Module 5
Incidence
• The actual prevalence of eating disorders is likely far
underestimated as many people are reluctant to disclose
information about their eating behaviors or do not meet
the strict diagnostic criteria for an eating disorder
• Up to 90% of those with an eating disorder may go
untreated.
• More than 7 million girls and women in addition to 1
million boys and men in the United States are expected to
suffer from an eating disorder during their lifetime.
• 10% of eating disorders are diagnosed prior to age 10 and
86% are diagnosed before the teen years are done.
• Eating disorders are thought to arise from the interplay of genetics,
biology, and psycho-socio-cultural factors.
• Poor nutrition has been viewed as both a contributor to the
development and a consequence of eating disorders.
• Dramatic emotional changes that accompany food restriction
include depression, anxiety, and attitudes and behaviors related to
food, some of which persist after refeeding.
• Obesity is coded as a medical condition and is not included in the
DSM. As such, psychological issues included in its etiology or
maintenance may not be fully addressed in treatment.
Obesity
• In eating disorders, loss of control over eating is more related to
psychological distress than is the actual amount of food consumed.
• Obesity may be the result of food addiction for many people.
• Obesity may be resistant to treatment due to the myriad of factors that
appear to contribute to its etiology, including genetics, metabolism,
biological pathways in the brain, behavior, food habits, physical activity,
environment, and the use of pharmacotherapies that promote weight
gain, such as antipsychotic medications.
• Functional neuroimaging suggests that obese individuals may have a
delayed awareness of satiety and altered chemical neuromediators that
contribute to a sense of loss of control in eating, appetite drive, and
craving similar to addiction.
• There are more similarities than differences among core features of eating
disorders.
Risk Factors and Signs for the
Development of Eating Disorders
• Dietary habits including avoidance of specific foods or food
groups, picky eating
• Exercise habits or athletes involved in sports that emphasize
thin body build, body building, or body appearance
• Sociocultural values, including perception of health or beauty,
that influence drive for thinness, negative body image, and/or
body dissatisfaction
• Perceived pressure to perform such as in academics or
athletics
• Psychological factors, including temperament, anxiety
disorders, low self-esteem, self-regulation, attachment issues,
and history of abuse
Nutrition Counseling
• A process by which a health professional with
special training in nutrition helps people make
healthy food choices and form healthy eating
habits
• Registered Dietitians (RDs) are considered to
be the most uniquely qualified and trained to
provide nutrition therapy across the full
continuum of disordered eating
Nutrition Counseling
• The nutrition therapist assists with medical monitoring, understanding
medications and pharmacotherapies, and using medical nutrition protocols
toward providing optimal nutrition and the normalization of eating.
• They also help people in recognize that disordered eating may meet their need for
safety or the relief of pain.
• Nutrition counseling guides patients in identifying problematic behaviors and
setting realistic and achievable nutrition-related goals to support clients in
making behavior changes.
• Nutrition education includes conversations about discrepancies between
knowledge, beliefs, and behaviors, ultimately empowering the patient to
normalize eating and make healthier decisions.
• Recovery indicators include reaching and maintaining a healthful body weight,
normalization of eating patterns and perceptions of hunger and satiety, and the
correction of malnutrition-affected biological and psychological function.
• Nutrition therapy assists clients in making changes related to food intake,
supplement use, compensatory behaviors, physical activity, and the person’s
relationship with their body.
Nutrition Counseling
• Strategies include exploring potential solutions to problems, taking
risks, assertiveness, getting needed support, and setting
boundaries. More specifically, patients become competent in
eating in various social situations and selecting food from all food
groups in appropriate amounts to meet nutrition needs.
• The nutrition therapist considers the factors that affect food intake:
lifestyle and socioeconomic factors, personal values, interpersonal
relationships and skills, trauma history, body image, self-esteem,
substance abuse, and participation in sports.
• Resources that lead to the success of nutrition therapy might
include: access to healthy food, knowledge of food selection and
preparation, and sources of support such as family, friends, and the
workplace.
Counseling Styles Informing Nutrition
Therapy
• 3 sets of individual skills that are the basis of effective healthcare counseling:
– “attending skills” (culturally appropriate body language) essential to establish safety
– “responding skills” keep patients involved, allows counselor to understand issues from client’s
perspective
– “influencing skills” facilitate change.
• The “stages of change” model by Prochaska et al. guides treatment to facilitate change in
thoughts, feelings, and behaviors based on a concept known as the “processes of change.”
• Motivational interviewing (MI) is a counseling style that is designed to promote motivation
to change. MI has been show to be effective in eating disorders and obesity treatment.
• The principles of cognitive behavior therapy (CBT) and social cognitive/social learning
theory facilitate change in diet for weight management, diabetes, and cardiovascular disease.
• Using individual or group CBT, dialectical behavior therapy (DBT), or psychoeducation in
nutrition therapy is intended to promote greater understanding of the mental, emotional,
spiritual, and medical aspects of the eating disorder.
• Self-monitoring, therapeutic repetition/clarification, role-play, modeling, imagery, and real-
life performance may be used to enhance skill and reduce anxiety and guilt.
Various Roles in Nutrition Therapy
• Some faith-based inpatient programs have shown superior results when
spirituality oriented CBT was used as compared to secular CBT. Supporting and
using one’s spirituality in reducing mealtime anxiety and disorders related to food,
particularly among spiritually devout patients, can promote successful outcomes.
• Nutrition therapy should be coordinated with mental health professionals who
use psychological assessments related to motivation, mood, anxiety, personality,
and substance use disorders: this coordination is likely to promote positive change
as well as develop realistic expectations regarding the course of illness and
recovery
• Nutrition professionals may find themselves in a position to counsel eating-
disordered people on physical activity or dental health.
• Nutrition deficiencies; purging behaviors; use of caffeinated, carbonated, or
sweetened drinks; and the use of vinegar and lemon to reduce hunger level are
examples of relational links between nutrition, oral health, and the eating
disorder.
• Patients, families, and other members of the multidisciplinary treatment team
frequently look to the nutrition therapist for guidance on balancing physical
activity and energy intake.
Binge-Eating & Addiction
• It is known that binge eating increases in response to perceived stress and
associated negative mood.
• Binge eating may be the result of a complex relationship between mood and the
influence of that mood on loss of control over eating and nutrition or vice versa.
• Some weight management and treatment programs for bulimia and binge eating
disorder operate from an addictions model based on evidence that food affects
the same neuronal systems as do substances typically associated with abuse
• Similarities between the criteria for substance dependence and the concept of
food addiction
– Progressive use over time
– Withdrawal symptoms
– Use more than intended
– Tried to cut back
– Time pursuing, using, recovering
– Missed important activities
– Continued despite the consequences
Factors & Treatment of Eating
Problems
• It appears that concern related to highly palatable (tasty) foods
being inherently addictive in and of themselves is without support,
but the pattern of intake of these foods (repetitious, intermittent,
“gorging”) may increase the likelihood of eliciting loss of control in
eating.
• Others identify problems in interpersonal relationships, sense of
not belonging or lack of fulfillment, not being loved, feeling afraid
or incompetent, and the drive to feel nurtured and safe as driving
forces to becoming dependent on foods to meet needs.
• Treatment which includes attention to quality and availability of
food, inclusion of family members, behavioral strategies that
include motivation and readiness to change, and physical activity
are all components of a program that recognizes potential
influences of neuropsychosocial underpinnings of food on reward
pathways.
Athletes
• The prevalence of eating disorders among athletes appears to be growing, but
is debated, with reports that range from 1%-62% among female athletes and
0%-57% among male athletes.
• Athletes may be at higher risk for developing an eating disorder because of the
very traits that make them good at their sport (perfectionism,
competitiveness, concern with performance) and emphasis on leanness.
• There is also a possibility that individuals with pre-existing eating disorders
may gravitate toward sports that support their desire to achieve a certain
physique.
• Some dietary and weight control practiced by athletes are transient and safely
managed as part of the demands of the sport. However, others are persistent
and pose a threat to health, performance, and even life.
• The primary goal of dietary counseling for the athlete is to provide for optimal
food and fluid intake.
• An eating-disordered athlete is at risk of inadequate energy and nutrient
intake to meet the demands of the sport, even if weight is within a desirable
range.
Pregnant Women
• An individual with an eating disorder may become pregnant and
experience unfavorable outcomes related to inadequate nutrition
and purging behaviors such as excessive exercise and use of
laxatives, diuretics, or appetite suppressants.
• However, as many as 70% of pregnant women with eating disorders
report a reduction or full remission of eating disorder symptoms
during pregnancy.
• One of the most predictive factors in pregnancy outcome is weight
gain during pregnancy
• Mothers with anorexia are at risk of underfeeding their infants
either by diluting the formula or prolonged breastfeeding and
delayed introduction to solids. Some women may exacerbate their
symptoms to avoid weight gain with pregnancy.
Target Weight
• For the underweight patient, there is disagreement in the literature regarding
weight criteria considered “remission”
• Failure to achieve complete weight restoration increases risk for relapse, with
people struggling with symptoms of their disorder for a longer period of time.
• Nutrition therapists are often consulted to recommend target weight ranges to the
treatment team.
• There is wide variation of normal weight within the population, including both
children and adults. Some patients may meet “normal” weight parameters and
actually be underweight given their biological heritage.
• As a result, most clinicians make recommendations considering family history,
growth and development, weight history, and actual functionality.
• Although BMI is commonly considered a screening tool for risk of weight-related
disease and monitoring growth, it is not considered a tool for rigidly predicting an
individual’s healthiest weight at any given life stage or lifestyle or for determining
level of care needed.
• Ultimately, target weight ranges are goals that are informed but not necessarily a
fixed number.
Refeeding
• Overly aggressive feeding can be lethal to the chronically malnourished person. Underweight
people must be carefully rehabilitated to prevent complications from refeeding.
• Overfeeding a patient whose body has downregulated in response to negative energy balance can
result in refeeding syndrome (a combination of challenges to multiple body systems that can be
dangerous)
• Judicious monitoring and cautious provision of energy can limit the likelihood of refeeding
syndrome.
• The general practice is to begin the refeeding process cautiously. Inpatient programs often start
feedings on reduced calorie regimens, typically 30-40 kcal/kg/d (often 1000-1200 kcal among low-
weight patients), with the initial goal being medical stabilization and safety rather than weight
recovery. This phase of treatment may last 1-3 weeks.
• Access to sodium and simple sugars (gum, candy, breath mints, and even cough drops) may
therefore need to be limited to reduce risk of refeeding syndrome. This can prove to be challenging
in orally fed people who have relied on personal control of oral intake and whose psychological
tolerance of the process may be limited.
• The risk of refeeding syndrome increases with more invasive feeding methods. Thus, the goal is to
provide balanced eating using the oral route as a first preference, enteral route as a second
preference, and parenteral route as a last preference.
Other Considerations
• Once medical stability is achieved, weight restoration at a rate of 2-3 lb per week for hospitalized
patients and 0.5-1 lb per week for clients in outpatient treatment is generally accepted and
desirable.
• Forced treatment and feeding should be considered a life-saving rescue effort
• Tolerance for a low body weight is lower when treating children and teens compared with adults:
inpatient care may be recommended even though weight loss is not severe enough to avert
irreversible impacts on growth and development.
• Rapid weight restoration is likely to carry greater psychological distress for the client, although it
may meet demands of insurer.
• People with anorexia may require more energy than expected to achieve weight restoration:
– People may interfere with the weight restoration process through dishonesty, discarding food, exercising, or
vomiting
– Some people will actually have a higher than expected energy demand. An increased thermic effect of food
and challenges with absorption of nutrition have been postulated as contributors to the increased energy
demand.
• Research suggests that bulimic people may be more metabolically efficient, requiring fewer calories
than their non–eating-disordered peers
Macro & Micronutrient
Considerations
• Currently, there is no recommendation for macronutrient distribution specific to
the eating-disordered population.
• Nutrition therapy includes individualized planning to assist each person in
addressing cognitive distortions with regard to the nutrition quality of food,
specifically carbohydrate, protein, and fat.
• The satiety effect of dietary fat can be helpful to some people who are
experiencing impulses to binge eat as an aid in the prevention of overeating.
Introduction of fat in the diet as an antibinge nutrient can assist people with fat
phobia. However, one has to be careful of the early satiety effect of dietary fat for
other disordered eating populations.
• Eating-disordered patients often have limited intake of vitamins and minerals,
potentially leading to micronutrient deficiency
• An association between B vitamin deficiency and mood disorders typical of eating
disorders has led to supplementation with niacin, vitamin B12, and folic acid and
reported improvement in appetite and mental state
• It is common practice to routinely supplement clients with a complete
multivitamin/mineral preparation during treatment
Vitamin D
• Bone health is of concern due to overwhelming
evidence of bone loss in this population
• Many experts now recommend a dose vitamin D to
maintain levels; greater doses are needed to promote
vitamin D repletion for individuals with levels reflecting
vitamin D deficiency or insufficiency.
• Vitamin D promotes bone health, dental health,
muscle strength, and a variety of other conditions.
Thus, vitamin D status is routinely assessed in the
eating-disordered population.
Food Groups Recommendations
• Limited processed foods, no added salt, and
selection of foods in their most nutrient-dense
form that are free of any added fat or energy-
containing sweeteners.
• Meats in the leanest, trimmed cuts, and milk
products of the lowest in fat
• Many individuals with eating disorders will need a
meal plan at some point in the recovery process
that provides more than 3200 kcal/d
Gut & Immunity
• Exposure to internal and environmental stress interrupts the
development of gut flora, with increasing stress resulting in more
pronounced damage and increased risk of inflammatory and allergic
disease.
• The body’s natural gut flora are affected by various other factors,
including chronic constipation, antibiotics, and excess alcohol use.
• Studies of adolescents under challenging life circumstances,
including those with anorexia, suggest that including probiotics
such as those in yogurt can result in beneficial effects on immunity
• Individuals with an eating disorder may be at higher risk of
developing Irritable Bowel Syndrome (IBS)
Medical Impacts of Eating Disorders
• The literature indicates a long course of illness for many patients with eating disorders
Clients require consistent medical monitoring and ongoing care to manage any lingering effects of the
eating disorder
• Long-term complications of eating disorders involve growth interruption, bone loss, cardiovascular
abnormality, compromised reproductive function, gastrointestinal challenges, and death, which are
caused in part by ongoing nutrition disturbances.
Complications of eating disorders affect the following:
• Electrolyte balance
• Cardiovascular system
• Gastrointestional system
• Reproductive system
• Metabolism
• Nutrition status
• Skeletal and dental health
• Muscular strength
• Body weight and composition
• Cognition
• Growth
• Sudden death related to eating disorders cannot be predicted by length of illness.
Characteristics of Successful Programs
that Reduce the Risk of Eating Pathology
• Target high-risk individuals (vs universal)
• Include interactive programs (ex. cognitive
behavioral strategies, guided discovery, and
active dissonance-induction) and promote
internalization of concepts
• Multisession interventions delivered by
trained professionals to participants 15 years
or older.
Assisting those with Eating Disorders
& Obesity
• There are concerns that efforts to prevent or treat overweight or obesity among
children may inadvertently contribute to the development of eating disorder
behaviors, poor body image, weight bias, or unhealthy weight gain.
• Recent research suggests that moderate calorie restriction does not pose a
psychological risk among children or adults, but this conclusion is preliminary as an
abundance of evidence suggests that emphasizing appearance and weight can
promote eating disorder symptoms
Recommendations for both preventing obesity and eating disorders (all of which are
directly applicable to the expertise of dietitians):
• Discourage dieting and encourage healthy eating
• Sustainable eating and physical activity programs
• Promote a positive body image
• Encourage frequent and enjoyable family meals
• Encourage families to avoid “weight talk” and do more at home to facilitate
healthy eating and physical activity
• Address weight mistreatment among overweight teens and their families.
Final Thoughts
• Eating disorders are complex, multifactorial
illnesses that are difficult to successfully treat.
• A coordinated, well-planned approach by a
multidisciplinary team that includes a protocol for
transition between levels of care is
recommended for the best possible care.
• It is wise to remember the first principle of
medicine is primum non nocere (above all, do no
harm).
