This document discusses eating disorders and provides information about anorexia nervosa and bulimia nervosa. It defines the diagnostic criteria for these disorders according to the DSM and describes their prevalence, risk factors, psychological and physical symptoms, and pathophysiology. Anorexia is characterized by restricted food intake and fear of gaining weight, while bulimia involves binge eating followed by purging behaviors. Both disorders predominantly affect adolescent and young adult females and can have serious long-term health consequences if not properly treated.

1. MNT inMNT in
EatingEating
DisorderDisorder
ss

2. The Ideal Body ImageThe Ideal Body Image
 MediaMedia
promotionpromotion
 SocialSocial
acceptanceacceptance
 Influence andInfluence and
stress onstress on
youngyoung
individualsindividuals

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

4. Eating Disorders (APAEating Disorders (APA
Diagnoses)Diagnoses)
 Anorexia nervosaAnorexia nervosa
 Bulimia nervosaBulimia nervosa
 Eating disorder not otherwise specifiedEating disorder not otherwise specified
(EDNOS)(EDNOS)
 Binge eating disorder (BED)Binge eating disorder (BED)
Schebendach in Krause, 12th
ed., p. 564)

5. Genetic Link?Genetic Link?
 Identical twins have a higher chanceIdentical twins have a higher chance
of eating disordersof eating disorders
 Fraternal twins are less likelyFraternal twins are less likely

6. Profile of AnorexiaProfile of Anorexia
 Usually occurs between the ages of 12-18Usually occurs between the ages of 12-18
 Typically white femaleTypically white female
 Lifetime prevalence among women is .3 toLifetime prevalence among women is .3 to
3.7%, depending on criteria used3.7%, depending on criteria used
 5%-10% are male5%-10% are male
 Middle-upper socioeconomic classMiddle-upper socioeconomic class
 Often coexists with other psychiatricOften coexists with other psychiatric
disorders: major depression or dysthymia (50-disorders: major depression or dysthymia (50-
75%), anxiety disorders, OCD (40%)75%), anxiety disorders, OCD (40%)
 5-20% mortality rate, mostly from heart failure5-20% mortality rate, mostly from heart failure
or arrhythmiasor arrhythmias
Schebendach in Krause, 12th
Ed, p 564

7. Anorexia Nervosa:Anorexia Nervosa:
Psychological FeaturesPsychological Features
 PerfectionismPerfectionism
 Harm avoidanceHarm avoidance
 Feelings of ineffectivenessFeelings of ineffectiveness
 Inflexible thinkingInflexible thinking
 Overly restrained emotionalOverly restrained emotional
expressionexpression
 Limited social spontaneityLimited social spontaneity
Schebendach in Krause, 12th
Ed., p. 564

8. 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

9. Diagnostic CriteriaDiagnostic Criteria
 American PsychiatricAmerican Psychiatric
Association DiagnosticAssociation Diagnostic
and Statistical Manual ofand Statistical Manual of
Mental Disorders (DSM)Mental Disorders (DSM)
criteria are the standardcriteria are the standard

10. AN APA Diagnostic CriteriaAN APA Diagnostic Criteria
 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 consecutiveWomen: amenorrhea: absence of 3 consecutive
periodsperiods
 Restricting typeRestricting type
– Not regularly engaged in binge eating-purgingNot regularly engaged in binge eating-purging
behaviorbehavior
 Binge eating/purging typeBinge eating/purging type
– Regularly engaged in binge eating and purgingRegularly engaged in binge eating and purging
behaviorbehavior

11. AN Diagnostic CriteriaAN Diagnostic Criteria
 Weight deficit is necessary (<85% ofWeight deficit is necessary (<85% of
expected)expected)
 If AN develops in childhood or earlyIf AN develops in childhood or early
adolescence, failure to make expectedadolescence, failure to make expected
weight gains instead of weight loss mayweight gains instead of weight loss may
occuroccur
– Stunting possible in prepubertal childrenStunting possible in prepubertal children
– Growth charts are essentialGrowth charts are essential
 Amenorrhea may not be useful in youngerAmenorrhea may not be useful in younger
patients as menarche may be delayedpatients as menarche may be delayed

12. Related Psych DisordersRelated Psych Disorders
in ANin AN
 Depression: May be due, in part, toDepression: May be due, in part, to
the psychological stress of starvationthe psychological stress of starvation
 Obsessive-compulsive disorder: mayObsessive-compulsive disorder: may
be exacerbated by malnutritionbe exacerbated by malnutrition
 Comorbid personality disorders: poorComorbid personality disorders: poor
impulse control, substance abuse,impulse control, substance abuse,
mood swings, and suicide tendenciesmood swings, and suicide tendencies

13. Prevalence of ANPrevalence of AN
 More prevalent in industrializedMore prevalent in industrialized
countries that idealize a thin body typecountries that idealize a thin body type
although expected to become morealthough expected to become more
widely distributedwidely distributed
 Lifetime prevalence among women is .Lifetime prevalence among women is .
5% to 3.7%, depending on criteria5% to 3.7%, depending on criteria
usedused
 Prevalence among men is one tenth ofPrevalence among men is one tenth of
that among womenthat among women
Schebendach in Krause, 12th
edition, p. 564

14. Risk Periods forRisk Periods for
Anorexia NervosaAnorexia Nervosa
 Age 14 – puberty,Age 14 – puberty,
high schoolhigh school
 Age 18 – college,Age 18 – college,
full time jobsfull time jobs

15. Pathophysiology of ANPathophysiology of AN
 Physical andPhysical and
psychologicalpsychological
consequences ofconsequences of
malnutritionmalnutrition

16. Pathophysiology of ANPathophysiology of AN
 Depleted fat stores; muscle wastingDepleted fat stores; muscle wasting
 AmenorrheaAmenorrhea
 CheilosisCheilosis
 Postural hypotension; dehydration orPostural hypotension; dehydration or
edemaedema
 Bradycardia; hypothermiaBradycardia; hypothermia
 Sleep disturbancesSleep disturbances

17. Pathophysiology of AN:Pathophysiology of AN:
OsteopeniaOsteopenia
 Reduced bone mineral densityReduced bone mineral density
 May result in vertebral compression,May result in vertebral compression,
fracturesfractures
 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

18. Pathophysiology of ANPathophysiology of AN
 Low body temperature/coldLow body temperature/cold
intoleranceintolerance
 Lower metabolism: low thyroidLower metabolism: low thyroid
hormonehormone
 Bone marrow hypoplasia (50% of ANBone marrow hypoplasia (50% of AN
patients) results in leukopenia,patients) results in leukopenia,
anemia, thrombocytopeniaanemia, thrombocytopenia

19. Pathophysiology of AN:Pathophysiology of AN:
CardiovascularCardiovascular
 Decreased heart rate <60 bpmDecreased heart rate <60 bpm
– Fatigue, faintingFatigue, fainting
 Decreased blood pressure <70 mm/HgDecreased blood pressure <70 mm/Hg
systolic; orthostatic hypotensionsystolic; orthostatic hypotension
 Reduction in heart massReduction in heart mass
 Mitral valve prolapse related toMitral valve prolapse related to
hypovolemia or cardiomyopathyhypovolemia or cardiomyopathy
– Death from CHFDeath from CHF

20. Pathophysiology of ANPathophysiology of AN
 Iron deficiency anemiaIron deficiency anemia
 Increased infectionsIncreased infections
 Dry skin, hairDry skin, hair
 Yellow skin due to hypercarotenemiaYellow skin due to hypercarotenemia
 Desquamation, hair loss, alopeciaDesquamation, hair loss, alopecia
 HirsutismHirsutism
 Lanugo: fine body hairsLanugo: fine body hairs

21. Pathophysiology of AN:Pathophysiology of AN:
GIGI
 Bloating, abnormal fullness afterBloating, abnormal fullness after
eatingeating
 ConstipationConstipation
 Digestive enzymes lowDigestive enzymes low

22. Pathophysiology of ANPathophysiology of AN
 Electrolyte imbalanceElectrolyte imbalance → heart→ heart
failure, deathfailure, death
– Low intake potassiumLow intake potassium
– Loss in vomiting, diureticsLoss in vomiting, diuretics
– Refeeding syndrome: electrolyteRefeeding syndrome: electrolyte
imbalances caused by too-rapidimbalances caused by too-rapid
refeedingrefeeding

23. Bulimia NervosaBulimia Nervosa
An illness characterized by repeatedAn illness characterized by repeated
episodes of binge eating followed byepisodes of binge eating followed by
inappropriate compensatory methodsinappropriate compensatory methods
– Purging, including self-induced vomitingPurging, including self-induced vomiting
or misuse of laxatives, diuretics,or misuse of laxatives, diuretics,
or enemasor enemas
– Non-purging including fasting orNon-purging including fasting or
engaging in excessive exerciseengaging in excessive exercise

24. Bulimia Nervosa APA CriteriaBulimia Nervosa APA Criteria
 Characterized by recurrent episodes ofCharacterized 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, diuretics,Purge regularly: vomiting, laxatives, diuretics,
strict dieting, fasting, vigorous exercisestrict dieting, fasting, vigorous exercise
 Continues at least 2x/wk for ≥ 3 monthsContinues at least 2x/wk for ≥ 3 months
American Psychological Association. DSM-IV-TR, ed 4, Washington DC,
2000

25. Bulimia NervosaBulimia Nervosa
PrevalencePrevalence
 Lifetime prevalence of BN amongLifetime prevalence of BN among
young adult women is 1% to 3%young adult women is 1% to 3%
 Rate of occurrence in males is 10% ofRate of occurrence in males is 10% of
that in femalesthat in females
 Rarely seen in childhoodRarely seen in childhood
Schebenbach, in Krause, 12th
edition, p. 565

26. Bulimia NervosaBulimia Nervosa
PrevalencePrevalence
 5% of college women5% of college women
 20% of college women exhibit20% of college women exhibit
symptoms (Sx)symptoms (Sx)
 50% of those with anorexia nervosa50% of those with anorexia nervosa
develop bulimia nervosadevelop bulimia nervosa
 Gorging and purging/vomitingGorging and purging/vomiting
 Susceptible populations—athletes,Susceptible populations—athletes,
actors, dancers, wrestlers, runnersactors, dancers, wrestlers, runners

27. Profile of BulimiaProfile of Bulimia
 Young (usually female) adults (collegeYoung (usually female) adults (college
students)students)
 May be predisposed to becomingMay be predisposed to becoming
overweightoverweight
 Usually at or slightly above normal weightUsually at or slightly above normal weight
 Tried frequent weight-reduction diets as aTried frequent weight-reduction diets as a
teenteen
 ImpulsiveImpulsive
 Often goes undiagnosedOften goes undiagnosed

28. Profile of BulimiaProfile of Bulimia
NervosaNervosa
 Other psychological disorders,Other psychological disorders,
including major depression,including major depression,
dysthymia, anxiety disorders,dysthymia, anxiety disorders,
personality disorders, substancepersonality disorders, substance
abuseabuse
 Low self esteemLow self esteem
 GuiltGuilt
 Preoccupied with foodPreoccupied with food
 Recognize behavior is abnormalRecognize behavior is abnormal

29. Binge DefinitionBinge Definition
 Eating, in a discrete period of timeEating, in a discrete period of time
(e.g., within any 2-hour period) an(e.g., within any 2-hour period) an
amount of food that is definitely largeramount of food that is definitely larger
than most people would eat underthan most people would eat under
similar circumstancessimilar circumstances
 A sense of lack of control over eatingA sense of lack of control over eating
during the episodeduring the episode

30. 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

31. PurgePurge
 Laxatives, enemasLaxatives, enemas
– Act on large intestineAct on large intestine
– 90% of calories are absorbed in small90% of calories are absorbed in small
intestineintestine
– Damages large intestineDamages large intestine → constipation→ constipation

32. VomitingVomiting
 Most commonly used compensatoryMost 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 throatFingers 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

33. VomitingVomiting
 TeethTeeth
– Stomach acid erodes enamelStomach acid erodes enamel
– Pain, decayPain, decay

34. DiureticsDiuretics
 Water lossWater loss
 Electrolyte lossElectrolyte loss
 NO fat loss!NO fat loss!

35. Hypergymnasia:Hypergymnasia:
Excessive ExerciseExcessive Exercise
 Compulsive exercise: that whichCompulsive exercise: that which
significantly interferes with lifesignificantly interferes with life
activitiesactivities
 Occurs at inappropriate times or inOccurs at inappropriate times or in
inappropriate settingsinappropriate settings
 Continues despite injury or otherContinues despite injury or other
medical complicationsmedical complications

36. Symptoms of BNSymptoms of BN
 Usually normal weight and secretive inUsually normal weight and secretive in
behaviorbehavior
 Scarring of the dorsum of the hand used toScarring of the dorsum of the hand used to
stimulate the gag reflex, known as Russell’sstimulate the gag reflex, known as Russell’s
SignSign
 Parotid gland enlargementParotid gland enlargement
 Erosion of dental enamel with increasedErosion of dental enamel with increased
dental caries resulting from gastric acid indental caries resulting from gastric acid in
the mouththe mouth

37. Pathophysiology of BN:Pathophysiology of BN:
VomitingVomiting
 DehydrationDehydration
 AlkalosisAlkalosis
 HypokalemiaHypokalemia
 Sore throat, esophagitis, mildSore throat, esophagitis, mild
hematemesishematemesis
 Abdominal painAbdominal pain

38. Pathophysiology of BN:Pathophysiology of BN:
VomitingVomiting
 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

39. Pathophysiology of BN:Pathophysiology of BN:
Laxative AbuseLaxative Abuse
 DehydrationDehydration
 Elevation of serum aldosterone andElevation of serum aldosterone and
vasopressin levelsvasopressin levels
 Rectal bleedingRectal bleeding
 Intestinal atonyIntestinal atony
 Abdominal crampsAbdominal cramps

40. Pathophysiology of BN:Pathophysiology of BN:
Diuretic AbuseDiuretic Abuse
 DehydrationDehydration
 HypokalemiaHypokalemia

41. Pathophysiology of BNPathophysiology of BN
 Cardiac arrhythmias related toCardiac arrhythmias related to
electrolyte and acid-base imbalanceelectrolyte and acid-base imbalance
caused by vomiting, laxative, andcaused by vomiting, laxative, and
diuretic abusediuretic abuse
 Ipecac may cause irreversibleIpecac may cause irreversible
myocardial damage and sudden deathmyocardial damage and sudden death
 Menstrual irregularitiesMenstrual irregularities

42. Vicious Cycle of BulimiaVicious Cycle of Bulimia

43. Eating Disorder Not OtherwiseEating Disorder Not Otherwise
Specified (EDNOS)Specified (EDNOS)
 A diagnostic category for eatingA diagnostic category for eating
disorders that fail to meet full criteriadisorders that fail to meet full criteria
for either anorexia nervosa or bulimiafor either anorexia nervosa or bulimia
nervosanervosa
 May have partial symptoms of eitherMay have partial symptoms of either
AN or BNAN or BN
 For example, all criteria for AN may beFor example, all criteria for AN may be
met except patient has regularmet except patient has regular
mensesmenses
 OR significant weight loss but wt still inOR significant weight loss but wt still in

44. Physical ManifestationsPhysical Manifestations
of Eating Disordersof Eating Disorders

45. Treatment of EatingTreatment of Eating
DisordersDisorders

46. AN: TreatmentAN: 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 ofSome weight restoration and treatment of
malnutrition may make psychotherapy moremalnutrition may make psychotherapy more
effectiveeffective

47. AN: TreatmentAN: Treatment
PsychologicalPsychological
 Cognitive behavior therapyCognitive behavior therapy
 Determine underlying emotionalDetermine underlying emotional
problemsproblems
 Reject the sense of accomplishmentReject the sense of accomplishment
associated with weight lossassociated with weight loss
 Family therapy, support groupFamily therapy, support group

48. Nutrition AssessmentNutrition Assessment
in Eating Disordersin Eating Disorders

49. Assessment of Intake inAssessment of Intake in
Eating DisordersEating Disorders
 Calories compared with DRICalories compared with DRI
 Evaluate macronutrient mix (carbohydrate,Evaluate macronutrient mix (carbohydrate,
protein, fat)protein, fat)
 Evaluate micronutrient intake compared withEvaluate micronutrient intake compared with
DRIDRI
 Estimate fluids and compare with needsEstimate fluids and compare with needs
 Evaluate alcohol, caffeine, drugs, dietaryEvaluate alcohol, caffeine, drugs, dietary
supplementssupplements

50. Dietary Intake in ANDietary Intake in AN
 Generally inadequate caloric intake,Generally inadequate caloric intake,
<1000 kcals/day<1000 kcals/day
 Tend to avoid fatTend to avoid fat
 Many follow a vegetarian lifestyleMany follow a vegetarian lifestyle
– Identify whether vegetarian lifestyleIdentify whether vegetarian lifestyle
coincided with onset of diseasecoincided with onset of disease

51. Dietary Intake in BNDietary Intake in BN
 Highly variable; in one study meanHighly variable; in one study mean
intake of 4446 kcals; 44% overeating,intake of 4446 kcals; 44% overeating,
19% undereating19% undereating
 When not binge eating may follow aWhen not binge eating may follow a
low fat dietlow fat diet

52. Eating Behavior inEating 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 for aMeal spacing, length of time allocated for a
mealmeal
 BN: may eat quicklyBN: may eat quickly
 AN: may eat in excessively slow mannerAN: may eat in excessively slow manner

53. 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 eliminatesMisconception that purging eliminates
all calories from a binge episodeall calories from a binge episode

54. Lab AssessmentLab Assessment
 Visceral proteins: generally normal inVisceral proteins: generally normal in
ANAN
 Lipids: elevated cholesterol andLipids: elevated cholesterol and
abnormal lipid profile; may be due toabnormal lipid profile; may be due to
hepatic dysfunction, decreased bilehepatic dysfunction, decreased bile
acid secretion, hypothalamicacid secretion, hypothalamic
dysfunction, eating patternsdysfunction, eating patterns
– Does not warrant prescription of low fat,Does not warrant prescription of low fat,
low cholesterol dietlow cholesterol diet
– Reassess after weight restoredReassess after weight restored

55. Lab AssessmentLab Assessment
 Serum glucose: low due to lack ofSerum glucose: low due to lack of
precursors for gluconeogenesis andprecursors for gluconeogenesis and
productionproduction
 Low T3 syndrome: low levels of activeLow T3 syndrome: low levels of active
form of thyroid hormone; resolves withform of thyroid hormone; resolves with
refeedingrefeeding

56. Vitamin-MineralVitamin-Mineral
AbnormalitiesAbnormalities
 Hypercarotenemia: in AN restrictors;Hypercarotenemia: in AN restrictors;
mobilization of lipid stores, catabolicmobilization of lipid stores, catabolic
changes, metabolic stress; normalizes withchanges, metabolic stress; normalizes with
rehabrehab
 Deficiency diseases rare in AN, possiblyDeficiency diseases rare in AN, possibly
due to use of supplements, catabolic state,due to use of supplements, catabolic state,
use of nutrient-dense foodsuse of nutrient-dense foods
 Osteopenia and osteoporosis are commonOsteopenia and osteoporosis are common

57. Metabolic ChangesMetabolic Changes
 AN: low metabolic rates (REE 62-70% ofAN: low metabolic rates (REE 62-70% of
expected, or 700-1000 kcals)expected, or 700-1000 kcals)
 Refeeding causes increases in REERefeeding causes increases in REE
 Elevated diet-induced thermogenesisElevated diet-induced thermogenesis
(DIT) and(DIT) and ↑ REE may require high↑ REE may require high
calorie prescriptions in nutritional rehabcalorie prescriptions in nutritional rehab
 BN: unpredictable metabolic rateBN: unpredictable metabolic rate
 Helpful to measure REE using indirectHelpful to measure REE using indirect
calorimetrycalorimetry

58. AnthropometricAnthropometric
AssessmentAssessment
 AN patients meet criteria for marasmusAN 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 orBody composition: underwater weighing or
DEXA; BIA of questionable validityDEXA; BIA of questionable validity
 Skinfolds from 4 sites (triceps, biceps,Skinfolds from 4 sites (triceps, biceps,
subscapular, suprailiac crest)subscapular, suprailiac crest)
 MAMCMAMC

59. Body WeightBody Weight
AssessmentAssessment
 Goal weight determined by various methodsGoal weight determined by various methods
(NCHS growth tables to age 18)(NCHS growth tables to age 18)
 Daily preprandial early morning weight inDaily preprandial early morning weight in
hospitalhospital
 Gowned weight on the same scale once aGowned weight on the same scale once a
week in outpatient (pt should void and urineweek in outpatient (pt should void and urine
specific gravity checked or patient examinedspecific gravity checked or patient examined
to determine if bladder is full)to determine if bladder is full)

60. Management of EatingManagement of Eating
DisordersDisorders
 Multidisciplinary team includingMultidisciplinary team including
physicians, nutritionists,physicians, nutritionists,
psychotherapistspsychotherapists
 May include inpatient medical orMay include inpatient medical or
psychiatric hospitalization, partialpsychiatric hospitalization, partial
hospitalization and residentialhospitalization and residential
treatment, intensive outpatient, ortreatment, intensive outpatient, or
outpatient programsoutpatient programs

61. Treatment GoalsTreatment Goals
 AN: weight gain and correction ofAN: weight gain and correction of
malnutrition disorders; normalization ofmalnutrition disorders; normalization of
eating patterns and behaviorseating patterns and behaviors
 BN: weight maintenance in the short termBN: weight maintenance in the short term
even if patient is overweight until eatingeven if patient is overweight until eating
habits are stabilizedhabits are stabilized

62. Factors Affecting WeightFactors Affecting Weight
Gain in ANGain 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

63. Factors Affecting WeightFactors Affecting Weight
Gain in ANGain 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

64. Nutritional Care in ANNutritional Care in AN
 Often require hospitalization to beginOften require hospitalization to begin
refeedingrefeeding
 Some require enteral feedings, but most canSome require enteral feedings, but most can
be rehabbed with oral feedingsbe rehabbed with oral feedings
 Goal is increase in energy intake withGoal is increase in energy intake with
weight gainweight gain
 Energy intake must be increased graduallyEnergy intake must be increased gradually
while minimizing caloric expenditurewhile minimizing caloric expenditure

65. Nutritional Care in ANNutritional Care in AN
 Initial calorie prescriptions 1000-1600Initial calorie prescriptions 1000-1600
kcals, or 30-40 kcals/kgkcals, or 30-40 kcals/kg
 Increase 100 to 200 kcals q 2-3 days;Increase 100 to 200 kcals q 2-3 days;
may be as high as 70-100 kcal/kg/daymay be as high as 70-100 kcal/kg/day
 Hospitalized patients: goal is 2-3Hospitalized patients: goal is 2-3
lb/weeklb/week
 Outpatients: 1 pound/weekOutpatients: 1 pound/week
APA Practice Guidelines for the Treatment of Eating Disorders,
January, 2006

66. Refeeding SyndromeRefeeding Syndrome
 Refeeding malnourished patients with AN canRefeeding 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 feedingMay be precipitated by high-calorie feeding
regimensregimens
 Patients weighing less than 70% desirable bodyPatients weighing less than 70% desirable body
weight at greatest riskweight at greatest risk
 Serum phos, mg, K+, calcium must be closelySerum phos, mg, K+, calcium must be closely
monitored and supplements provided asmonitored and supplements provided as
neededneeded

67. Energy Needs in ANEnergy Needs in AN
 70-100 kcals/kg may be needed for70-100 kcals/kg may be needed for
continued weight gain (depends oncontinued weight gain (depends on
REE and type of tissue gained)REE and type of tissue gained)
 AN more physically active thanAN more physically active than
controls; requirecontrols; require ↑↑ kcals for weightkcals for weight
maintenancemaintenance
 May require 3000-4000 kcals/day laterMay require 3000-4000 kcals/day later
in wt restoration (males 4000-4500)in wt restoration (males 4000-4500)

68. Energy Needs in ANEnergy Needs in AN
 If unsuccessful in weight gain, evaluate forIf unsuccessful in weight gain, evaluate for
discarding food, vomiting, exercising,discarding food, vomiting, exercising,
increased motor activity, metabolicincreased motor activity, metabolic
resistanceresistance
 Use indirect calorimetry in fasting and post-Use indirect calorimetry in fasting and post-
prandial stateprandial state
 Once at goal rate, 40-60 kcals/kg shouldOnce at goal rate, 40-60 kcals/kg should
promote wt maintenance and continuedpromote wt maintenance and continued
growth and development in adolescentsgrowth and development in adolescents

69. Macronutrient MixMacronutrient Mix
 Fat intake of 25%-30% of calories isFat intake of 25%-30% of calories is
recommended as added fat or less obviousrecommended 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 ageProtein: 15%-20% of calories; RDA for age
and sex in grams/kg of IBW; high biologicaland sex in grams/kg of IBW; high biological
value sources; vegetarian diets should bevalue sources; vegetarian diets should be
discouraged during rehabdiscouraged during rehab
 Carbohydrate: 50%-55%; include sources ofCarbohydrate: 50%-55%; include sources of
insoluble fiber to relieve constipationinsoluble fiber to relieve constipation

70. MicronutrientsMicronutrients
 Vitamin-mineral supplements: may haveVitamin-mineral supplements: may have
increased need in anabolism; 100%increased need in anabolism; 100%
RDA multivitamin with minerals (ironRDA multivitamin with minerals (iron
maymay ↑ constipation)↑ constipation)
 Encourage calcium-rich foods andEncourage calcium-rich foods and
Vitamin DVitamin D

71. MNT in ANMNT in AN
 Early treatment: caloric intake usually low,Early treatment: caloric intake usually low,
can be provided in 3 meals per day;can be provided in 3 meals per day;
snacking may relieve some physicalsnacking may relieve some physical
discomfortdiscomfort
 Later treatment: as caloric prescriptionLater treatment: as caloric prescription
increases, snacks become unavoidableincreases, snacks become unavoidable
 Defined formula liquid supplements may beDefined formula liquid supplements may be
helpful; patients may be more willing tohelpful; patients may be more willing to
accept them than large volumes of foodaccept them than large volumes of food

72. MNT in BNMNT in BN
 Immediate goal interruption of theImmediate goal interruption of the
binge and purge cycle with weightbinge and purge cycle with weight
maintenancemaintenance
 Rarely hospitalized except forRarely hospitalized except for
electrolyte disturbanceselectrolyte disturbances

73. Energy Needs in BNEnergy Needs in BN
 May be hypocaloric; poor correlationMay be hypocaloric; poor correlation
between predicted and actual REEbetween predicted and actual REE
 Measured REE preferable; provideMeasured REE preferable; provide
calories at 120%-130% measured REEcalories at 120%-130% measured REE
– Signs of low metabolism: history of chronicSigns of low metabolism: history of chronic
dieting, low T3 level, cold intolerancedieting, low T3 level, cold intolerance
– In presence of low metabolism, provideIn presence of low metabolism, provide
1500-1600 kcals/day) or determine average1500-1600 kcals/day) or determine average
calories/day based on current intakecalories/day based on current intake

74. Energy Needs in BNEnergy Needs in BN
 Monitor anthropometric status andMonitor anthropometric status and
adjust caloric prescription for weightadjust caloric prescription for weight
maintenancemaintenance
 Avoid weight reduction diets untilAvoid weight reduction diets until
eating patterns and body weight areeating patterns and body weight are
stabilizedstabilized
 May be on low-calorie intakes forMay be on low-calorie intakes for
longer periods than anorectic patientslonger periods than anorectic patients

75. Monitoring of BNMonitoring of BN
PatientsPatients
 Bingeing, purging, restrained intakeBingeing, purging, restrained intake
impair recognition of hunger andimpair recognition of hunger and
satiety cuessatiety cues
 Many patients with BN are afraid to eatMany patients with BN are afraid to eat
early in the day as they might bingeearly in the day as they might binge
laterlater
 May digress from meal plan after aMay digress from meal plan after a
binge, attempting to compensatebinge, attempting to compensate

76. Macronutrients in BNMacronutrients in BN
 Protein: 15-20% of calories; meet RDProtein: 15-20% of calories; meet RD
in g/kg IBW; HBV sourcesin g/kg IBW; HBV sources
 Carbohydrate: 50%-55% of calories;Carbohydrate: 50%-55% of calories;
encourage insoluble fiberencourage insoluble fiber
 Fat: 25%-30% of caloriesFat: 25%-30% of calories
– Provide source of essential fatty acidsProvide source of essential fatty acids
 MVI: multivitamin with mineralsMVI: multivitamin with minerals

77. Cognitive BehavioralCognitive Behavioral
TherapyTherapy
 Structured psychotherapeutic methodStructured psychotherapeutic method
alters attitudes and problem behaviorsalters attitudes and problem behaviors
 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 aboutEvaluates and changes beliefs about
shape and weightshape and weight
– Prevents relapsePrevents relapse

78. Female Athlete TriadFemale Athlete Triad

79. 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

80. Female Athlete TriadFemale Athlete Triad
 Female athletesFemale athletes
participating inparticipating in
appearance-basedappearance-based
and enduranceand 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

81. Female Athlete TriadFemale Athlete Triad
 Performance thinness: the commonlyPerformance thinness: the commonly
held belief that achieving a lowerheld belief that achieving a lower
weight and percentage of body fat willweight and percentage of body fat will
enhance performanceenhance performance
 Appearance thinness: trend to rewardAppearance thinness: trend to reward
thinner athletes in adjudicated sportsthinner athletes in adjudicated sports
such as gymnastics and figure skatingsuch as gymnastics and figure skating

82. Treatment for FemaleTreatment for Female
Athlete TriadAthlete Triad
 Reduce preoccupation with food,Reduce preoccupation with food,
weight, and body fatweight, and body fat
 Increase meals and snacks graduallyIncrease meals and snacks gradually
 Rebuild body to healthy weightRebuild body to healthy weight
 Establish regular mensesEstablish regular menses
 Decrease trainingDecrease training

83. Binge-Eating DisorderBinge-Eating Disorder
(Compulsive Overeating)(Compulsive Overeating)
 Complex and serious eating disorderComplex and serious eating disorder
 Occurs in ~30% -50% of subjects inOccurs in ~30% -50% of subjects in
weight control programs (40% are males)weight control programs (40% are males)
 More common with obese individuals withMore common with obese individuals with
history of restrictive dietinghistory 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

84. Binge Eating DisorderBinge Eating Disorder
Diagnostic CriteriaDiagnostic Criteria
(APA)(APA)
 Recurrent episodes ofRecurrent episodes of
binge eating in thebinge eating in the
absence of the regular useabsence of the regular use
of inappropriateof inappropriate
compensatory behaviorscompensatory behaviors
characteristic of BNcharacteristic of BN
 At least 2x week over 6At least 2x week over 6
month periodmonth period
 Distress, disgust, guilt,Distress, disgust, guilt,
depressiondepression

85. Binge-Eating DisorderBinge-Eating Disorder
(Compulsive Overeating)(Compulsive 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

86. Binge Eating ProcessBinge Eating Process
 PreconditionPrecondition
 Trigger phaseTrigger phase
 Maintenance phaseMaintenance phase
 Ending phaseEnding phase
 Post-binge phase (consequences)Post-binge phase (consequences)

87. Characteristics of aCharacteristics 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, provideFood is used to reduce stress, provide
feeling of power and well-beingfeeling of power and well-being

88. Treatment for Binge-Treatment for Binge-
EatingEating
 Learn to eat inLearn to eat in
response toresponse to
hungerhunger
 Learn to eat inLearn to eat in
moderationmoderation
 Avoid restrictiveAvoid restrictive
diets which candiets which can
intensify problemsintensify problems
 Increase activityIncrease activity

89. Treatment for Binge-Treatment for Binge-
EatingEating
 Increase self-acceptance andIncrease self-acceptance and
improved body imageimproved body image
 Address hidden emotionsAddress hidden emotions
 Overeaters AnonymousOvereaters Anonymous
 AntidepressantsAntidepressants

90. BaryophobiaBaryophobia
 ““The fear of becoming heavy”The fear of becoming heavy”
 Children are given a low-fat, restricted dietChildren are given a low-fat, restricted diet
in hopes to ward off obesity or heartin hopes to ward off obesity or heart
diseasedisease
 Detrimental to children; affect growth andDetrimental to children; affect growth and
developmentdevelopment
 Self-imposed restrictive diets by youngSelf-imposed restrictive diets by young
adults to avoid obesityadults to avoid obesity
 Lack of appropriate nutrition informationLack of appropriate nutrition information

91. Treatment forTreatment for
BaryophobiaBaryophobia
 Nutrition educationNutrition education
 Nutrition required for proper growthNutrition required for proper growth
 Appropriateness of sweets and fats inAppropriateness of sweets and fats in
the dietthe diet

92. Childhood EatingChildhood Eating
DisordersDisorders
 DSM criteria not appropriate in youngDSM criteria not appropriate in young
childrenchildren
 Cases of AN reported in children asCases 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, difficultyC/o nausea, abdominal pain, difficulty
swallowing, concerns about weight,swallowing, concerns about weight,
shape, and body fatnessshape, and body fatness

93. Five Warning Signs ofFive Warning Signs of
Childhood EatingChildhood 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 ofReports of purging in the context of
dietingdieting

94. Eating Disorders inEating Disorders in
Dietetics StudentsDietetics Students
 There is some evidence that theThere is some evidence that the
prevalence of disordered eating isprevalence of disordered eating is
higher in dietetics students than inhigher in dietetics students than in
other majors, though the research hasother majors, though the research has
been mixedbeen mixed

95. Eating Disorders in UGEating Disorders in UG
College StudentsCollege Students
 Worobey and Schoenfeld surveyedWorobey and Schoenfeld surveyed
165 undergraduate women (mean age165 undergraduate women (mean age
21.621.6++4.9 years and 46 men (22.44.9 years and 46 men (22.4++6.66.6
years) from dietetics, exerciseyears) from dietetics, exercise
science, dance, psychology, andscience, dance, psychology, and
biology/nursingbiology/nursing
Worobey J, Schoenfeld D. Eating disordered behavior in dietetics students and
students in other majors. JADA 1999;99:1100-1102

96. Eating Disorders in UGEating Disorders in UG
College StudentsCollege Students
 Nursing/biology majors hadNursing/biology majors had
significantly higher BMI and weightsignificantly higher BMI and weight
 Dietetics students scored highest onDietetics students scored highest on
Cognitive concerns and binge/purgeCognitive concerns and binge/purge
behaviorbehavior
Worobey J, Schoenfeld D. Eating disordered behavior in dietetics students and
students in other majors. JADA 1999;99:1100-1102

97. Eating Disorders inEating Disorders in
College StudentsCollege Students
 Dietetics and dance majors scoredDietetics and dance majors scored
highest on Life Interferencehighest on Life Interference
 Dance students scored highest onDance students scored highest on
Excessive ExerciseExcessive Exercise
Worobey J, Schoenfeld D. Eating disordered behavior in dietetics students and
students in other majors. JADA 1999;99:1100-1102

98. Eating Disorders inEating Disorders in
College StudentsCollege Students
 Fredenberg et al surveyed 5 groups ofFredenberg et al surveyed 5 groups of
students in DPD dietetics, CPstudents in DPD dietetics, CP
dietetics, non-food home economicsdietetics, non-food home economics
curricula, college basketball orcurricula, college basketball or
volleyball programs, and sororitiesvolleyball programs, and sororities
Fredenberg JP, Berglund PT, Dieken HA. Incidence of eating disorders among
selected female university students. J Am Diet Assoc 1996;96:64-65.

99. Eating Disorders inEating Disorders in
College StudentsCollege Students
 Fredenberg and colleagues found no significantFredenberg and colleagues found no significant
differences among the groups of collegedifferences among the groups of college
women surveyed in EAT scores (Eating Attitudewomen surveyed in EAT scores (Eating Attitude
Test.)Test.)
 However, 17.7% of DPD students had EATHowever, 17.7% of DPD students had EAT
scores symptomatic of eating disordersscores symptomatic of eating disorders
compared with 3.3% and 2.9%, respectively forcompared with 3.3% and 2.9%, respectively for
CP and home economics students (NS)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)
Worobey J, Schoenfeld D. Eating disordered behavior in dietetics students and

100. 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 with20% to 30% will have a lifelong struggle with
foodfood
 Bulimics may need long-term counseling toBulimics may need long-term counseling to
correct underlying philosophies and beliefs.correct underlying philosophies and beliefs.
 Family counseling is useful for both ANFamily counseling is useful for both AN
and bulimia.and bulimia.
 High relapse rate after treatmentHigh relapse rate after treatment

101. Topics for NutritionTopics for Nutrition
EducationEducation
 Impact of malnutrition on growth andImpact 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.

102. Topics for NutritionTopics for Nutrition
Education —cont’dEducation —cont’d
 Impact of exercise on caloric expenditureImpact of exercise on caloric expenditure
 Ineffectiveness of vomiting, laxatives, andIneffectiveness 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.

103. 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 fluctuatesWeight normally fluctuates
 Treat physical and emotional problemsTreat physical and emotional problems
earlyearly
 Discourage restrictive dietsDiscourage restrictive diets
 Correct misconception about foodsCorrect misconception about foods
 Thin is not necessary betterThin is not necessary better

104. SummarySummary
 Nutritional intervention supportsNutritional intervention supports
psychologic strategypsychologic strategy