MNT in

Eating
Disorder
s

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
(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 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, 12th edition, p. 564

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 populationsathletes,
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
Russells 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
in normal range

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
Reassess after weight restored

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 10001600 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
post-prandial 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 contd

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