Nutrition Therapy for Clients with Disordered Eating

Nutrition Therapy for Clients with Nutrition Therapy for Clients with Disordered EatingDisordered Eating

By: Megan Holt, MPH, RDBy: Megan Holt, MPH, RD

REVIEW OF ED CRITERIA for AN (DSM-IV)REVIEW OF ED CRITERIA for AN (DSM-IV)

Refusal to maintain body weight at or above a minimally normal weight Refusal to maintain body weight at or above a minimally normal weight for age and height (or failure to make expected weight gain during period for age and height (or failure to make expected weight gain during period of growth)of growth)

Intense fear of gaining weight or becoming fat, even though underweight.Intense fear of gaining weight or becoming fat, even though underweight.

Disturbance in the way in which one's body weight or shape is Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.or denial of the seriousness of the current low body weight.

In postmenarchal females, amenorrhea ie, the absence of at least three In postmenarchal females, amenorrhea ie, the absence of at least three consecutive cycles. (A woman is considered to have amenorrhea if her consecutive cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone administration.) periods occur only following hormone administration.)

Specify type:Specify type: Restricting Type:Restricting Type: During the current episode of AN, the person has During the current episode of AN, the person has

not regularly engaged in binge-eating or purging behavior not regularly engaged in binge-eating or purging behavior Binge-Eating/Purging Type:Binge-Eating/Purging Type: During the current episode of AN, the During the current episode of AN, the

person has regularly engaged in binge-eating or purging behaviorperson has regularly engaged in binge-eating or purging behavior

REVIEW OF ED CRITERIA for BN (DSM-IV)REVIEW OF ED CRITERIA for BN (DSM-IV)

Recurrent episodes of binge eating characterized by both of the following:(1) Recurrent episodes of binge eating characterized by both of the following:(1) Eating, in a discrete period of time (eg, within any 2-hour period), an amount Eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is larger than most would eat during a similar period of time and of food that is larger than most would eat during a similar period of time and under similar circumstances.(2) A sense of lack of control over eating during under similar circumstances.(2) A sense of lack of control over eating during the episode the episode

Recurrent inappropriate compensatory behavior in order to prevent weight Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas or other medications, fasting or excessive exercise. or other medications, fasting or excessive exercise.

The binge eating and compensatory behaviors both occur, on average, at The binge eating and compensatory behaviors both occur, on average, at least twice/week for 3 months. least twice/week for 3 months.

Self-evaluation is unduly influenced by body shape and weight. Self-evaluation is unduly influenced by body shape and weight. The disturbance does not occur exclusively during episodes of AN.The disturbance does not occur exclusively during episodes of AN. Specify type:Specify type:

Purging typePurging type: During the current episode of BN, the person has regularly : During the current episode of BN, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas. enemas.

Nonpurging typeNonpurging type: During the current episode of BN, the person has used : During the current episode of BN, the person has used inappropriate compensatory behaviors, such as fasting or excessive exercise, inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas. laxatives, diuretics or enemas.

REVIEW OF ED CRITERIA for ED-NOS (DSM-IV)REVIEW OF ED CRITERIA for ED-NOS (DSM-IV)

For females, all AN criteria are met except that the individual has regular For females, all AN criteria are met except that the individual has regular menses. menses.

All AN criteria are met except that, despite significant weight loss the All AN criteria are met except that, despite significant weight loss the current weight is in the normal range. current weight is in the normal range.

All BN criteria are met except that the binge eating and inappropriate All BN criteria are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a compensatory mechanisms occur at a frequency of less than twice a week or for duration of less than 3 months. week or for duration of less than 3 months.

The regular use of inappropriate compensatory behavior by an individual The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (eg, self-of normal body weight after eating small amounts of food (eg, self-induced vomiting after the consumption of two cookies). induced vomiting after the consumption of two cookies).

Repeatedly chewing and spitting out, but not swallowing, large amounts Repeatedly chewing and spitting out, but not swallowing, large amounts of food. of food.

Binge-eating disorder (falls under DSM-IV for now): recurrent episodes of Binge-eating disorder (falls under DSM-IV for now): recurrent episodes of binge eating in the absence of inappropriate compensatory behaviors binge eating in the absence of inappropriate compensatory behaviors characteristic of BN.characteristic of BN.

AN: PathophysiologyAN: Pathophysiology

Depleted fat stores; muscle Depleted fat stores; muscle wasting wasting

Amenorrhea Amenorrhea Cheilosis Cheilosis Postural hypotension; dehydration Postural hypotension; dehydration

or edema or edema Sleep disturbances Sleep disturbances Low body temperature/cold Low body temperature/cold

intolerance intolerance Lower metabolism: low thyroid Lower metabolism: low thyroid

hormone hormone

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

Iron deficiency anemia Iron deficiency anemia Increased infections Increased infections Dry skin, hair and hair lossDry skin, hair and hair loss Yellow skin due to Yellow skin due to

hypercarotenemia hypercarotenemia Lanugo: fine body hairsLanugo: fine body hairs


Osteopenia/OsteoporosisOsteopenia/Osteoporosis Reduced bone mineral density Reduced bone mineral density May result in vertebral May result in vertebral

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

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

Affects males and females Affects males and females

T-ScoreT-Score


GIGI Bloating, abnormal Bloating, abnormal fullness fullness

after eating after eating Constipation Constipation DiarrheaDiarrhea Digestive enzymes low (i.e. Digestive enzymes low (i.e.

lactase)lactase)


Cardiovascular Cardiovascular Decreased heart rate <60 bpm Decreased heart rate <60 bpm

Fatigue, fainting Fatigue, fainting Decreased blood pressure <70 mm/Hg systolic; orthostatic Decreased blood pressure <70 mm/Hg systolic; orthostatic

hypotension hypotension Reduction in heart mass Reduction in heart mass Mitral valve prolapse related to hypovolemia or Mitral valve prolapse related to hypovolemia or

cardiomyopathy cardiomyopathy Death from CHF Death from CHF

Electrolyte imbalance → heart failure, death Electrolyte imbalance → heart failure, death Low intake potassium Low intake potassium Loss in vomiting, diuretics Loss in vomiting, diuretics Refeeding syndrome: electrolyte imbalances caused by rapid Refeeding syndrome: electrolyte imbalances caused by rapid

refeedingrefeeding

BN: PathophysiologyBN: Pathophysiology

VomitingVomiting Dehydration Dehydration Alkalosis Alkalosis Hypokalemia (low potassium)Hypokalemia (low potassium) Sore throat, esophagitis, mild hematemesis Sore throat, esophagitis, mild hematemesis Abdominal pain Abdominal pain Subconjunctival hemorrhage Subconjunctival hemorrhage Esophageal tears/ruptures (rare) Esophageal tears/ruptures (rare) Acute gastric dilatation or rupture Acute gastric dilatation or rupture Salivary gland infections Salivary gland infections Cardiac arrhythmias related to electrolyte and acid-base imbalance caused Cardiac arrhythmias related to electrolyte and acid-base imbalance caused

by vomiting, laxative, and diuretic abuse by vomiting, laxative, and diuretic abuse Ipecac may cause irreversible myocardial damage and sudden death Ipecac may cause irreversible myocardial damage and sudden death Menstrual irregularitiesMenstrual irregularities

BN: PathophysiologyBN: Pathophysiology

Laxative AbuseLaxative Abuse Dehydration Dehydration Elevation of serum aldosterone and vasopressin levels Elevation of serum aldosterone and vasopressin levels Rectal bleeding Rectal bleeding Intestinal atony Intestinal atony Abdominal cramps Abdominal cramps

Diuretic AbuseDiuretic Abuse Dehydration Dehydration Hypokalemia Hypokalemia

Role of the dietitian in a treatment team and Role of the dietitian in a treatment team and goals of nutrition therapygoals of nutrition therapy

AN: weight gain/prevention of further loss and correction of AN: weight gain/prevention of further loss and correction of malnutrition induced disorders; normalization of eating patterns and malnutrition induced disorders; normalization of eating patterns and behaviors behaviors

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

Increase food intake to raise the BMR (basal metabolic rate)Increase food intake to raise the BMR (basal metabolic rate) Some weight restoration and treatment of malnutrition may make Some weight restoration and treatment of malnutrition may make

psychotherapy more effective due to improved cognitionpsychotherapy more effective due to improved cognition(Nutritional intervention must support psychological strategy) (Nutritional intervention must support psychological strategy)

Role of the dietitian in a treatment team and Role of the dietitian in a treatment team and goals of nutrition therapygoals of nutrition therapy

Often require hospitalization to begin refeeding Often require hospitalization to begin refeeding Some require enteral feedings, but most can be Some require enteral feedings, but most can be

rehabbed with oral feedings rehabbed with oral feedings Goal is increase in energy intake with weight gain Goal is increase in energy intake with weight gain Energy intake must be increased gradually while Energy intake must be increased gradually while

minimizing caloric expenditure minimizing caloric expenditure Hospitalized patients: goal is 2-3 lb/week Hospitalized patients: goal is 2-3 lb/week Outpatients: 1 pound/week Outpatients: 1 pound/week

(APA Practice Guidelines for the Treatment (APA Practice Guidelines for the Treatment of Eating Disorders, January, 2006)of Eating Disorders, January, 2006)

Part I: Nutrition AssessmentPart I: Nutrition Assessment

Calories compared with DRI Calories compared with DRI (dietary reference intake) (dietary reference intake)

Evaluate macronutrient mix Evaluate macronutrient mix (carbohydrate, protein, fat) (carbohydrate, protein, fat)

Evaluate micronutrient intake Evaluate micronutrient intake compared with DRI compared with DRI

Estimate fluids and compare Estimate fluids and compare with needs with needs

Evaluate alcohol, caffeine, Evaluate alcohol, caffeine, drugs, dietary supplements drugs, dietary supplements

((www.usda.gov) for DRI) for DRI’’ss (The Eating Disorders Clinical Pocket (The Eating Disorders Clinical Pocket Guide Guide by Jessica Setnickby Jessica Setnick))

Pertinent medical historyPertinent medical history Ex: diabetes, hypertension, high cholesterol, kidney Ex: diabetes, hypertension, high cholesterol, kidney

disease, etc .disease, etc .

Pertinent family history (parents, siblings)Pertinent family history (parents, siblings) ED, heart disease, etc.ED, heart disease, etc. Eating habits, weight and stature, relationship with foodEating habits, weight and stature, relationship with food

Nutrition AssessmentNutrition Assessment


HeightHeight (verify- particularly in adolescents)(verify- particularly in adolescents)ED historyED history bingeing, purging, relationship bingeing, purging, relationship with food/shape/exercisewith food/shape/exerciseWeight historyWeight history lifetime highest, lifetime highest,

lowest during EDlowest during ED Conditions around extreme weightsConditions around extreme weights


CurrentCurrent ED behaviors ED behaviors How often does the client How often does the client

weight at home?weight at home? Binge Binge Purge (33-75% kcals still absorbed) Purge (33-75% kcals still absorbed) Fluid intake Fluid intake

(caffeinated and decaf)(caffeinated and decaf)

Food RitualsFood Rituals Eating foods in certain orders Eating foods in certain orders

(ex: veggies first)(ex: veggies first) Excessive chewing (or Excessive chewing (or

counting chews)counting chews) Rearranging food on a plate Rearranging food on a plate

(ex: 8 peas)(ex: 8 peas) Eating finger foods with fork Eating finger foods with fork

and knifeand knife Wiping fork after each useWiping fork after each use Not allowing foods to touchNot allowing foods to touch One food per meal (ex: One food per meal (ex:

blueberries) blueberries)


Medical changes related to EDMedical changes related to ED Constipation, diarrhea, Constipation, diarrhea,

lactose intolerance, dental lactose intolerance, dental problems, bone health?problems, bone health?

Last period and when Last period and when

stopped if amenorrhea stopped if amenorrhea

Medications and Medications and

supplements supplements BCP, calcium, MVI, herbal BCP, calcium, MVI, herbal

supplements, miralax, etc.supplements, miralax, etc.

Nutrition Nutrition AssessmentAssessment

Methods to suppress hungerMethods to suppress hunger Gum, diet soda/products, Gum, diet soda/products,

coffee, condimentscoffee, condimentsVegetarianismVegetarianism How long? Does this coincide with start of ED?How long? Does this coincide with start of ED? Honoring vegetarianism and level of care (later)Honoring vegetarianism and level of care (later)Food Allergies?Food Allergies? GlutenGluten LactoseLactose Other?Other?


Blood values and nutritional significance:Blood values and nutritional significance: AlbuminAlbumin Total proteinTotal protein Blood Urea Nitrogen (BUN)Blood Urea Nitrogen (BUN) Creatinine Creatinine MangnesiumMangnesium PhosphorusPhosphorus SodiumSodium PotassiumPotassium Hemoglobin/HematocritHemoglobin/Hematocrit EstradiolEstradiol

Frequency of blood draws?Frequency of blood draws?

Food JournalFood Journal

(see sample food journal)(see sample food journal) Keeps for three days prior to visitKeeps for three days prior to visit Continues until eating and B/P stableContinues until eating and B/P stable More useful with clients that are newMore useful with clients that are new

to treatment/little knowledge of nutritionto treatment/little knowledge of nutrition No judgment!!!!No judgment!!!!

Plan of CarePlan of Care

MVI/Supplement recommendations MVI/Supplement recommendations

Calcium: Needs 1200mg/dayCalcium: Needs 1200mg/day Supplementation: 500-1000mg/day Supplementation: 500-1000mg/day Calcium Carbonate most commonCalcium Carbonate most common MVI with Vitamin DMVI with Vitamin D

Plan of CarePlan of Care

MVI/Supplement recommendationsMVI/Supplement recommendations Iron: Needs 15-18mg/dayIron: Needs 15-18mg/day Supplementation: 50-60mg twice dailySupplementation: 50-60mg twice daily Frequent complaints: constipation, nauseaFrequent complaints: constipation, nausea Vitamin C, meat protein (heme iron) increases absorptionVitamin C, meat protein (heme iron) increases absorption Caffeine and phytates inhibit absorptionCaffeine and phytates inhibit absorption Other supplements per MD (ex: B12)Other supplements per MD (ex: B12)

WhatWhat’’s wrong with this picture?s wrong with this picture?

Break up into groupsBreak up into groups Look at the 3 different sample menusLook at the 3 different sample menus How would you make this day more How would you make this day more

balanced? balanced?

Mindful Eating!Mindful Eating!

Synonymous words:Synonymous words: Intuitive eatingIntuitive eating Conscious eatingConscious eating Thoughtful eatingThoughtful eating

Characteristics of:Characteristics of: Being connected and presentBeing connected and present AwarenessAwareness Respecting body Respecting body Being in-tune with physical hunger and fullness cuesBeing in-tune with physical hunger and fullness cues Being non-judgmentalBeing non-judgmental

Mindful Eating PracticeMindful Eating Practice

Take your time (slow down!)Take your time (slow down!) Use timerUse timer Put utensils downPut utensils down Push plate awayPush plate away

Use your 4 sensesUse your 4 senses Limit distractionsLimit distractions Set environment to be calmSet environment to be calm Meditation or prayerMeditation or prayer

Body CuesBody Cues

How to distinguish between emotional and How to distinguish between emotional and physical hunger and fullnessphysical hunger and fullness Use Hunger Scale (on food journal)Use Hunger Scale (on food journal) Use inquiryUse inquiry

When did I eat last?When did I eat last? Did I have a balanced meal or snack?Did I have a balanced meal or snack? Was I fully satisfied when I finished?Was I fully satisfied when I finished? Are there any particular emotions present?Are there any particular emotions present?

Part II:Meal PlanningPart II:Meal Planning

Estimating needs for ANEstimating needs for AN 30-40 kcals/kg body weight (1200-1600kcals 30-40 kcals/kg body weight (1200-1600kcals

daily to start)daily to start) 200-300 kcal increases 2 times weekly200-300 kcal increases 2 times weekly 70-100 kcals/kg ultimately, with weight 70-100 kcals/kg ultimately, with weight

restoration goal of 1-2 lbs weekly (outpatient) or restoration goal of 1-2 lbs weekly (outpatient) or 2-3 lbs weekly (inpatient)2-3 lbs weekly (inpatient)

Fluids 30-40ml/kg body weight or 64ozFluids 30-40ml/kg body weight or 64oz(APA Practice Guidelines for (APA Practice Guidelines for

Treatment of EDTreatment of ED’’s 2006)s 2006)

Determining Goal Weight Determining Goal Weight

CDC Growth Charts (adolescents) CDC Growth Charts (adolescents)

http://www.cdc.gov/GROWTHCHARTS/http://www.cdc.gov/GROWTHCHARTS/ Hamwi Equation:Hamwi Equation:

Hamwi Formula for MenHamwi Formula for Men

106 lbs for first 5 feet + 6 lbs for each inch over 5 feet (med. frame)106 lbs for first 5 feet + 6 lbs for each inch over 5 feet (med. frame)

Small frame (- 10%), Large frame (+ 10%)Small frame (- 10%), Large frame (+ 10%)Hamwi Formula for WomenHamwi Formula for Women100 lbs for first 5 feet + 5 lbs for each inch over 5 feet (med. frame)100 lbs for first 5 feet + 5 lbs for each inch over 5 feet (med. frame)

Small frame (- 10%), Large frame (+ 10%)Small frame (- 10%), Large frame (+ 10%)

Past History/ menstruationPast History/ menstruation Genetics: parents build and eating habitsGenetics: parents build and eating habits

Meal Planning-ANMeal Planning-AN

3 meals and 3 snacks3 meals and 3 snacks Liquids and use of supplementsLiquids and use of supplements May need reglan due to delayed May need reglan due to delayed

gastric emptying for comfortgastric emptying for comfort

Meal Planning-BNMeal Planning-BN

Estimating needs for BN:Estimating needs for BN: 25-35 kcals/kg body weight, depending25-35 kcals/kg body weight, depending on current intake and exerciseon current intake and exercise Primary goal: interuption of B/PPrimary goal: interuption of B/P Initial prescription typically around 1500 kcalsInitial prescription typically around 1500 kcals Adjust for weight maintenance, and avoid weightAdjust for weight maintenance, and avoid weight reduction diet until eating is stablereduction diet until eating is stable Expect impairment of hunger/satiety signals Expect impairment of hunger/satiety signals

Ex: 5 ft 4 in., 128 lbs (58kg)=1450-2030 kcalsEx: 5 ft 4 in., 128 lbs (58kg)=1450-2030 kcals

(APA Practice Guidelines for Treatment of ED(APA Practice Guidelines for Treatment of ED’’s 2006)s 2006)

Meal Planning: MacronutrientsMeal Planning: Macronutrients

50-55% carbohydrate (25-30g fiber)50-55% carbohydrate (25-30g fiber) 15-20% protein (0.8-1.0g/kg body wt)15-20% protein (0.8-1.0g/kg body wt) 25-30% fat (less than 10% total kcals 25-30% fat (less than 10% total kcals

from saturated/trans fatty acids)from saturated/trans fatty acids)

www.mypyramid.gov

www.eatright.org

www.americanheart.org

Exchange SystemExchange System

Exchanges versus CaloriesExchanges versus Calories More flexible than Calorie countingMore flexible than Calorie counting Emphasizes balance and moderationEmphasizes balance and moderation Incorporates evidence based suggestions Incorporates evidence based suggestions for macronutrients from ADA and AHAfor macronutrients from ADA and AHA

www.diabetes.org

Exchange SystemExchange System Grains/Starches 6-11Grains/Starches 6-11 Milk/Dairy 3-4Milk/Dairy 3-4 Fruit 2-4Fruit 2-4 Vegetables 3-5Vegetables 3-5 Protein/Meat 4-6Protein/Meat 4-6 Fats 4-6Fats 4-6 Above guidelines mayAbove guidelines may

not be adequate for weightnot be adequate for weight

restoration!!restoration!! See sample exchange See sample exchange

listslists

Exchange SystemExchange System

Starches/Grains:Starches/Grains: 15g 15g Carb, 3g protein, 0-1g Carb, 3g protein, 0-1g fat, fat, 80 kcals80 kcals

Dairy/Milk:Dairy/Milk: 12g Carb, 8g 12g Carb, 8g protein, 0-3g fat, 100 protein, 0-3g fat, 100 kcalskcals

Fruit:Fruit: 15g Carb, 0g 15g Carb, 0g fat/protein, 60 kcalsfat/protein, 60 kcals

Veggies:Veggies: 5g Carb, 0-2g 5g Carb, 0-2g protein, 0g fat, 25 kcalsprotein, 0g fat, 25 kcals

Meat/Protein (lean):Meat/Protein (lean): 0 0 Carb, 7g protein, 0-3g Carb, 7g protein, 0-3g fat, 45 kcals fat, 45 kcals

Fats:Fats: 0g Carb, 0g 0g Carb, 0g protein, protein, 5g fat, 45 kcals 5g fat, 45 kcals

Measuring foodMeasuring food Discouraged!!Discouraged!!

Exceptions: Exceptions: First time with a new food and First time with a new food and

very distorted view of portionsvery distorted view of portions New to treatment/meal New to treatment/meal

planningplanning Assure client that exchanges Assure client that exchanges

consider balance and quality of consider balance and quality of dietdiet

GOAL: GOAL: NORMALIZE NORMALIZE EATINGEATING

NO!!!!NO!!!!

Portion DistortionPortion Distortion Woman's fist or baseball -Woman's fist or baseball - a serving of vegetables or fruit a serving of vegetables or fruit A rounded handful -A rounded handful - about one half cup cooked or raw veggies or about one half cup cooked or raw veggies or

cut fruit, a piece of fruit, or ½ cup of cooked rice or pasta - this is a cut fruit, a piece of fruit, or ½ cup of cooked rice or pasta - this is a good measure for a snack serving, such as chips or pretzelsgood measure for a snack serving, such as chips or pretzels

Deck of cards -Deck of cards - a serving of meat, fish or poultry or the palm of a serving of meat, fish or poultry or the palm of your hand (don't count your fingers!) – ex: one chicken breast, ¼ your hand (don't count your fingers!) – ex: one chicken breast, ¼ pound hamburger pattypound hamburger patty

Golf ball or large egg -Golf ball or large egg - one quarter cup of dried fruit or nuts one quarter cup of dried fruit or nuts Tennis ball -Tennis ball - about one half cup of ice cream about one half cup of ice cream Computer mouse -Computer mouse - about the size of a small baked potato about the size of a small baked potato Compact disc -Compact disc - about the size of one serving of pancake or small about the size of one serving of pancake or small

wafflewaffle Thumb tip -Thumb tip - about one teaspoon of peanut butter about one teaspoon of peanut butter Six dice -Six dice - a serving of cheese a serving of cheese Check book -Check book - a serving of fish (approximately 3 oz.) a serving of fish (approximately 3 oz.)

No Weighing!No Weighing! Ask client to refrain from Ask client to refrain from

weighing at homeweighing at home Weight 1-2/week with Weight 1-2/week with

practitioner, less if stable practitioner, less if stable

(ex: normal wt BN)(ex: normal wt BN) Blind weight: challenge client Blind weight: challenge client

to focus on other measures of to focus on other measures of health and remind them of past health and remind them of past experiences with weighing (i.e. experiences with weighing (i.e. triggers ED behaviors)triggers ED behaviors)

WhatWhat’’s the point?s the point?

Where does exercise fit in?Where does exercise fit in? Restrict with AN until eating Restrict with AN until eating

improves and client reaches improves and client reaches 90% ideal body weight90% ideal body weight

With normal weight BN, wait With normal weight BN, wait for improvement in B/Pfor improvement in B/P

Monitor client for Monitor client for compensatory exercise compensatory exercise (trading vomiting for exercise)(trading vomiting for exercise)

Explain rationale and caution Explain rationale and caution against exercising on purging against exercising on purging days due to electrolyte days due to electrolyte disturbancedisturbance

Start with mindful activity: yogaStart with mindful activity: yoga Weight bearing exercise and Weight bearing exercise and

osteoporosisosteoporosis

Female Athlete TriadFemale Athlete Triad

Characterized by disordered eating, Characterized by disordered eating, amenorrhea, and osteoporosis. amenorrhea, and osteoporosis.

50% of these athletes may have 50% of these athletes may have bone mineral densities that are 1 bone mineral densities that are 1 standard deviation below normal for standard deviation below normal for age.age.

Requires exercise restriction. Requires exercise restriction. Coaches must de-emphasize weight Coaches must de-emphasize weight

and are cautioned to stop weighing and are cautioned to stop weighing athletes continually/focus on athletes continually/focus on strength and mental conditioning. strength and mental conditioning.

Some highly motivated and Some highly motivated and competitive athletes may correct competitive athletes may correct their eating disorder if they are told their eating disorder if they are told that malnutrition will affect their that malnutrition will affect their performance.performance.

Meal Planning Using Meal Planning Using Exchange SystemExchange System

Case StudyCase Study see assessment form, see assessment form,

sample meal plan sample meal plan

and sample menusand sample menus

Vegetarianism and ConsiderationsVegetarianism and Considerations

Duration of vegetarianism Duration of vegetarianism

and motivationand motivation Minor/AdultMinor/Adult Lacto-ovo? Vegan? Lacto-ovo? Vegan? Level of careLevel of care Able to meet needs Able to meet needs

through other foods?through other foods?

Food AllergiesFood Allergies Often used in service of ED and Often used in service of ED and

learned in higher LOClearned in higher LOC Verify if feasible (parents, allergist) Verify if feasible (parents, allergist)

and if accommodating allergy will and if accommodating allergy will limit progresslimit progress

Ex: gluten, nuts, mayoEx: gluten, nuts, mayo

Offer alternativesOffer alternatives Ex: for lactose intolerance offer lactaid Ex: for lactose intolerance offer lactaid

tablet, lactaid milk, soy milk/yogurttablet, lactaid milk, soy milk/yogurt

Play detective! If it sounds fishy, it Play detective! If it sounds fishy, it probably is!probably is!

Ex: pt states gluten intolerant, but eats Ex: pt states gluten intolerant, but eats oatmeal/bran muffinsoatmeal/bran muffins

GOAL: help to normalize eating and GOAL: help to normalize eating and making peace with fear foods!making peace with fear foods!

HAES Model: Health at Every SizeHAES Model: Health at Every Size

Health enhancement—attention to emotional, physical and spiritual well-Health enhancement—attention to emotional, physical and spiritual well-being without focus on weight loss or achieving a specific being without focus on weight loss or achieving a specific ““ideal weightideal weight””

Size and self-acceptance—respect and appreciation for the wonderful Size and self-acceptance—respect and appreciation for the wonderful diversity of body shapes and sizes (including one's own!), rather than the diversity of body shapes and sizes (including one's own!), rather than the pursuit of an idealized weight or shape pursuit of an idealized weight or shape

The pleasure of eating well—eating based on internal cues of hunger, The pleasure of eating well—eating based on internal cues of hunger, satiety, and appetite, rather than on external food plans or diets satiety, and appetite, rather than on external food plans or diets

The joy of movement—encouraging all physical activities for the associated The joy of movement—encouraging all physical activities for the associated pleasure and health benefits, rather than following a specific routine of pleasure and health benefits, rather than following a specific routine of regimented exercise for the primary purpose of weight loss regimented exercise for the primary purpose of weight loss

An end to weight bias—recognition that body shape, size and/or weight are An end to weight bias—recognition that body shape, size and/or weight are not evidence of any particular way of eating, level of physical activity, not evidence of any particular way of eating, level of physical activity, personality, psychological issue or moral characterpersonality, psychological issue or moral character

Confirmation that there is beauty and worth in EVERYbody Confirmation that there is beauty and worth in EVERYbody

Nutrition Education TopicsNutrition Education Topics Calcium intake and OsteoporosisCalcium intake and Osteoporosis Set Point Theory (KeySet Point Theory (Key’’s Study)s Study) Danger of Fad DietsDanger of Fad Diets Function of Foods: Carbohydrate, Fat, ProteinFunction of Foods: Carbohydrate, Fat, Protein Changes to Expect with Refeeding (constipation, bloating, fullness)Changes to Expect with Refeeding (constipation, bloating, fullness) Moderate vs. Compulsive/Compensatory ExerciseModerate vs. Compulsive/Compensatory Exercise HAES model (Health at Every Size)HAES model (Health at Every Size) Laxative AbuseLaxative Abuse Consequences of Malnutrition Consequences of Malnutrition

(Client ready handouts can be found in (Client ready handouts can be found in Winning the War WithinWinning the War Within))

Questions?Questions?

Thank you!Thank you!

Nutrition Therapy for Clients with Disordered Eating

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Transcript of Nutrition Therapy for Clients with Disordered Eating