MNT in
Eating
Disorders
The Ideal Body Image



Media
promotion
Social
acceptance
Influence and
stress on
young
individuals
Food: More Than Just
Nutrients




Linked to personal emotions
Comfort
Release of natural opioids
Reward
Eating Disorders (APA
Diagnoses)




Anorexia nervosa
Bulimia nervosa
Eating 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 disorders
Fraternal twins are less likely
Profile of Anorexia







Usually occurs between the ages of 12-18
Typically white female
Lifetime prevalence among women is .3 to
3.7%, depending on criteria used
5%-10% are male
Middle-upper socioeconomic class
Often coexists with other psychiatric
disorders: major depression or dysthymia (5075%), anxiety disorders, OCD (40%)
5-20% mortality rate, mostly from heart
failure or arrhythmias
Schebendach in Krause, 12th Ed, p 564
Anorexia Nervosa:
Psychological Features






Perfectionism
Harm avoidance
Feelings of ineffectiveness
Inflexible thinking
Overly restrained emotional expression
Limited social spontaneity
Schebendach in Krause, 12th Ed., p. 564
Anorexia Nervosa

Food rituals
– Cuts food in small pieces
– Rearranges food on plate

Eliminates foods gradually
– 300-600 calories a day
– Diet pop, sugarless gum




Prolonged exercise
Preoccupation with food
Cooks for others
Hungry, but refuses to eat
Diagnostic Criteria

American Psychiatric
Association Diagnostic
and Statistical Manual of
Mental Disorders (DSM)
criteria are the standard
AN APA Diagnostic Criteria






Weight <85% standard
Intense fear weight gain/fat although underweight
Distorted body image
Women: amenorrhea: absence of 3 consecutive
periods
Restricting type
– Not regularly engaged in binge eating-purging
behavior
Binge eating/purging type
– Regularly engaged in binge eating and purging
behavior
AN Diagnostic Criteria


Weight deficit is necessary (<85% of
expected)
If AN develops in childhood or early
adolescence, failure to make expected
weight gains instead of weight loss may
occur
– Stunting possible in prepubertal children
– Growth charts are essential

Amenorrhea may not be useful in younger
patients as menarche may be delayed
Related Psych Disorders
in AN



Depression: May be due, in part, to
the psychological stress of starvation
Obsessive-compulsive disorder: may
be exacerbated by malnutrition
Comorbid personality disorders: poor
impulse control, substance abuse,
mood swings, and suicide tendencies
Prevalence of AN



More prevalent in industrialized
countries that idealize a thin body type
although expected to become more
widely distributed
Lifetime prevalence among women is
.5% to 3.7%, depending on criteria
used
Prevalence among men is one tenth of
that
among women
Schebendach in Krause, 12 edition, p. 564
th
Risk Periods for Anorexia
Nervosa


Age 14 – puberty,
high school
Age 18 – college,
full time jobs
Pathophysiology of AN

Physical and
psychological
consequences of
malnutrition
Pathophysiology of AN

Depleted fat stores; muscle wasting

Amenorrhea

Cheilosis

Postural hypotension; dehydration or
edema

Bradycardia; hypothermia

Sleep disturbances
Pathophysiology of AN:
Osteopenia




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
Pathophysiology of AN



Low body temperature/cold
intolerance
Lower metabolism: low thyroid
hormone
Bone marrow hypoplasia (50% of AN
patients) results in leukopenia,
anemia, thrombocytopenia
Pathophysiology of AN:
Cardiovascular

Decreased heart rate <60 bpm
– Fatigue, fainting



Decreased blood pressure <70 mm/Hg
systolic; orthostatic hypotension
Reduction in heart mass
Mitral valve prolapse related to
hypovolemia or cardiomyopathy
– Death from CHF
Pathophysiology of AN







Iron deficiency anemia
Increased infections
Dry skin, hair
Yellow skin due to hypercarotenemia
Desquamation, hair loss, alopecia
Hirsutism
Lanugo: fine body hairs
Pathophysiology of AN:
GI
Bloating, abnormal fullness after
eating
 Constipation
 Digestive enzymes low

Pathophysiology of AN

Electrolyte imbalance → heart
failure, death
– Low intake potassium
– Loss in vomiting, diuretics
– Refeeding syndrome: electrolyte
imbalances caused by too-rapid
refeeding
Bulimia Nervosa
An illness characterized by repeated
episodes of binge eating followed by
inappropriate compensatory methods
– Purging, including self-induced vomiting
or misuse of laxatives, diuretics,
or enemas
– Non-purging including fasting or
engaging in excessive exercise
Bulimia Nervosa APA Criteria


Characterized by recurrent episodes of
binge/purge eating
Average ≥ 2 binges/purge cycles/week
– Uncontrollable eating during binge
– Purge regularly: vomiting, laxatives,
diuretics, strict dieting, fasting, vigorous
exercise

Continues at least 2x/wk for ≥ 3 months
American Psychological Association. DSM-IV-TR, ed 4, Washington DC,
2000
Bulimia Nervosa
Prevalence



Lifetime prevalence of BN among
young adult women is 1% to 3%
Rate of occurrence in males is 10% of
that in females
Rarely seen in childhood
Schebenbach, in Krause, 12th edition, p. 565
Bulimia Nervosa Prevalence





5% of college women
20% of college women exhibit
symptoms (Sx)
50% of those with anorexia nervosa
develop bulimia nervosa
Gorging and purging/vomiting
Susceptible populations—athletes,
actors, dancers, wrestlers, runners
Profile of Bulimia






Young (usually female) adults (college
students)
May be predisposed to becoming overweight
Usually at or slightly above normal weight
Tried frequent weight-reduction diets as a
teen
Impulsive
Often goes undiagnosed
Profile of Bulimia Nervosa





Other psychological disorders,
including major depression, dysthymia,
anxiety disorders, personality
disorders, substance abuse
Low self esteem
Guilt
Preoccupied with food
Recognize behavior is abnormal
Binge Definition


Eating, 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 circumstances
A sense of lack of control over eating
during the episode
Binge


Relieves stress
Common binge foods:
– High carbohydrate, high fat
– Convenience foods
– Cakes, cookies, ice cream
– Soft, easier to purge

High food bills
Purge

Laxatives, enemas
– Act on large intestine
– 90% of calories are absorbed in small
intestine
– Damages large intestine → constipation
Vomiting



Most commonly used compensatory
behavior (80%-90% of BN)
33-75% of calories still absorbed
Fingers down throat
– Damaged knuckles

Syrup of Ipecac
– Toxic to heart, liver, kidneys
– Poison if taken repeatedly
Vomiting

Teeth
– Stomach acid erodes enamel
– Pain, decay
Diuretics



Water loss
Electrolyte loss
NO fat loss!
Hypergymnasia:
Excessive Exercise



Compulsive exercise: that which
significantly interferes with life
activities
Occurs at inappropriate times or in
inappropriate settings
Continues despite injury or other
medical complications
Symptoms of BN




Usually normal weight and secretive in
behavior
Scarring of the dorsum of the hand used to
stimulate the gag reflex, known as Russell’s
Sign
Parotid gland enlargement
Erosion of dental enamel with increased
dental caries resulting from gastric acid in
the mouth
Pathophysiology of BN:
Vomiting





Dehydration
Alkalosis
Hypokalemia
Sore throat, esophagitis, mild
hematemesis
Abdominal pain
Pathophysiology of BN:
Vomiting





Subconjunctival hemorrhage
Mallory-Weiss esophageal tears
Esophageal ruptures (rare)
Acute gastric dilatation or rupture
Salivary gland infections
Pathophysiology of BN:
Laxative Abuse





Dehydration
Elevation of serum aldosterone and
vasopressin levels
Rectal bleeding
Intestinal atony
Abdominal cramps
Pathophysiology of BN:
Diuretic Abuse


Dehydration
Hypokalemia
Pathophysiology of BN



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
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
nervosa
May have partial symptoms of either
AN or BN
For example, all criteria for AN may be
met except patient has regular menses
OR significant weight loss but wt still
Physical Manifestations of
Eating Disorders
Treatment of Eating
Disorders
AN: Treatment
Nutrition





Increase food intake to raise the BMR
Prevent further weight loss
Restore appropriate food habits
Ultimately weight gain
Some weight restoration and treatment of
malnutrition may make psychotherapy more
effective
AN: Treatment
Psychological




Cognitive behavior therapy
Determine underlying emotional
problems
Reject the sense of accomplishment
associated with weight loss
Family therapy, support group
Nutrition Assessment in
Eating Disorders
Assessment of Intake in
Eating Disorders





Calories compared with DRI
Evaluate macronutrient mix (carbohydrate,
protein, fat)
Evaluate micronutrient intake compared
with DRI
Estimate fluids and compare with needs
Evaluate alcohol, caffeine, drugs, dietary
supplements
Dietary Intake in AN



Generally inadequate caloric intake,
<1000 kcals/day
Tend to avoid fat
Many follow a vegetarian lifestyle
– Identify whether vegetarian lifestyle
coincided with onset of disease
Dietary Intake in BN


Highly variable; in one study mean
intake of 4446 kcals; 44% overeating,
19% undereating
When not binge eating may follow a
low fat diet
Eating Behavior in AN/BN







Unusual or ritualistic behaviors
Unusual food combinations
Nontraditional utensils
Excessive spices, vinegar, lemon juice,
noncaloric sweeteners
Meal spacing, length of time allocated for a
meal
BN: may eat quickly
AN: may eat in excessively slow manner
AN/BN Eating Attitudes






Food aversions
“Safe” foods
Magical thinking
Binge trigger foods
Ideas on appropriate amounts of food
Misconception that purging eliminates
all calories from a binge episode
Lab Assessment


Visceral proteins: generally normal in
AN
Lipids: elevated cholesterol and
abnormal lipid profile; may be due to
hepatic dysfunction, decreased bile
acid secretion, hypothalamic
dysfunction, eating patterns
– Does not warrant prescription of low fat,
low cholesterol diet
Lab Assessment


Serum glucose: low due to lack of
precursors for gluconeogenesis and
production
Low T3 syndrome: low levels of active
form of thyroid hormone; resolves
with refeeding
Vitamin-Mineral
Abnormalities



Hypercarotenemia: in AN restrictors;
mobilization of lipid stores, catabolic
changes, metabolic stress; normalizes with
rehab
Deficiency diseases rare in AN, possibly due
to use of supplements, catabolic state, use
of nutrient-dense foods
Osteopenia and osteoporosis are common
Metabolic Changes





AN: low metabolic rates (REE 62-70% of
expected, or 700-1000 kcals)
Refeeding causes increases in REE
Elevated diet-induced thermogenesis
(DIT) and ↑ REE may require high
calorie prescriptions in nutritional rehab
BN: unpredictable metabolic rate
Helpful to measure REE using indirect
calorimetry
Anthropometric
Assessment




AN patients meet criteria for marasmus
(depleted adipose and somatic protein
stores but intact visceral proteins)
Body composition: underwater weighing or
DEXA; BIA of questionable validity
Skinfolds from 4 sites (triceps, biceps,
subscapular, suprailiac crest)
MAMC
Body Weight Assessment



Goal weight determined by various methods
(NCHS growth tables to age 18)
Daily preprandial early morning weight in
hospital
Gowned 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
Disorders


Multidisciplinary team including
physicians, nutritionists,
psychotherapists
May include inpatient medical or
psychiatric hospitalization, partial
hospitalization and residential
treatment, intensive outpatient, or
outpatient programs
Treatment Goals


AN: weight gain and correction of
malnutrition disorders; normalization of
eating patterns and behaviors
BN: weight maintenance in the short term
even if patient is overweight until eating
habits are stabilized
Factors Affecting Weight
Gain in AN

Fluid balance
– Polyuria seen in starvation
– Edema from starvation or refeeding
– Hydration ratio in tissues

Metabolic rate
– Resting energy expenditure
– Postprandial energy expenditure
Factors Affecting Weight
Gain in AN

Energy cost of tissue gained
– Lean body mass
– Adipose tissue


Previous obesity
Physical activity
Nutritional Care in AN




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
Nutritional Care in AN




Initial calorie prescriptions 1000-1600
kcals, or 30-40 kcals/kg
Increase 100 to 200 kcals q 2-3 days;
may be as high as 70-100 kcal/kg/day
Hospitalized patients: goal is 2-3
lb/week
Outpatients: 1 pound/week
APA Practice Guidelines for the Treatment of Eating Disorders,
January, 2006
Refeeding Syndrome




Refeeding malnourished patients with AN can
result in life-threatening hypophosphatemia,
cardiac arrhythmia, and delirium
May be precipitated by high-calorie feeding
regimens
Patients weighing less than 70% desirable body
weight at greatest risk
Serum phos, mg, K+, calcium must be closely
monitored and supplements provided as
needed
Energy Needs in AN



70-100 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
maintenance
May require 3000-4000 kcals/day later
in wt restoration (males 4000-4500)
Energy Needs in AN



If unsuccessful in weight gain, evaluate for
discarding food, vomiting, exercising,
increased motor activity, metabolic
resistance
Use indirect calorimetry in fasting and postprandial state
Once at goal rate, 40-60 kcals/kg should
promote wt maintenance and continued
growth and development in adolescents
Macronutrient Mix



Fat 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 rehab
Carbohydrate: 50%-55%; include sources of
insoluble fiber to relieve constipation
Micronutrients


Vitamin-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 AN



Early treatment: caloric intake usually low,
can be provided in 3 meals per day;
snacking may relieve some physical
discomfort
Later treatment: as caloric prescription
increases, snacks become unavoidable
Defined formula liquid supplements may be
helpful; patients may be more willing to
accept them than large volumes of food
MNT in BN


Immediate goal interruption of the
binge and purge cycle with weight
maintenance
Rarely hospitalized except for
electrolyte disturbances
Energy Needs in BN


May be hypocaloric; poor correlation
between predicted and actual REE
Measured REE preferable; provide
calories at 120%-130% measured REE
– Signs of low metabolism: history of chronic
dieting, low T3 level, cold intolerance
– In presence of low metabolism, provide
1500-1600 kcals/day) or determine average
calories/day based on current intake
Energy Needs in BN



Monitor anthropometric status and
adjust caloric prescription for weight
maintenance
Avoid weight reduction diets until
eating patterns and body weight are
stabilized
May be on low-calorie intakes for
longer periods than anorectic patients
Monitoring of BN Patients



Bingeing, purging, restrained intake
impair recognition of hunger and
satiety cues
Many patients with BN are afraid to
eat early in the day as they might
binge later
May digress from meal plan after a
binge, attempting to compensate
Macronutrients in BN



Protein: 15-20% of calories; meet RD
in g/kg IBW; HBV sources
Carbohydrate: 50%-55% of calories;
encourage insoluble fiber
Fat: 25%-30% of calories
– Provide source of essential fatty acids

MVI: multivitamin with minerals
Cognitive Behavioral
Therapy



Structured psychotherapeutic method
alters attitudes and problem behaviors
Identifies and replaces negative,
inaccurate thoughts
Typically a 20-week intervention that
– Establishes a regular eating pattern
– Evaluates and changes beliefs about
shape and weight
– Prevents relapse
Female Athlete Triad
Three Components



Eating disorder
Lack of menstrual periods
Osteoporosis
– Bones like 60-year-old
– Caused by low estrogen
– Often irreversible
– Early warning: stress fractures

Also meet criteria for EDNOS
Female Athlete Triad


Female athletes
participating in
appearance-based
and endurance
sports
Seen in 15%
swimmers, 62%
gymnasts, and 32%
of all other sport
Female Athlete Triad


Performance thinness: the commonly
held belief that achieving a lower
weight and percentage of body fat will
enhance performance
Appearance thinness: trend to reward
thinner athletes in adjudicated sports
such as gymnastics and figure skating
Treatment for Female
Athlete Triad





Reduce preoccupation with food,
weight, and body fat
Increase meals and snacks gradually
Rebuild body to healthy weight
Establish regular menses
Decrease training
Binge-Eating Disorder
(Compulsive Overeating)






Complex and serious eating disorder
Occurs 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 depression
Not preoccupied with body shape
Onset 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 BN
At least 2x week over 6
month period
Distress, disgust, guilt,
depression
Binge-Eating Disorder
(Compulsive Overeating)





Eat more rapidly than usual
Eat until uncomfortable
Eat when not hungry
Cannot control binges
Embarrassed, guilty after binge
Binge Eating Process





Precondition
Trigger phase
Maintenance phase
Ending phase
Post-binge phase (consequences)
Characteristics of a
Binge-Eater






Consider self as hungrier than normal
Isolate self to eat large quantities
Triggered by stress, depression,
anxiety, loneliness, anger, frustration
Usually binge on “junk” foods
Eat without regards to biological need
Food is used to reduce stress, provide
feeling of power and well-being
Treatment for BingeEating




Learn to eat in
response to
hunger
Learn to eat in
moderation
Avoid restrictive
diets which can
intensify problems
Increase activity
Treatment for BingeEating




Increase self-acceptance and
improved body image
Address hidden emotions
Overeaters Anonymous
Antidepressants
Baryophobia





“The fear of becoming heavy”
Children are given a low-fat, restricted diet
in hopes to ward off obesity or heart
disease
Detrimental to children; affect growth and
development
Self-imposed restrictive diets by young
adults to avoid obesity
Lack of appropriate nutrition information
Treatment for
Baryophobia



Nutrition education
Nutrition required for proper growth
Appropriateness of sweets and fats in
the diet
Childhood Eating
Disorders




DSM criteria not appropriate in young
children
Cases of AN reported in children as
young as 8 years old
BN rare in childhood
C/o nausea, abdominal pain, difficulty
swallowing, concerns about weight,
shape, and body fatness
Five Warning Signs of
Childhood Eating Disorder





Decreasing weight goal
Increasing criticism of the body
Increasing social isolation
Disruption of menstruation
Reports of purging in the context of
dieting
Eating Disorders in
Dietetics Students

There 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 Students

Worobey 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 weight
Dietetics students scored highest on
Cognitive concerns and binge/purge
behavior
Worobey J, Schoenfeld D. Eating disordered behavior in dietetics students and
students in other majors. JADA 1999;99:1100-1102
Eating Disorders in
College Students


Dietetics and dance majors scored
highest on Life Interference
Dance 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 Students

Fredenberg et al surveyed 5 groups of
students in DPD dietetics, CP dietetics,
non-food home economics curricula,
college basketball or volleyball
programs, and sororities
Fredenberg 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 Students



Fredenberg 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
Prognosis





Mortality has declined for AN from 10%
to 2%.
20% to 30% will have a lifelong struggle
with food
Bulimics 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
Education

Impact of malnutrition on growth and
development

Impact of malnutrition on behavior

Set-point theory

Metabolic adaptation to dieting

Restrained eating and disinhibition

Causes of bingeing and purging

What 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 —cont’d









Impact of exercise on caloric expenditure
Ineffectiveness of vomiting, laxatives, and
diuretics in long-term weight control
Portion control
Food exchange system
Social dining and holiday dining
Food Guide Pyramid
Hunger and satiety cues
Interpreting food labels
Nutrition misinformation
Modified from Schebendach J, Nussbaum MP: Nutrition management in Adolescents with eating disorders. Adoles Med:
State Art Rev 3 (3): 556, 1992.
Dying To Be Thin






Normal to be concerned about diet,
health, and body weight
Weight normally fluctuates
Treat physical and emotional problems
early
Discourage restrictive diets
Correct misconception about foods
Thin is not necessary better
Summary

Nutritional intervention supports
psychologic strategy