating Disorders:
The Health Professional’s Guide to the Process of Recovery.
Binge eating disorder
• Similar to bulimia nervosa; absence of
purging behaviors.
• Ongoing and/or repetitive cycles often
include
unusually fast eating, usually alone.
unusually large amounts consumed.
uncomfortably full; often “buzzed” after
eating.
embarrassment, shame, guilt, depression.
Dietary treatment for bulimia
nervosa and binge eating disorder
• Set healthy weight range.
• Keep food journal: food, timing, thoughts,
feelings, events—difficult for these disorders.
• Record hunger cues and feelings to uncover
distortions.
• Experience weight control without purging to
build trust and self-esteem.
• Encourage moderate, regular exercise.
Dietary strategies for bulimia
nervosa or BED
Establish regular eating and stabilize weight:
• Identify safe and unsafe foods.
• Set an agreed-upon food and eating plan (will vary with
treatment approach).
• Include adequate protein, fat, carbohydrate. Incorporate
high-bulk foods: fruits and veggies. Work with trigger
foods to fit intervention strategy—team will decide.
• Help maintain adequate nutrition.
• Include food in first part of day.
Breakfast
Lunch
Tips for parents
•
•
•
•
Same as for anorexia nervosa.
Request that individual eat at the table.
Make eating pleasurable.
Focus on positive aspects of food other
than nutrient content.
• Eliminate specific binge trigger foods from
home if necessary.
Tools of the trade
(varies among nutritionists)
•
•
•
•
•
Food journals
Food acceptance/fears survey
Beliefs about food, hunger, and weight
Good foods/bad foods
Others
Indicators of recovery
It takes time!
• Metabolic rate
• Variety of foods
• Body symptoms: menstruation,
thermoregulation, hair and skin health, dental
health, energy, digestion and absorption
• Weight shifts
• Food consumption pattern
Reference: Reiff, D. W., and Reiff, K. K. (1991) Eating Disorders: The Health Professional’s Guide to the Process of
Recovery.
Indicators of recovery (continued)
• Hunger
• Amount of time spent thinking about food, body,
weight
• Exercise level
• Caloric intake
• Food fears
• Weight
• Social eating
Reference: Reiff, D. W., and Reiff, K. K. (1991) Eating Disorders: The Health Professional’s Guide to the Process of Recovery.
The end
“Eating with hunger is about beginning to know
the self on an intimate level. It is about feeling
entitled to take care of the self. It is about being
okay with the self. For those moving away from
eating problems, eating with hunger is about
forming a new, healthy, nurturing relationship
with the self.”
Reference: Johnston, Anita. Eating in the Light of the Moon.
References
Berg, F. M. (2001) Children and Teens Afraid to Eat: Helping Youth in
Today’s Weight Obsessed World. Hettinger, N.D.: Healthy Weight Network.
Garner, D. M. (1997) “Psychoeducational Principles in Treatment.” In Garner, D. M., and
Garfinkel, P. E., eds., Handbook of Treatment for Eating Disorders, 2nd ed., pp. 145–
177. New York: Guilford Press.
Glanz, K., Lewis, F. M., and Rimer, B. K. (1997) Health Behavior and Health Education: Theory
Research, and Practice, pp. 153–178. San Francisco: Jossey–Bass.
Kratina, K. (1993) Counseling Forms. Plantation, Fla: Reflective Image, Inc.
Kreipe, R. E., and Travis, S. (2002) “Eating Disorders.” In Finberg, L., and Kleinman, R., eds.,
Manual of Pediatric Practice, 2nd ed. Orlando, Fla.: W. B. Saunders.
“Position of the American Dietetic Association: Nutrition Intervention in the Treatment of
Anorexia Nervosa, Bulimia Nervosa, and Eating Disorders Not Otherwise Specified
(EDNOS)” (2001) Journal of the American Dietetic Association 101:7, 810–819.
Reiff, D. W., and Reiff, K.K.L. (1991) Eating Disorders: The Health Professional’s Guide to the
Process of Recovery. Frederick, Md.: Aspen.
Wall, J. M. (1991) Eating Disorders: A Manual for Nutritionists. Brattleboro, Vt.: Nutrition
Resources.