Whole Person Treatment of Eating Disorders

Whole Person Treatment of
Eating Disorders
Gregory L. Jantz, PhD, CEDS
IAEDP‐Certified Eating Disorder Specialist
Approved Supervisor

Anorexia Nervosa‐Historical Perspective
14th Century – Catherine of Siena practiced an extreme form of
fasting and eventually died of starvation
1868 – Sir William W. Gull names the illness anorexia nervosa –
which means “nervous loss of appetite.”
1870 – Charles Lasègue, without the knowledge of Gull’s work,
described the condition as “L’anorexic hysterique.”
1947 – John Berkman: “Among adolescents the cause for the
psychic upset can often be traced to a parent.”
1973 – Hilde Bruch’s idea that an unhealthy pursuit of thinness
was caused by psychological or cultural factors became part of
the common consciousness.
Source: James Greenblatt, MD; Dietary Fats in the Prevention and Treatment of Eating Disorders, presented to IAEDP March 22,
2013; used by permission

Not Otherwise Specified?
Under DSM‐IV‐TR, the majority of
patients were given a diagnosis
without specified criteria.

Changes to Eating Disorder Criteria between DSM‐IV‐TR & DSM‐V:
Anorexia Nervosa
•The core diagnostic criteria for anorexia nervosa are conceptually unchanged
from DSM‐IV with one exception: the requirement for amenorrhea has been
eliminated. In DSM‐IV, this requirement was waived in a number of situations
(e.g., for males, for females taking contraceptives). In addition, the clinical
characteristics and course of females meeting all DSM‐IV criteria for anorexia
nervosa except amenorrhea closely resemble those of females meeting all DSM‐
IV criteria. As in DSM‐IV, individuals with this disorder are required by Criterion
A to be at a significantly low body weight for their developmental stage. The
wording of the criterion has been changed for clarity, and guidance regarding
how to judge whether an individual is at or below a significantly low weight is
now provided in the text. In DSM‐5, Criterion B is expanded to include not only
overtly expressed fear of weight gain but also persistent behavior that interferes
with weight gain.
Source: Highlights of Changes from DSM‐IV‐TR to DSM‐5 (2013) from the American Psychiatric
Association, page 12.

Bulimia Nervosa
•The only change to the DSM‐IV criteria for bulimia nervosa
is a reduction in the required minimum average frequency
of binge eating and inappropriate compensatory behavior
frequency from twice to once weekly. The clinical
characteristics and outcome of individuals meeting this
slightly lower threshold are similar to those meeting the
DSM‐IV criterion.

Binge‐Eating Disorder
•Extensive research followed the promulgation of
preliminary criteria for binge eating disorder in Appendix B
of DSM‐IV, and findings supported the clinical utility and
validity of binge‐eating disorder. The only significant
difference from the preliminary DSM‐IV criteria is that the
minimum average frequency of binge eating required for
diagnosis has been changed from at least twice weekly for 6
months to at least once weekly over the last 3 months,
which is identical to the DSM‐5 frequency criterion for
bulimia nervosa.

Difficulties in Treating Patients with Eating Disorders
Greater than 30% of patients with AN become chronically ill over
10 years
Mortality rates: 10% at 10 years, 20% at 20 years
Highest risk for suicide among all psychiatric illnesses
Highest number of hospital days of any psychiatric illness
No Advances in the Biological Treatment of Anorexia Nervosa
in 50 years.
Source: James Greenblatt, MD; Dietary Fats in the Prevention and Treatment of Eating Disorders, presented to
IAEDP March 22, 2013; used by permission

What is the “Whole‐Person” approach?
•Integration of multiple factors for long‐term
recovery of eating disorders
•Emotional
•Relational
•Intellectual
•Medical/Brain‐science
•Nutritional
•Chemical dependency/Substance Abuse
•Dental
•Spiritual/Faith‐based

Source: James S. Goodwin, MD, Jean M. Goodwin, MD, MHP
JAMA May 11, 1984, Vol. 251, No. 18
The TOMATO Effect:
Rejection of Highly Efficacious Therapies

The TOMATO Effect:
Rejection of Highly Efficacious Therapies
•When an efficacious treatment for a certain disease is ignored
or rejected because it does not “make sense” in light of accepted
theories of disease
•Americans would not eat tomatoes for over 200 years even
though they were eaten since the 16th century in Europe
•In 1820, there was a public tasting that occurred without
consequences
Source: James Greenblatt, MD; Dietary Fats in the Prevention and Treatment
of Eating Disorders, presented to IAEDP March 22, 2013; used by permission

Whole‐Person recovery requires an integrated
treatment team model
A treatment team approach is the recommended model, including
medical personnel (either a physician or a psychiatrist), a
registered dietitian or medical professional who is trained in
nutritional rehabilitation, and a mental health clinician. Dental
professionals may also be part of the team.
(From Key Elements to a Good Treatment Plan by Cris Haltom, Ph.D., June 26, 2006)

When a patient is managed by an inter‐disciplinary team in an
outpatient setting, communication among the professionals is
essential to monitoring the patient’s progress, making
necessary adjustments to the treatment plan, and delineating
the specific roles and tasks of each team member.
American Psychiatric Association – Practice Guidelines for the Treatment of Patients with Eating Disorders, 3rd
Edition, 2006, Executive Summary (a) Coordinating care and collaborating with other clinicians

The authors of a textbook edited by Grilo and Mitchell (2010) describe
therapeutic approaches and reviews supporting evidence on all
aspects of eating disorder treatment, from assessment to nutritional
rehabilitation to managing the chronically ill.  The authors state that
there is no single treatment for patients with eating disorders.
Rather, a diversity of approaches is recommended.
Source:  American Psychiatric Association – Guideline Watch (August 2012): Practice Guidelines for the Treatment
of Patients with Eating Disorders, 3rd Edition (page 2); The Treatment of Eating Disorders: A Clinical Handbook,
edited by Carlos M. Grilo, PhD and James E. Mitchell, MD.

A team that includes professionals with experience in psychiatry and
psychology, internal medicine and nutrition, social work, nursing
and even recreation is needed to provide the full range of therapy
and treatment to help patients develop the skills necessary to gain
control of destructive eating disorder behavior, improve their
support system, increase self‐esteem , and establish a foundation
for long‐term recovery.
Source: A “Continuum of Care” Approach to Eating Disorders by Stuart Koman, Ph.D.;
http://www.waldenbehavioralcare.com/pdfs/ContinuumOfCare.pdf

•Approximately 50% of individuals with an eating disorder
(ED) abuse or are dependent on alcohol or illicit substances
compared with approximately 9% of the general population
Source:  (Holderness et al., 1994; The National Center on Addiction and Substance Abuse
(CASA at Columbia University, 2003)
•Of individuals with a substance use disorder, more than 35%
report some form of an ED (CASA, 2003) compared to lifetime
prevalence estimates of approximately 5% for women in the
United States
(Hudson et al., 2007).
Source:  From the Introduction to Patterns of Comorbidity of Eating Disorders and Substance Use
in Swedish Females, Root et al., 2009); http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2788663.

It is the position of the American Dietetic Association that
nutritional intervention, including nutritional counseling, by a
registered dietitian (RD) is an essential component of the team
treatment of patients with anorexia nervosa, bulimia nervosa,
and other eating disorders during assessment and treatment
across the continuum of care.
Source: Position of the American Dietetic Association: Nutrition Intervention in the Treatment of
Anorexia Nervosa, Bulimia Nervosa, and Other Eating Disorders (J Am Diet Assoc. 2006; 106:20773‐
2082)

Eating disorders arise from a variety of physical,
emotional and social issues all of which need to
be addressed to help prevent and treat these
disorders . . . while eating disorders appear to
focus on body image, food and weight, they are
often related to many other issues.  Referral to
healthcare professionals and encouragement to
seek treatment is critical as early diagnosis and
intervention greatly improve the opportunities
for recovery.
Source:  American Dental Association, Oral Health Topics, Anorexia Nervosa (Eating
Disorders); http://www.ada.org/2582.aspx?currentTab=2

The Poly‐Pharmacy Highway
Photo Source: Walden Behavioral Care

There is no FDA‐approved medication for Anorexia
Nervosa . . .
Source: WebMD August 25, 2011‐ http://www.webmd.com/mental‐health/eating‐disorders/anorexia‐
nervosa/anorexia‐nervosa‐medications
Standard of Care
. . . Yet, the majority of
patients treated are with
psychotropics
Polypharmacy is the norm

Benefits of a Multiple‐Disciplinary Team Approach to
Treatment
Non‐response to SSRI medication in ill AN
subjects could be a consequence of an
inadequate supply of nutrients, which are
essential to normal serotonin synthesis and
function. [These data suggest that a disturbed
serotonin activity may create a vulnerability for
the expression of a cluster of symptoms common
to both AN and BN and that nutritional factors
may affect SSRI response in depression and/or
obsessive‐compulsive disorder.]
Source: Kaye W, Gendall K, Strober M Biol Psychiatry 1998 Nov 1; 44(9):825‐38.

Anorexics with low body weight, low BMI,
and low serum albumin (the main protein in
blood) levels are at increased risk for vitamin
and mineral deficiency.  Vitamin
abnormalities may contribute to cognitive
difficulties such as poor judgment or
memory loss and other psychiatric
conditions.  These deficiencies can often be
corrected with dietary interventions.
Source:  From the University of Maryland Medical Center – “Anorexia
Nervosa”; http://www.umm.edu/altmed/articles/anorexia‐nervosa‐
000012.htm
Treatment

A Medical Mystery?
Eating disorders are characterized by
severe weight loss from self‐
starvation yet signs or symptoms of
vitamin, mineral and fat deficiencies
are rarely studied or integrated into
treatment.
Pellagra?

Incidence of Eating Disorders
A majority of young women diet at
some point in time yet only a small
fraction develop eating disorders.
Why?

Research shows that many
nutrients, such as vitamin B12
and iron, are essential to human
brain function and that
deficiencies in these nutrients
and others can lead to impaired
cognitive function and impaired
memory and concentration.
Treatment

Impaired Cognitive Function
Used by permission of Dr. Daniel Amen

You don’t
see what
I see!
Is This a Struggle for CONTROL?

Treatment
Nutritional deficiencies are also
directly related to:
• impaired emotional functioning,
i.e., irritability;
• apathy;
• withdrawn behavior;
• decreased ability to focus;
• decreased ability to listen;
• decreased ability to process
information;
• and fatigue.

•50% of caloric intake of American children is obtained from
added fat and sugar
•20‐24% of calories for 2‐19 year‐olds come from soft drinks!
•<15% of school children consume recommended servings of
fruit
•<20% of school children consume recommended servings of
vegetables
Source: James Greenblatt, MD; Dietary Fats in the Prevention and Treatment of Eating Disorders, presented to IAEDP March
22, 2013; used by permission
Standard American Diet (SAD)

The Journal of the Academy of Nutrition and Dietetics
published a study where they found that:
•53% of women with eating disorders were vegetarians
•12% of healthy women are vegetarians
Source: Jenny Sangler, August 30, 2012
The majority of women with eating disorders are
vegetarian

Treatment
Decreased food intake, a cyclic pattern of eating,
and weight loss are major manifestations of zinc
deficiency. Patients with eating disorders may
develop zinc deficiencies for the following
reasons:
• lower dietary intake of zinc
• impaired zinc absorption
• vomiting
• diarrhea
• bingeing on low‐zinc foods

Anorexia Nervosa
1. Decreased appetite and
meat avoidance
2. Decreased taste and smell
3. Nausea and bloating during
re‐feeding
4. Insomnia and poor sleep
habits
5. Depression
6. Attention difficulties
Physical Symptoms of AN and Zinc Deficiency
Source: Zinc deficiency and eating disorders. Humphries L, Vivian B, Stuart M, McClain CJ. J Clin Psychiatry 1989
Dec; 50(12):456‐9
Zinc Deficiency
1. Decreased appetite and
meat avoidance
2. Decreased taste and smell
3. Nausea and bloating during
re‐feeding
4. Insomnia and poor sleep
habits
5. Depression
6. Attention difficulties

Recommended nutritional therapies for recovery
•Daily multivitamin
•Essential fatty acids, such as Omega 3’s
•Vitamin C
•Coenzyme Q10
•5‐HTP
•Creatine
•Probiotic supplement (Lactobacillus acidophilus)
•L‐glutamine
•DHEA
•Melatonin
From the University of Maryland Medical Center, accessed 7/8/13

•42 patients (40.% y/0) with dietary intake of Omega 3 < 3 gms/day
•DBPC 1.8 gms EPA .4 gms DDHA) Omega 3 supplements or placebo
BID x 8 weeks
•Celexa 20‐40 mg
•Higher proportion of patients achieved full remission in Omego 3
group versus the placebo group ‐ 44% verses 18%
Source: Gertsik, L, Poland, RE, Bresee, C, Rapaport, MH.
J Clin Psychpharmacol. 2012 Feb;32(1):61:4.
Omega‐3 Fatty Acids – Augmentation of
Antidepressants

AN patients received 1 g EPA/day for 3 months:
43% recovered
57% showed improved symptoms in:
Weight gain
Reversal of growth retardation
Improvement in mood
Improvement in general functioning
Source: Ayton, et al., Prostaglandins, Leukotrienes and Essential Fatty Acids; 2004;71:205‐209
A pilot open case series of Ethyl‐EPA supplementation
in the treatment of anorexia nervosa

Study participants:  81 adolescents or young adults with sub‐
threshold psychosis
Supplementation:  1.2 g omega‐3 fatty acids or placebo for 12
weeks
After 40 weeks:
5% (2 out of 41 individuals) in omega‐3 group developed psychosis
28% (11 of 40 individuals) in placebo group developed psychosis
Source:  Amminger, et al, Archives of General Psychiatry, 2010, 67(2):146‐154
Omega‐3s may have ability to delay or prevent
psychosis

Dietary intake and information on psychotic‐like symptoms was
derived from a food frequency questionnaire among 33,623
women, aged 30‐49 years‐old
Participants were classified into three predefined levels:  low,
middle and high frequency of symptoms
Findings raise a possibility that adult women with a high intake
of fish, omega‐3 or omega‐6 PUFA and vitamin D have a lower
rate of psychotic‐like symptoms
Source:  Hedelin et al.  Dietary intake of fish, omega‐3, omega‐6 polyunsaturated fatty acids and vitamin D and
the prevalence of psychotic‐like symptoms in a cohort of 33 000 women from the general population.  BMC
Psychiatry 2010, 10:38.
Fatty Acids for Prevention of Psychotic Disorders

It takes at least 10 weeks
for cerebral membranes’
highly unsaturated fatty
acid levels to recover
following chronic
deficiency.
Source: Bourre, et al., Prostaglandins Leukot
Essent Fatty Acids, 1993
Not a Quick Fix

From Complimentary and Alternative Medicine Treatments in Psychiatry; 2012; Stradford, Vickar, Berger, Cass
. . . there is a place for nutritional treatments in mental health
treatment.  Some patients, due to poor diets or metabolic
abnormalities, have unusually high needs for some nutrients
– biochemicals that are required for normal physiological
function.  Supplementation can sometimes fully or partially
restore neurological activity that has gone awry.
Additionally, some supplements – as lithium has for decades
– have a palliative effect on symptoms and, in moderate
doses, can improve the patient’s condition with few or no
side effects (page 45).

(pg. 51)
Vitamin B6 Deficiencies
Nervousness
Irritability
Depression
Difficulty concentrating
Short‐term memory loss

From Complimentary and Alternative Medicine Treatments in Psychiatry; 2012; Stradford, Vickar, Berger, Cass (pg. 50)
Vitamin B12 Deficiencies
Concentration difficulties
Confusion
Irritation
Impaired memory
Dementia
Irritability
Depression
Personality changes
Psychosis

(pg. 55)
Vitamin D Deficiencies
Although clinical studies are few,
epidemiological studies show
remarkable associations between
low Vitamin D and psychiatric
disorders, including depression
and bipolar disorder.

(pg. 57)
Calcium/Magnesium Deficiencies
Depressive symptoms
Confusion
Anxiety
Hallucinations
Nervousness
Apprehension
Numbness

From NIH Osteoporosis and Related Bone Diseases National Resource Center, “What People with Anorexia
Nervosa need to know about Osteoporosis”; January 2012;
http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Conditions_Behaviors/anorexia_nervosa.asp
Anorexia nervosa has significant physical consequences. Affected
individuals can experience nutritional and hormonal problems that
negatively impact bone density. Low body weight in females causes the
body to stop producing estrogen, resulting in a condition known as
amenorrhea, or absent menstrual periods. Low estrogen levels contribute to
significant losses in bone density.
In addition, individuals with anorexia often produce excessive amounts
of the adrenal hormone cortisol, which is known to trigger bone loss. Other
problems, such as a decrease in the production of growth hormone and
other growth factors, low body weight (apart from the estrogen loss it
causes), calcium deficiency, and malnutrition, contribute to bone loss in girls
and women with anorexia. Weight loss, restricted dietary intake, and
testosterone deficiency may be responsible for the low bone density found
in males with the disorder.

•The Japanese eat very little fat and
suffer fewer heart attacks than the
British or Americans.
•The French eat a lot of fat and also
suffer fewer heart attacks than the
British or Americans.
Medical Research

Medical Research
•The Japanese drink very little red wine and
suffer fewer heart attacks than the British or
Americans.
•The Italians drink excessive amounts of red
wine and also suffer fewer heart attacks than
the British or Americans.
•The Germans drink a lot of beer and eat lots of
sausages and fats and suffer fewer heart
attacks than the British or Americans.

Medical Research
Eat and drink what you like.
Speaking English is apparently what kills you.

Faith in the Treatment of Eating Disorders

My eating disorder
destroyed my relationship
with God. It blocked me from
God and I lost all faith and
trust in God. I became very
angry with God because I felt
like God had abandoned me.
Eventually, I just stopped
thinking about God. My
eating disorder became my
God and my body became
the Devil.
From Spirituality and Eating Disorders;
http://www.byui.edu/counseling‐center/self‐
help/eating‐disorders

Beneficial effects of faith integration in recovery from
eating disorders
Patients who actively engage
in making decisions about their
care, and who are self‐directed
toward meaningful life goals,
are far more likely to follow
through with treatment and
achieve lasting results.
From A Continuum of Care Approach to Eating
Disorders by Stuart Koman, Ph.D.
Faith assists patients to develop meaningful life goals

eating disorders
7 Common Spiritual Issues
1. Negative image of God who judges, is
unforgiving and punishing
2. Feelings of spiritual unworthiness and shame
resulting in a resistance to asking for God’s help
Many eating disorder patients attempt to compensate for their
feelings of unworthiness through perfectionism,
relentlessly striving to meet impossibly high standards –
physically, morally, religiously, academically and so forth.
Reference: Lack of Spiritual Well‐Being as a Predictor of Eating Disorders Among College Students by Ghazala Saleem, Department
of Psychology, Missouri Western State University, page 265 – http://clearinghouse.missouriwestern.edu/manuscripts/809.asp
submitted May 6, 2006.

eating disorders
7 Common Spiritual Issues
3. Fear of abandonment by God, resulting in a distrust of God’s love
4. Guilt and shame about sexuality, sexual activity and promiscuity
5. Reduced capacity to love and serve others
6. Difficulty surrendering and having faith due to a belief that only
they are able to control their lives
7. Shame about the dishonesty and deception they practice due to
the secrecy of their eating disorder behaviors
Reference: Lack of Spiritual Well‐Being as a Predictor of Eating Disorders Among College Students by Ghazala Saleem, Department
of Psychology, Missouri Western State University, page 265 – http://clearinghouse.missouriwestern.edu/manuscripts/809.asp
submitted May 6, 2006.

Integrated Whole‐Person Treatment Team
Mental health counselors, including those familiar
and comfortable with spiritual issues
Chemical dependency professionals
Medical professionals, including dental
professionals
Nutritional professionals

www.aplaceofhope.com
www.drgregoryjantz.com

Whole Person Treatment of Eating Disorders

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