MNT in Eating Disorders. The Ideal Body Image Media promotion Media promotion Social acceptance...

MNT in MNT in Eating Eating DisorderDisorderss

The Ideal Body ImageThe Ideal Body Image

Media Media promotionpromotion

Social Social acceptanceacceptance

Influence and Influence and stress on stress on young young individualsindividuals

Food: More Than Just Food: More Than Just NutrientsNutrients Linked to personal emotionsLinked to personal emotions ComfortComfort Release of natural opioidsRelease of natural opioids RewardReward

Eating Disorders (APA Eating Disorders (APA Diagnoses)Diagnoses) Anorexia nervosaAnorexia nervosa Bulimia nervosaBulimia nervosa Eating disorder not otherwise Eating disorder not otherwise

specified (EDNOS)specified (EDNOS) Binge eating disorder (BED)Binge eating disorder (BED)

Schebendach in Krause, 12th ed., p. 564)

Genetic Link?Genetic Link?

Identical twins have a higher Identical twins have a higher chance of eating disorderschance of eating disorders

Fraternal twins are less likelyFraternal twins are less likely

Profile of AnorexiaProfile of Anorexia Usually occurs between the ages of 12-Usually occurs between the ages of 12-

1818 Typically white femaleTypically white female Lifetime prevalence among women is .3 Lifetime prevalence among women is .3

to 3.7%, depending on criteria usedto 3.7%, depending on criteria used 5%-10% are male5%-10% are male Middle-upper socioeconomic classMiddle-upper socioeconomic class Often coexists with other psychiatric Often coexists with other psychiatric

disorders: major depression or dysthymia disorders: major depression or dysthymia (50-75%), anxiety disorders, OCD (40%)(50-75%), anxiety disorders, OCD (40%)

5-20% mortality rate, mostly from heart 5-20% mortality rate, mostly from heart failure or arrhythmiasfailure or arrhythmias

Schebendach in Krause, 12th Ed, p 564

Anorexia Nervosa: Anorexia Nervosa: Psychological FeaturesPsychological Features

PerfectionismPerfectionism Harm avoidanceHarm avoidance Feelings of ineffectivenessFeelings of ineffectiveness Inflexible thinkingInflexible thinking Overly restrained emotional Overly restrained emotional

expressionexpression Limited social spontaneityLimited social spontaneity

Schebendach in Krause, 12th Ed., p. 564

Anorexia NervosaAnorexia Nervosa

Food ritualsFood rituals– Cuts food in small piecesCuts food in small pieces– Rearranges food on plateRearranges food on plate

Eliminates foods graduallyEliminates foods gradually– 300-600 calories a day300-600 calories a day– Diet pop, sugarless gumDiet pop, sugarless gum

Prolonged exerciseProlonged exercise Preoccupation with foodPreoccupation with food Cooks for othersCooks for others Hungry, but refuses to eatHungry, but refuses to eat

Diagnostic CriteriaDiagnostic Criteria

American Psychiatric American Psychiatric Association Diagnostic Association Diagnostic and Statistical Manual and Statistical Manual of Mental Disorders of Mental Disorders (DSM) criteria are the (DSM) criteria are the standardstandard

AN APA Diagnostic AN APA Diagnostic CriteriaCriteria Weight <85% standardWeight <85% standard Intense fear weight gain/fat although underweightIntense fear weight gain/fat although underweight Distorted body imageDistorted body image Women: amenorrhea: absence of 3 consecutive Women: amenorrhea: absence of 3 consecutive

periodsperiods Restricting typeRestricting type

– Not regularly engaged in binge eating-purging Not regularly engaged in binge eating-purging behaviorbehavior

Binge eating/purging typeBinge eating/purging type– Regularly engaged in binge eating and purging Regularly engaged in binge eating and purging

behaviorbehavior

AN Diagnostic CriteriaAN Diagnostic Criteria

Weight deficit is necessary (<85% of Weight deficit is necessary (<85% of expected)expected)

If AN develops in childhood or early If AN develops in childhood or early adolescence, failure to make expected adolescence, failure to make expected weight gains instead of weight loss weight gains instead of weight loss may occurmay occur– Stunting possible in prepubertal childrenStunting possible in prepubertal children– Growth charts are essentialGrowth charts are essential

Amenorrhea may not be useful in Amenorrhea may not be useful in younger patients as menarche may be younger patients as menarche may be delayeddelayed

Related Psych Related Psych Disorders in ANDisorders in AN Depression: May be due, in part, to Depression: May be due, in part, to

the psychological stress of starvationthe psychological stress of starvation Obsessive-compulsive disorder: may Obsessive-compulsive disorder: may

be exacerbated by malnutritionbe exacerbated by malnutrition Comorbid personality disorders: poor Comorbid personality disorders: poor

impulse control, substance abuse, impulse control, substance abuse, mood swings, and suicide tendenciesmood swings, and suicide tendencies

Prevalence of ANPrevalence of AN

More prevalent in industrialized More prevalent in industrialized countries that idealize a thin body countries that idealize a thin body type although expected to type although expected to become more widely distributedbecome more widely distributed

Lifetime prevalence among Lifetime prevalence among women is .5% to 3.7%, depending women is .5% to 3.7%, depending on criteria usedon criteria used

Prevalence among men is one Prevalence among men is one tenth of that among womententh of that among womenSchebendach in Krause, 12th edition, p. 564

Risk Periods for Risk Periods for Anorexia NervosaAnorexia Nervosa

Age 14 – Age 14 – puberty, high puberty, high schoolschool

Age 18 – college, Age 18 – college, full time jobsfull time jobs

Pathophysiology of ANPathophysiology of AN

Physical and Physical and psychological psychological consequences consequences of malnutritionof malnutrition


Depleted fat stores; muscle Depleted fat stores; muscle wastingwasting

AmenorrheaAmenorrhea

CheilosisCheilosis

Postural hypotension; Postural hypotension; dehydration or edemadehydration or edema

Bradycardia; hypothermia Bradycardia; hypothermia

Sleep disturbancesSleep disturbances

Pathophysiology of Pathophysiology of AN: OsteopeniaAN: Osteopenia Reduced bone mineral densityReduced bone mineral density May result in vertebral May result in vertebral

compression, fracturescompression, fractures Caused by estrogen deficiency, Caused by estrogen deficiency,

elevated glucocorticoid levels, elevated glucocorticoid levels, malnutrition, reduced body massmalnutrition, reduced body mass

Affects males and femalesAffects males and females


Low body temperature/cold Low body temperature/cold intoleranceintolerance

Lower metabolism: low thyroid Lower metabolism: low thyroid hormonehormone

Bone marrow hypoplasia (50% of Bone marrow hypoplasia (50% of AN patients) results in leukopenia, AN patients) results in leukopenia, anemia, thrombocytopeniaanemia, thrombocytopenia

Pathophysiology of Pathophysiology of AN: Cardiovascular AN: Cardiovascular Decreased heart rate <60 bpmDecreased heart rate <60 bpm

– Fatigue, faintingFatigue, fainting Decreased blood pressure <70 Decreased blood pressure <70

mm/Hg systolic; orthostatic mm/Hg systolic; orthostatic hypotensionhypotension

Reduction in heart massReduction in heart mass Mitral valve prolapse related to Mitral valve prolapse related to

hypovolemia or cardiomyopathyhypovolemia or cardiomyopathy– Death from CHFDeath from CHF


Iron deficiency anemiaIron deficiency anemia Increased infectionsIncreased infections Dry skin, hairDry skin, hair Yellow skin due to Yellow skin due to

hypercarotenemiahypercarotenemia Desquamation, hair loss, alopeciaDesquamation, hair loss, alopecia

HirsutismHirsutism Lanugo: fine body hairsLanugo: fine body hairs

Pathophysiology of Pathophysiology of AN: GIAN: GI Bloating, abnormal fullness Bloating, abnormal fullness

after eatingafter eating ConstipationConstipation Digestive enzymes lowDigestive enzymes low


Electrolyte imbalance Electrolyte imbalance → heart → heart failure, deathfailure, death– Low intake potassiumLow intake potassium– Loss in vomiting, diureticsLoss in vomiting, diuretics– Refeeding syndrome: Refeeding syndrome:

electrolyte imbalances caused electrolyte imbalances caused by too-rapid refeedingby too-rapid refeeding

Bulimia NervosaBulimia Nervosa

An illness characterized by repeated An illness characterized by repeated episodes of binge eating followed episodes of binge eating followed by inappropriate compensatory by inappropriate compensatory methods methods – Purging, including self-induced Purging, including self-induced

vomiting or misuse of laxatives, vomiting or misuse of laxatives, diuretics, diuretics, or enemasor enemas

– Non-purging including fasting or Non-purging including fasting or engaging in excessive exerciseengaging in excessive exercise

Bulimia Nervosa APA Bulimia Nervosa APA CriteriaCriteria

Characterized by recurrent episodes of Characterized by recurrent episodes of binge/purge eatingbinge/purge eating

Average ≥ 2 binges/purge cycles/weekAverage ≥ 2 binges/purge cycles/week– Uncontrollable eating during bingeUncontrollable eating during binge– Purge regularly: vomiting, laxatives, Purge regularly: vomiting, laxatives,

diuretics, strict dieting, fasting, vigorous diuretics, strict dieting, fasting, vigorous exerciseexercise

Continues at least 2x/wk for ≥ 3 Continues at least 2x/wk for ≥ 3 monthsmonthsAmerican Psychological Association. DSM-IV-TR, ed 4, Washington DC, 2000

Bulimia Nervosa Bulimia Nervosa PrevalencePrevalence Lifetime prevalence of BN among Lifetime prevalence of BN among

young adult women is 1% to 3%young adult women is 1% to 3% Rate of occurrence in males is Rate of occurrence in males is

10% of that in females10% of that in females Rarely seen in childhoodRarely seen in childhood

Schebenbach, in Krause, 12th edition, p. 565

Bulimia Nervosa Bulimia Nervosa PrevalencePrevalence

5% of college women 5% of college women 20% of college women exhibit 20% of college women exhibit

symptoms (Sx)symptoms (Sx) 50% of those with anorexia 50% of those with anorexia

nervosa develop bulimia nervosanervosa develop bulimia nervosa Gorging and purging/vomitingGorging and purging/vomiting Susceptible populations—athletes, Susceptible populations—athletes,

actors, dancers, wrestlers, runnersactors, dancers, wrestlers, runners

Profile of BulimiaProfile of Bulimia

Young (usually female) adults (college Young (usually female) adults (college students)students)

May be predisposed to becoming May be predisposed to becoming overweightoverweight

Usually at or slightly above normal weight Usually at or slightly above normal weight Tried frequent weight-reduction diets as a Tried frequent weight-reduction diets as a

teenteen ImpulsiveImpulsive Often goes undiagnosedOften goes undiagnosed

Profile of Bulimia Profile of Bulimia NervosaNervosa Other psychological disorders, Other psychological disorders,

including major depression, including major depression, dysthymia, anxiety disorders, dysthymia, anxiety disorders, personality disorders, substance personality disorders, substance abuseabuse

Low self esteemLow self esteem GuiltGuilt Preoccupied with foodPreoccupied with food Recognize behavior is abnormalRecognize behavior is abnormal

Binge DefinitionBinge Definition

Eating, in a discrete period of Eating, in a discrete period of time (e.g., within any 2-hour time (e.g., within any 2-hour period) an amount of food that is period) an amount of food that is definitely larger than most people definitely larger than most people would eat under similar would eat under similar circumstancescircumstances

A sense of lack of control over A sense of lack of control over eating during the episodeeating during the episode

BingeBinge

Relieves stressRelieves stress Common binge foods:Common binge foods:

– High carbohydrate, high fatHigh carbohydrate, high fat– Convenience foodsConvenience foods– Cakes, cookies, ice creamCakes, cookies, ice cream– Soft, easier to purgeSoft, easier to purge

High food billsHigh food bills

PurgePurge

Laxatives, enemasLaxatives, enemas– Act on large intestineAct on large intestine– 90% of calories are absorbed in 90% of calories are absorbed in

small intestinesmall intestine– Damages large intestine Damages large intestine → →

constipationconstipation

VomitingVomiting

Most commonly used compensatory Most commonly used compensatory behavior (80%-90% of BN)behavior (80%-90% of BN)

33-75% of calories still absorbed33-75% of calories still absorbed Fingers down throat Fingers down throat

– Damaged knucklesDamaged knuckles Syrup of IpecacSyrup of Ipecac

– Toxic to heart, liver, kidneysToxic to heart, liver, kidneys– Poison if taken repeatedlyPoison if taken repeatedly

VomitingVomiting

TeethTeeth– Stomach acid erodes Stomach acid erodes

enamelenamel– Pain, decayPain, decay

DiureticsDiuretics

Water lossWater loss Electrolyte lossElectrolyte loss NO fat loss! NO fat loss!

Hypergymnasia: Hypergymnasia: Excessive ExerciseExcessive Exercise Compulsive exercise: that which Compulsive exercise: that which

significantly interferes with life significantly interferes with life activitiesactivities

Occurs at inappropriate times or Occurs at inappropriate times or in inappropriate settingsin inappropriate settings

Continues despite injury or other Continues despite injury or other medical complicationsmedical complications

Symptoms of BNSymptoms of BN

Usually normal weight and secretive in Usually normal weight and secretive in behaviorbehavior

Scarring of the dorsum of the hand Scarring of the dorsum of the hand used to stimulate the gag reflex, used to stimulate the gag reflex, known as Russell’s Signknown as Russell’s Sign

Parotid gland enlargementParotid gland enlargement Erosion of dental enamel with Erosion of dental enamel with

increased dental caries resulting from increased dental caries resulting from gastric acid in the mouthgastric acid in the mouth

Pathophysiology of Pathophysiology of BN: VomitingBN: Vomiting DehydrationDehydration AlkalosisAlkalosis HypokalemiaHypokalemia Sore throat, esophagitis, mild Sore throat, esophagitis, mild

hematemesishematemesis Abdominal painAbdominal pain

Pathophysiology of Pathophysiology of BN: VomitingBN: Vomiting Subconjunctival hemorrhageSubconjunctival hemorrhage Mallory-Weiss esophageal tearsMallory-Weiss esophageal tears Esophageal ruptures (rare)Esophageal ruptures (rare) Acute gastric dilatation or ruptureAcute gastric dilatation or rupture Salivary gland infectionsSalivary gland infections

Pathophysiology of Pathophysiology of BN: Laxative AbuseBN: Laxative Abuse DehydrationDehydration Elevation of serum aldosterone Elevation of serum aldosterone

and vasopressin levelsand vasopressin levels Rectal bleedingRectal bleeding Intestinal atonyIntestinal atony Abdominal crampsAbdominal cramps

Pathophysiology of Pathophysiology of BN: Diuretic AbuseBN: Diuretic Abuse DehydrationDehydration HypokalemiaHypokalemia

Pathophysiology of BNPathophysiology of BN

Cardiac arrhythmias related to Cardiac arrhythmias related to electrolyte and acid-base electrolyte and acid-base imbalance caused by vomiting, imbalance caused by vomiting, laxative, and diuretic abuselaxative, and diuretic abuse

Ipecac may cause irreversible Ipecac may cause irreversible myocardial damage and sudden myocardial damage and sudden deathdeath

Menstrual irregularitiesMenstrual irregularities

Vicious Cycle of Vicious Cycle of Bulimia Bulimia

Eating Disorder Not Eating Disorder Not Otherwise Specified Otherwise Specified (EDNOS)(EDNOS) A diagnostic category for eating A diagnostic category for eating

disorders that fail to meet full disorders that fail to meet full criteria for either anorexia nervosa criteria for either anorexia nervosa or bulimia nervosaor bulimia nervosa

May have partial symptoms of May have partial symptoms of either AN or BNeither AN or BN

For example, all criteria for AN may For example, all criteria for AN may be met except patient has regular be met except patient has regular menses menses

OR significant weight loss but wt OR significant weight loss but wt still in normal rangestill in normal range

Physical Physical Manifestations of Manifestations of Eating DisordersEating Disorders

Treatment of Eating Treatment of Eating DisordersDisorders

AN: Treatment AN: Treatment

NutritionNutrition Increase food intake to raise the BMRIncrease food intake to raise the BMR Prevent further weight lossPrevent further weight loss Restore appropriate food habitsRestore appropriate food habits Ultimately weight gainUltimately weight gain Some weight restoration and treatment Some weight restoration and treatment

of malnutrition may make of malnutrition may make psychotherapy more effectivepsychotherapy more effective

AN: TreatmentAN: Treatment

PsychologicalPsychological Cognitive behavior therapyCognitive behavior therapy Determine underlying emotional Determine underlying emotional

problemsproblems Reject the sense of Reject the sense of

accomplishment associated with accomplishment associated with weight lossweight loss

Family therapy, support groupFamily therapy, support group

Nutrition Assessment Nutrition Assessment in Eating Disordersin Eating Disorders

Assessment of Intake Assessment of Intake in Eating Disordersin Eating Disorders Calories compared with DRICalories compared with DRI Evaluate macronutrient mix Evaluate macronutrient mix

(carbohydrate, protein, fat)(carbohydrate, protein, fat) Evaluate micronutrient intake compared Evaluate micronutrient intake compared

with DRIwith DRI Estimate fluids and compare with needsEstimate fluids and compare with needs Evaluate alcohol, caffeine, drugs, Evaluate alcohol, caffeine, drugs,

dietary supplementsdietary supplements

Dietary Intake in ANDietary Intake in AN

Generally inadequate caloric Generally inadequate caloric intake, <1000 kcals/dayintake, <1000 kcals/day

Tend to avoid fatTend to avoid fat Many follow a vegetarian lifestyleMany follow a vegetarian lifestyle

– Identify whether vegetarian lifestyle Identify whether vegetarian lifestyle coincided with onset of diseasecoincided with onset of disease

Dietary Intake in BNDietary Intake in BN

Highly variable; in one study Highly variable; in one study mean intake of 4446 kcals; 44% mean intake of 4446 kcals; 44% overeating, 19% undereatingovereating, 19% undereating

When not binge eating may follow When not binge eating may follow a low fat dieta low fat diet

Eating Behavior in Eating Behavior in AN/BNAN/BN Unusual or ritualistic behaviorsUnusual or ritualistic behaviors Unusual food combinationsUnusual food combinations Nontraditional utensilsNontraditional utensils Excessive spices, vinegar, lemon juice, Excessive spices, vinegar, lemon juice,

noncaloric sweetenersnoncaloric sweeteners Meal spacing, length of time allocated Meal spacing, length of time allocated

for a mealfor a meal BN: may eat quicklyBN: may eat quickly AN: may eat in excessively slow mannerAN: may eat in excessively slow manner

AN/BN Eating AttitudesAN/BN Eating Attitudes

Food aversionsFood aversions ““Safe” foodsSafe” foods Magical thinkingMagical thinking Binge trigger foodsBinge trigger foods Ideas on appropriate amounts of foodIdeas on appropriate amounts of food Misconception that purging Misconception that purging

eliminates all calories from a binge eliminates all calories from a binge episodeepisode

Lab AssessmentLab Assessment

Visceral proteins: generally Visceral proteins: generally normal in ANnormal in AN

Lipids: elevated cholesterol and Lipids: elevated cholesterol and abnormal lipid profile; may be due abnormal lipid profile; may be due to hepatic dysfunction, decreased to hepatic dysfunction, decreased bile acid secretion, hypothalamic bile acid secretion, hypothalamic dysfunction, eating patternsdysfunction, eating patterns– Does not warrant prescription of low Does not warrant prescription of low

fat, low cholesterol dietfat, low cholesterol diet– Reassess after weight restoredReassess after weight restored

Lab AssessmentLab Assessment

Serum glucose: low due to lack of Serum glucose: low due to lack of precursors for gluconeogenesis precursors for gluconeogenesis and productionand production

Low T3 syndrome: low levels of Low T3 syndrome: low levels of active form of thyroid hormone; active form of thyroid hormone; resolves with refeedingresolves with refeeding

Vitamin-Mineral Vitamin-Mineral AbnormalitiesAbnormalities Hypercarotenemia: in AN restrictors; Hypercarotenemia: in AN restrictors;

mobilization of lipid stores, catabolic mobilization of lipid stores, catabolic changes, metabolic stress; normalizes changes, metabolic stress; normalizes with rehabwith rehab

Deficiency diseases rare in AN, possibly Deficiency diseases rare in AN, possibly due to use of supplements, catabolic due to use of supplements, catabolic state, use of nutrient-dense foodsstate, use of nutrient-dense foods

Osteopenia and osteoporosis are Osteopenia and osteoporosis are commoncommon

Metabolic ChangesMetabolic Changes

AN: low metabolic rates (REE 62-70% AN: low metabolic rates (REE 62-70% of expected, or 700-1000 kcals)of expected, or 700-1000 kcals)

Refeeding causes increases in REERefeeding causes increases in REE Elevated diet-induced thermogenesis Elevated diet-induced thermogenesis

(DIT) and (DIT) and ↑ REE may require high ↑ REE may require high calorie prescriptions in nutritional calorie prescriptions in nutritional rehabrehab

BN: unpredictable metabolic rateBN: unpredictable metabolic rate Helpful to measure REE using indirect Helpful to measure REE using indirect

calorimetrycalorimetry

Anthropometric Anthropometric AssessmentAssessment AN patients meet criteria for marasmus AN patients meet criteria for marasmus

(depleted adipose and somatic protein (depleted adipose and somatic protein stores but intact visceral proteins)stores but intact visceral proteins)

Body composition: underwater weighing Body composition: underwater weighing or DEXA; BIA of questionable validityor DEXA; BIA of questionable validity

Skinfolds from 4 sites (triceps, biceps, Skinfolds from 4 sites (triceps, biceps, subscapular, suprailiac crest)subscapular, suprailiac crest)

MAMCMAMC

Body Weight Body Weight AssessmentAssessment Goal weight determined by various Goal weight determined by various

methods (NCHS growth tables to age methods (NCHS growth tables to age 18)18)

Daily preprandial early morning weight Daily preprandial early morning weight in hospitalin hospital

Gowned weight on the same scale Gowned weight on the same scale once a week in outpatient (pt should once a week in outpatient (pt should void and urine specific gravity checked void and urine specific gravity checked or patient examined to determine if or patient examined to determine if bladder is full)bladder is full)

Management of Eating Management of Eating DisordersDisorders Multidisciplinary team including Multidisciplinary team including

physicians, nutritionists, physicians, nutritionists, psychotherapistspsychotherapists

May include inpatient medical or May include inpatient medical or psychiatric hospitalization, partial psychiatric hospitalization, partial hospitalization and residential hospitalization and residential treatment, intensive outpatient, treatment, intensive outpatient, or outpatient programsor outpatient programs

Treatment GoalsTreatment Goals

AN: weight gain and correction of AN: weight gain and correction of malnutrition disorders; normalization malnutrition disorders; normalization of eating patterns and behaviorsof eating patterns and behaviors

BN: weight maintenance in the short BN: weight maintenance in the short term even if patient is overweight until term even if patient is overweight until eating habits are stabilizedeating habits are stabilized

Factors Affecting Factors Affecting Weight Gain in ANWeight Gain in AN Fluid balanceFluid balance

– Polyuria seen in starvationPolyuria seen in starvation– Edema from starvation or refeedingEdema from starvation or refeeding– Hydration ratio in tissuesHydration ratio in tissues

Metabolic rateMetabolic rate– Resting energy expenditureResting energy expenditure– Postprandial energy expenditurePostprandial energy expenditure

Factors Affecting Factors Affecting Weight Gain in ANWeight Gain in AN Energy cost of tissue gainedEnergy cost of tissue gained

– Lean body massLean body mass– Adipose tissueAdipose tissue

Previous obesityPrevious obesity Physical activityPhysical activity

Nutritional Care in ANNutritional Care in AN

Often require hospitalization to begin Often require hospitalization to begin refeedingrefeeding

Some require enteral feedings, but Some require enteral feedings, but most can be rehabbed with oral most can be rehabbed with oral feedingsfeedings

Goal is increase in energy intake with Goal is increase in energy intake with weight gainweight gain

Energy intake must be increased Energy intake must be increased gradually while minimizing caloric gradually while minimizing caloric expenditureexpenditure

Nutritional Care in ANNutritional Care in AN

Initial calorie prescriptions 1000-Initial calorie prescriptions 1000-1600 kcals, or 30-40 kcals/kg1600 kcals, or 30-40 kcals/kg

Increase 100 to 200 kcals q 2-3 Increase 100 to 200 kcals q 2-3 days; may be as high as 70-100 days; may be as high as 70-100 kcal/kg/daykcal/kg/day

Hospitalized patients: goal is 2-3 Hospitalized patients: goal is 2-3 lb/weeklb/week

Outpatients: 1 pound/weekOutpatients: 1 pound/weekAPA Practice Guidelines for the Treatment of Eating Disorders, January, 2006

Refeeding SyndromeRefeeding Syndrome

Refeeding malnourished patients with AN can Refeeding malnourished patients with AN can result in life-threatening hypophosphatemia, result in life-threatening hypophosphatemia, cardiac arrhythmia, and deliriumcardiac arrhythmia, and delirium

May be precipitated by high-calorie feeding May be precipitated by high-calorie feeding regimensregimens

Patients weighing less than 70% desirable Patients weighing less than 70% desirable body weight at greatest riskbody weight at greatest risk

Serum phos, mg, K+, calcium must be Serum phos, mg, K+, calcium must be closely monitored and supplements provided closely monitored and supplements provided as neededas needed

Energy Needs in ANEnergy Needs in AN

70-100 kcals/kg may be needed for 70-100 kcals/kg may be needed for continued weight gain (depends on continued weight gain (depends on REE and type of tissue gained)REE and type of tissue gained)

AN more physically active than AN more physically active than controls; require controls; require ↑ ↑ kcals for weight kcals for weight maintenancemaintenance

May require 3000-4000 kcals/day May require 3000-4000 kcals/day later in wt restoration (males 4000-later in wt restoration (males 4000-4500)4500)

Energy Needs in ANEnergy Needs in AN

If unsuccessful in weight gain, If unsuccessful in weight gain, evaluate for discarding food, vomiting, evaluate for discarding food, vomiting, exercising, increased motor activity, exercising, increased motor activity, metabolic resistancemetabolic resistance

Use indirect calorimetry in fasting and Use indirect calorimetry in fasting and post-prandial statepost-prandial state

Once at goal rate, 40-60 kcals/kg Once at goal rate, 40-60 kcals/kg should promote wt maintenance and should promote wt maintenance and continued growth and development in continued growth and development in adolescentsadolescents

Macronutrient MixMacronutrient Mix

Fat intake of 25%-30% of calories is Fat intake of 25%-30% of calories is recommended as added fat or less obvious recommended as added fat or less obvious sources (whole milk or peanut butter)sources (whole milk or peanut butter)

Protein: 15%-20% of calories; RDA for age Protein: 15%-20% of calories; RDA for age and sex in grams/kg of IBW; high biological and sex in grams/kg of IBW; high biological value sources; vegetarian diets should be value sources; vegetarian diets should be discouraged during rehabdiscouraged during rehab

Carbohydrate: 50%-55%; include sources of Carbohydrate: 50%-55%; include sources of insoluble fiber to relieve constipationinsoluble fiber to relieve constipation

MicronutrientsMicronutrients

Vitamin-mineral supplements: may Vitamin-mineral supplements: may have increased need in anabolism; have increased need in anabolism; 100% RDA multivitamin with 100% RDA multivitamin with minerals (iron may minerals (iron may ↑ constipation)↑ constipation)

Encourage calcium-rich foods and Encourage calcium-rich foods and Vitamin DVitamin D

MNT in ANMNT in AN

Early treatment: caloric intake usually Early treatment: caloric intake usually low, can be provided in 3 meals per low, can be provided in 3 meals per day; snacking may relieve some day; snacking may relieve some physical discomfortphysical discomfort

Later treatment: as caloric prescription Later treatment: as caloric prescription increases, snacks become unavoidableincreases, snacks become unavoidable

Defined formula liquid supplements Defined formula liquid supplements may be helpful; patients may be more may be helpful; patients may be more willing to accept them than large willing to accept them than large volumes of foodvolumes of food

MNT in BNMNT in BN

Immediate goal interruption of Immediate goal interruption of the binge and purge cycle with the binge and purge cycle with weight maintenanceweight maintenance

Rarely hospitalized except for Rarely hospitalized except for electrolyte disturbanceselectrolyte disturbances

Energy Needs in BNEnergy Needs in BN

May be hypocaloric; poor correlation May be hypocaloric; poor correlation between predicted and actual REEbetween predicted and actual REE

Measured REE preferable; provide Measured REE preferable; provide calories at 120%-130% measured REEcalories at 120%-130% measured REE– Signs of low metabolism: history of chronic Signs of low metabolism: history of chronic

dieting, low T3 level, cold intolerancedieting, low T3 level, cold intolerance– In presence of low metabolism, provide In presence of low metabolism, provide

1500-1600 kcals/day) or determine average 1500-1600 kcals/day) or determine average calories/day based on current intakecalories/day based on current intake

Energy Needs in BNEnergy Needs in BN

Monitor anthropometric status and Monitor anthropometric status and adjust caloric prescription for weight adjust caloric prescription for weight maintenancemaintenance

Avoid weight reduction diets until Avoid weight reduction diets until eating patterns and body weight are eating patterns and body weight are stabilizedstabilized

May be on low-calorie intakes for May be on low-calorie intakes for longer periods than anorectic longer periods than anorectic patientspatients

Monitoring of BN Monitoring of BN PatientsPatients Bingeing, purging, restrained Bingeing, purging, restrained

intake impair recognition of intake impair recognition of hunger and satiety cueshunger and satiety cues

Many patients with BN are afraid Many patients with BN are afraid to eat early in the day as they to eat early in the day as they might binge latermight binge later

May digress from meal plan after a May digress from meal plan after a binge, attempting to compensatebinge, attempting to compensate

Macronutrients in BNMacronutrients in BN

Protein: 15-20% of calories; meet Protein: 15-20% of calories; meet RD in g/kg IBW; HBV sourcesRD in g/kg IBW; HBV sources

Carbohydrate: 50%-55% of Carbohydrate: 50%-55% of calories; encourage insoluble fibercalories; encourage insoluble fiber

Fat: 25%-30% of caloriesFat: 25%-30% of calories– Provide source of essential fatty Provide source of essential fatty

acidsacids MVI: multivitamin with mineralsMVI: multivitamin with minerals

Cognitive Behavioral Cognitive Behavioral TherapyTherapy Structured psychotherapeutic Structured psychotherapeutic

method alters attitudes and problem method alters attitudes and problem behaviorsbehaviors

Identifies and replaces negative, Identifies and replaces negative, inaccurate thoughtsinaccurate thoughts

Typically a 20-week intervention thatTypically a 20-week intervention that– Establishes a regular eating patternEstablishes a regular eating pattern– Evaluates and changes beliefs about Evaluates and changes beliefs about

shape and weightshape and weight– Prevents relapsePrevents relapse

Female Athlete TriadFemale Athlete Triad

Three ComponentsThree Components

Eating disorderEating disorder Lack of menstrual periodsLack of menstrual periods OsteoporosisOsteoporosis

– Bones like 60-year-oldBones like 60-year-old– Caused by low estrogenCaused by low estrogen– Often irreversibleOften irreversible– Early warning: stress fracturesEarly warning: stress fractures

Also meet criteria for EDNOSAlso meet criteria for EDNOS

Female Athlete TriadFemale Athlete Triad Female athletes Female athletes

participating in participating in appearance-based appearance-based and endurance and endurance sportssports

Seen in 15% Seen in 15% swimmers, 62% swimmers, 62% gymnasts, and 32% gymnasts, and 32% of all other sportof all other sport

Female Athlete TriadFemale Athlete Triad

Performance thinness: the Performance thinness: the commonly held belief that achieving commonly held belief that achieving a lower weight and percentage of a lower weight and percentage of body fat will enhance performancebody fat will enhance performance

Appearance thinness: trend to Appearance thinness: trend to reward thinner athletes in reward thinner athletes in adjudicated sports such as adjudicated sports such as gymnastics and figure skating gymnastics and figure skating

Treatment for Female Treatment for Female Athlete TriadAthlete Triad Reduce preoccupation with food, Reduce preoccupation with food,

weight, and body fatweight, and body fat Increase meals and snacks Increase meals and snacks

graduallygradually Rebuild body to healthy weightRebuild body to healthy weight Establish regular mensesEstablish regular menses Decrease training Decrease training

Binge-Eating Disorder Binge-Eating Disorder (Compulsive (Compulsive Overeating)Overeating)

Complex and serious eating disorderComplex and serious eating disorder Occurs in ~30% -50% of subjects in Occurs in ~30% -50% of subjects in

weight control programs (40% are males)weight control programs (40% are males) More common with obese individuals More common with obese individuals

with history of restrictive dietingwith history of restrictive dieting ~50% exhibit clinical depression~50% exhibit clinical depression Not preoccupied with body shapeNot preoccupied with body shape Onset adolescence or early 20sOnset adolescence or early 20s

Binge Eating Disorder Binge Eating Disorder Diagnostic Criteria Diagnostic Criteria (APA)(APA) Recurrent episodes of Recurrent episodes of

binge eating in the binge eating in the absence of the regular absence of the regular use of inappropriate use of inappropriate compensatory behaviors compensatory behaviors characteristic of BNcharacteristic of BN

At least 2x week over 6 At least 2x week over 6 month periodmonth period

Distress, disgust, guilt, Distress, disgust, guilt, depressiondepression

Binge-Eating Disorder Binge-Eating Disorder (Compulsive (Compulsive Overeating)Overeating) Eat more rapidly than usualEat more rapidly than usual Eat until uncomfortableEat until uncomfortable Eat when not hungryEat when not hungry Cannot control bingesCannot control binges Embarrassed, guilty after bingeEmbarrassed, guilty after binge

Binge Eating ProcessBinge Eating Process

PreconditionPrecondition Trigger phaseTrigger phase Maintenance phaseMaintenance phase Ending phaseEnding phase Post-binge phase Post-binge phase

(consequences)(consequences)

Characteristics of a Characteristics of a Binge-EaterBinge-Eater Consider self as hungrier than normalConsider self as hungrier than normal Isolate self to eat large quantitiesIsolate self to eat large quantities Triggered by stress, depression, Triggered by stress, depression,

anxiety, loneliness, anger, frustrationanxiety, loneliness, anger, frustration Usually binge on “junk” foodsUsually binge on “junk” foods Eat without regards to biological needEat without regards to biological need Food is used to reduce stress, provide Food is used to reduce stress, provide

feeling of power and well-beingfeeling of power and well-being

Treatment for Binge-Treatment for Binge-EatingEating

Learn to eat in Learn to eat in response to response to hungerhunger

Learn to eat in Learn to eat in moderationmoderation

Avoid restrictive Avoid restrictive diets which can diets which can intensify intensify problemsproblems

Increase activityIncrease activity

Treatment for Binge-Treatment for Binge-EatingEating

Increase self-acceptance and Increase self-acceptance and improved body imageimproved body image

Address hidden emotionsAddress hidden emotions Overeaters AnonymousOvereaters Anonymous AntidepressantsAntidepressants

BaryophobiaBaryophobia

““The fear of becoming heavy”The fear of becoming heavy” Children are given a low-fat, restricted Children are given a low-fat, restricted

diet in hopes to ward off obesity or diet in hopes to ward off obesity or heart diseaseheart disease

Detrimental to children; affect growth Detrimental to children; affect growth and developmentand development

Self-imposed restrictive diets by young Self-imposed restrictive diets by young adults to avoid obesityadults to avoid obesity

Lack of appropriate nutrition Lack of appropriate nutrition information information

Treatment for Treatment for BaryophobiaBaryophobia Nutrition educationNutrition education Nutrition required for proper Nutrition required for proper

growthgrowth Appropriateness of sweets and Appropriateness of sweets and

fats in the dietfats in the diet

Childhood Eating Childhood Eating DisordersDisorders DSM criteria not appropriate in DSM criteria not appropriate in

young childrenyoung children Cases of AN reported in children as Cases of AN reported in children as

young as 8 years oldyoung as 8 years old BN rare in childhoodBN rare in childhood C/o nausea, abdominal pain, C/o nausea, abdominal pain,

difficulty swallowing, concerns about difficulty swallowing, concerns about weight, shape, and body fatnessweight, shape, and body fatness

Five Warning Signs of Five Warning Signs of Childhood Eating Childhood Eating DisorderDisorder Decreasing weight goalDecreasing weight goal Increasing criticism of the bodyIncreasing criticism of the body Increasing social isolationIncreasing social isolation Disruption of menstruationDisruption of menstruation Reports of purging in the context Reports of purging in the context

of dietingof dieting

Eating Disorders in Eating Disorders in Dietetics StudentsDietetics Students There is some evidence that the There is some evidence that the

prevalence of disordered eating is prevalence of disordered eating is higher in dietetics students than higher in dietetics students than in other majors, though the in other majors, though the research has been mixedresearch has been mixed

Eating Disorders in UG Eating Disorders in UG College StudentsCollege Students Worobey and Schoenfeld Worobey and Schoenfeld

surveyed 165 undergraduate surveyed 165 undergraduate women (mean age 21.6women (mean age 21.6++4.9 4.9 years and 46 men (22.4years and 46 men (22.4++6.6 6.6 years) from dietetics, exercise years) from dietetics, exercise science, dance, psychology, and science, dance, psychology, and biology/nursing 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 Eating Disorders in UG College Students College Students Nursing/biology majors had Nursing/biology majors had

significantly higher BMI and significantly higher BMI and weightweight

Dietetics students scored highest Dietetics students scored highest on Cognitive concerns and on Cognitive concerns and binge/purge behaviorbinge/purge behavior


Eating Disorders in Eating Disorders in College StudentsCollege Students Dietetics and dance majors Dietetics and dance majors

scored highest on Life scored highest on Life InterferenceInterference

Dance students scored highest on Dance students scored highest on Excessive ExerciseExcessive Exercise


Eating Disorders in Eating Disorders in College StudentsCollege Students Fredenberg et al surveyed 5 Fredenberg et al surveyed 5

groups of students in DPD groups of students in DPD dietetics, CP dietetics, non-food dietetics, CP dietetics, non-food home economics curricula, home economics curricula, college basketball or volleyball college basketball or volleyball programs, and sororitiesprograms, 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 Eating Disorders in College StudentsCollege Students

Fredenberg and colleagues found no Fredenberg and colleagues found no significant differences among the groups of significant differences among the groups of college women surveyed in EAT scores (Eating college women surveyed in EAT scores (Eating Attitude Test.)Attitude Test.)

However, 17.7% of DPD students had EAT However, 17.7% of DPD students had EAT scores symptomatic of eating disorders scores symptomatic of eating disorders compared with 3.3% and 2.9%, respectively compared with 3.3% and 2.9%, respectively for CP and home economics students (NS)for CP and home economics students (NS)

This was lower than in a previous study (24%) This was lower than in a previous study (24%) (Drake et al, JADA, 1989)(Drake et al, JADA, 1989)


PrognosisPrognosis

Mortality has declined for AN from 10% Mortality has declined for AN from 10% to 2%.to 2%.

20% to 30% will have a lifelong struggle 20% to 30% will have a lifelong struggle with foodwith food

Bulimics may need long-term counseling Bulimics may need long-term counseling to correct underlying philosophies and to correct underlying philosophies and beliefs.beliefs.

Family counseling is useful for both AN Family counseling is useful for both AN and bulimia.and bulimia.

High relapse rate after treatmentHigh relapse rate after treatment

Topics for Nutrition Topics for Nutrition EducationEducation

Impact of malnutrition on growth and Impact of malnutrition on growth and developmentdevelopment

Impact of malnutrition on behaviorImpact of malnutrition on behavior Set-point theorySet-point theory Metabolic adaptation to dietingMetabolic adaptation to dieting Restrained eating and disinhibitionRestrained eating and disinhibition Causes of bingeing and purgingCauses of bingeing and purging What does “weight gain” mean?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 Topics for Nutrition Education —cont’dEducation —cont’d

Impact of exercise on caloric expenditureImpact of exercise on caloric expenditure Ineffectiveness of vomiting, laxatives, and Ineffectiveness of vomiting, laxatives, and

diuretics in long-term weight controldiuretics in long-term weight control Portion controlPortion control Food exchange systemFood exchange system Social dining and holiday diningSocial dining and holiday dining Food Guide PyramidFood Guide Pyramid Hunger and satiety cuesHunger and satiety cues Interpreting food labelsInterpreting food labels Nutrition misinformationNutrition 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 ThinDying To Be Thin

Normal to be concerned about diet, Normal to be concerned about diet, health, and body weighthealth, and body weight

Weight normally fluctuates Weight normally fluctuates Treat physical and emotional Treat physical and emotional

problems earlyproblems early Discourage restrictive dietsDiscourage restrictive diets Correct misconception about foodsCorrect misconception about foods Thin is not necessary betterThin is not necessary better

SummarySummary

Nutritional intervention supports Nutritional intervention supports psychologic strategypsychologic strategy

MNT in Eating Disorders. The Ideal Body Image Media promotion Media promotion Social acceptance...

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