Nutrition Assessment of Eating Disorders

Nutritional Assessment of
Eating Disorders
Erin Gonzalez, MS, RDN, LD

EATING
DISORDERS
Anorexia
Nervosa
Restricting
Type
Binge/Purge
Type
Bulimia
Nervosa
Purging Type
Exercise
Binge Eating Disorder EDNOS
Eating Disorders
Not Otherwise
Specified
Avoidant/
Restrictive Food
Intake Disorder
Atypical Anorexia Nervosa
Subthreshold Bulimia Nervosa/Binge
Eating Disorder
Night Eating Syndrome
Other Eating
Disorders
Orthorexia
Muscle Dysmorphia
Drunkorexia
Diabulimia
PICA
PANS/PANDAS
● Pediatric Acute-Onset
Neuropsychiatric
Syndrome/Associated with
Streptococcus

Eating Disorders Stats…
General Eating Disorder Statistics
● Eating disorders affect at least 9% of the population worldwide.1
● 9% of the U.S. population, or 28.8 million Americans, will have an eating disorder in their lifetime.2
● Less than 6% of people with eating disorders are medically diagnosed as “underweight.”1
● 28-74% of risk for eating disorders is through genetic heritability.1
● Eating disorders are among the deadliest mental illnesses, second only to opioid overdose.1
● 10,200 deaths each year are the direct result of an eating disorder—that’s one death every 52 minutes.2
● About 26% of people with eating disorders attempt suicide.1
● The economic cost of eating disorders is $64.7 billion every year.2

BIPOC Eating Disorder Statistics
● BIPOC are significantly less likely than white people to have been asked by a doctor about eating
disorder symptoms.3
● BIPOC with eating disorders are half as likely to be diagnosed or to receive treatment.2
● Black people are less likely to be diagnosed with anorexia than white people but may experience
the condition for a longer period of time.4
● Black teenagers are 50% more likely than white teenagers to exhibit bulimic behavior, such as
binge-eating and purging.3
● Hispanic people are significantly more likely to suffer from bulimia nervosa than their non-
Hispanic peers.3
● Asian American college students report higher rates of restriction compared with their white
peers and higher rates of purging, muscle building, and cognitive restraint than their white or
non-Asian, BIPOC peers.5
● Asian American college students report higher levels of body dissatisfaction and negative
attitudes toward obesity than their non-Asian, BIPOC peers.5

LGBTQ+ Eating Disorder Statistics
● Gay men are seven times more likely to report binge-eating and twelve times more likely to
report purging than heterosexual men.6
● Gay and bisexual boys are significantly more likely to fast, vomit, or take laxatives or diet pills to
control their weight.6
● Transgender college students report experiencing disordered eating at approximately four times
the rate of their cisgender classmates.7
● 32% of transgender people report using their eating disorder to modify their body without
hormones.8
● 56% of transgender people with eating disorders believe their disorder is not related to their
physical body.8
● Gender dysphoria and body dissatisfaction in transgender people is often cited as a key link to
eating disorders.7
● Non-binary people may restrict their eating to appear thin, consistent with the common
stereotype of androgynous people in popular culture.7

People with Disabilities Eating Disorder
Statistics
● Women with physical disabilities are more likely to develop eating disorders.9
● 20-30% of adults with eating disorders also have autism.10
● 3-10% of children and young people with eating disorders also have autism.10
● 20% of women with anorexia have high levels of autistic traits. There is some evidence that these
women benefit the least from current eating disorder treatment models.10
● ADHD is the most commonly missed diagnosis in relation to disordered eating.11

People in Larger Bodies Eating Disorder
Statistics
● Less than 6% of people with eating disorders are medically diagnosed as “underweight.”1
● Larger body size is both a risk factor for developing an eating disorder and a common outcome
for people who struggle with bulimia and binge eating disorder.12
● People in larger bodies are half as likely as those at a “normal weight” or “underweight” to be
diagnosed with an eating disorder.13

Athletes Eating Disorder Statistics
● Athletes report higher rates of excessive exercise than non‐athletes.14
● Athletes are more likely to screen positive for an eating disorder than non‐athletes, but
percentages across all probable eating disorder diagnoses are similar.14
● Athletes may be less likely to seek treatment for an eating disorder due to stigma, accessibility,
and sport‐specific barriers.14

Veterans Eating Disorder Statistics
● The most common type of eating disorders among military members is bulimia nervosa.”15
● Body dysmorphic disorder affects 1-3% of the overall population but 13% of male military
members and 21.7% of female military members.15
● A survey of 3,000 female military members found that the majority of respondents exhibited
eating disorder symptoms.15
● One study found high rates of body dissatisfaction and previous disordered eating behaviors in a
sample of young, female Marine Corps recruits.15

Children & Young Adults Eating Disorder
Statistics
● 42% of 1st-3rd grade girls want to be thinner.16
● 81% of 10 year old children are afraid of being fat.17
● 46% of 9-11 year-olds are “sometimes” or “very often” on diets.18
● 35-57% of adolescent girls engage in crash dieting, fasting, self-induced vomiting, diet pills, or
laxatives.19
● In a college campus survey, 91% of the women admitted to controlling their weight through
dieting.20

Contributing Factors
Biological
Psychological Social
Interpersonal
• Genetic effects
account for 59-88%
of the liability for
developing anorexia
and bulimia
•Low self-esteem
•Feelings of
inadequacy
•Depression, anxiety,
anger, or loneliness
•Cultural norms
that overvalue
appearance
•Body dissatisfaction
•Drive for thinness
•Difficulty expressing
emotions
•Weight-based bullying
•Traumatic
experiences
*Genetics loads the gun and the environment pulls the trigger.

Co-Occurring Disorders
It is not uncommon for someone struggling with an
eating disorder to have a co-occurring diagnosis.
Up to 50% of individuals
with eating disorders
abused alcohol or illicit
drugs, a rate five times
higher than the general
population. (National
Center on Addiction &
Substance Abuse)
Depression and other
mood disorders co-
occur with eating
disorders quite
frequently. (Mangweth
et al., 2003 & McElroy
et al., 2006)
Up to 69% of patients
with anorexia and 33%
of patients with bulimia
have a coexisting
diagnosis of obsessive-
compulsive disorder.
(National Center on
Addiction and
Substance Abuse)

“The mortality rate for those with anorexia nervosa is estimated at 5% per
decade… making it one of the leading contributors to excess mortality of
any of the psychiatric disorders. Research tells us that anorexia is a brain
disease with severe metabolic effects on the entire body. While the
symptoms are behavioral, this illness has a biological core, with genetic
components, changes in brain activity and neural pathways
currently under study.”
Thomas Insel, M.D., Director, National Institute of Mental Health, Bethesda, MD, April 2007

❖ While eating disorders often coexist with other mental health
disorders, eating disorders often go undiagnosed and untreated.
❖ A low number of sufferers obtain treatment for their eating disorder
hence inaccurate measures of incidence (Only 1 in 10).
What do you believe to be the main
barriers towards obtaining treatment?

Dr. Anita Johnston, Ph.D., CEDS “The Log”

Eating Feelings, Attitudes
& Behaviors Continuum
Body Image
Confidence
Preoccupation
with body
shape/size &
eating
Distress about
body
shape/size &
eating
Eating
Disorders
■Mostly positive
feelings about body
shape/size
■No “good” or “bad”
foods
■Regular moderate
exercise
■Don’t like the way
parts of body look or
consistently feel like
losing a few pounds
■Frequent thinking
about food, eating
and body
■Sometimes feel guilty
or bad for what you
have eaten and may
“make up for it”
■Thinking about food,
eating and body
interferes with daily
activities
■Rigidity in eating
patterns
■Working hard to
change body and
compensating for
eating (vomiting,
fasting, extreme
exercising)
■No significant weight
loss
■Anorexia Nervosa
■Bulimia Nervosa
■Binge Eating Disorder
■Eating Disorder NOS

Other Clues of an Eating Disorder
• Eliminating entire food groups
• Skipping meals, “I’m not hungry” or “I already ate”
• Lots of diet soda, gum, water, mints, etc
• Isolation from friends, activities
• Eating erratically, lots of rules
• Constant talk of food/weight/calories
• Eating in isolation (hiding the eating)
• Going to the bathroom or showering after eating
What
do
I see?

Physiological/Psychological/Behavioral
Manifestations of Eating Disorders

Treatment Options
• Outpatient
• Intensive Outpatient/Day program
• Residential
• Inpatient/Hospital Treatment

Eating Disorder Recovery Pathway
physiological
restriction
emotional
restriction
intuitive
eating H/F/S
neutrality
with food
healthful
eating
symptom
free/neutral
with food
H= Hunger
F= Fullness
S= Satiety

APA Diagnostic Criteria
• Weight <85% standard
• Intense fear of weight gain/fat although
underweight
• Distorted body image
• Women: amenorrhea: absence of 3
consecutive periods
• Restricting type
• Binge eating/purging type

Demographics of Anorexia
Peak of onset:
• 12-13 years old
• 17 years old
• 50% restrictors (limit food and exercise)
• 50% bulimic subtype: also purge

Review of Symptoms:
Anorexia
o Sizeable weight change
o Disturbed body image
o Cold intolerance/hypothermia
o Constipation
o Loss of muscle mass
o Depressive symptoms
o Anxiety
o Cognitive impairment
o Dizziness/fainting
o Loss/delay menses
(Amenorrhea)
o Orthostatic hypotension
o Self mutilation
o Sleep disturbance
o Brittle nails
o Thinning/dull hair

Physical Findings:
Anorexia
o Emaciation
o Bradycardia
o Hypothermia
o Lanugo hair
o Dry skin
o Carotenemia
o Hyperkeratosis
o Edema
o Anemia
o Cyanotic
extremities
o Hypotension
o Gastroparesis

Anorexia:
The Dangerous Reality
Mortality
• Anorexia Nervosa has the second highest mortality rate
among all psychiatric disorders. Second only to opioid
overdose.
• 10 – 20 % will die
• Death from cardiac arrest, suicide, starvation, other medical
complications

Anorexia Nervosa: Psychological Features
• Perfectionism
• Harm avoidance
• Feelings of ineffectiveness
• Inflexible thinking
• Overly restrained emotional expression
• Limited social spontaneity

AN: Malnutrition & Mental Health
Sensing starvation, the brain goes into overdrive with
constant thoughts of food in an effort to make the body
seek out and eat food. Obsession with food rules also
results from affect dysregulation. This is NOT about
control.
● Constant calorie calculations
● Constant planning of what to eat, how much
● Constant planning of how to burn calories and how
many
● Numbers, numbers, numbers...

Common Nutritional Symptoms
•Food rituals and rules
•Specific rules on what, when and how much they can eat
•Cuts food in small pieces
•Rearranges food on plate
•Eliminates foods gradually
•Prolonged exercise
•Preoccupation with food
•Cooks for others
•Hungry, but refuses to eat

Nutrition Treatment of AN
Step 1: What is the client currently eating?
Meal Event MONDAY
Breakfast apple
Snack
Lunch carrots
Snack
Dinner apple, salad (greens, no regular salad
dressing)
Snack

Meal Event MONDAY ADD ON:
Breakfast apple Cheese stick (week 1)
Snack
Lunch carrots 1 TBS hummus (week 1)
Snack
Dinner apple, salad 2 crackers (week 2)
Snack Yogurt (week 2)
Step 2: Meet the client where they are at….
“Add on’s” week 1-2...safe, low risk, “doable”

Step 3: Week 3-4 sample add on’s
Breakfast apple, cheese stick 1 slice regular bread
(week 3)
Snack
Lunch carrots, 1 TBS hummus 5 pita chips (week 3)
Snack
Dinner apple, salad, 2 crackers 1 TBS olive oil on salad
(week 4)
Snack Yogurt 2%, 8 oz

Step 4: Week 5-6
sample add on’s
Breakfast apple, cheese stick, 1
slice bread
1 TBS peanut butter
(week 5)
Snack Banana (week 6)
Lunch carrots, 1 TBS hummus,
5 pita chips
1 TBS hummus (week
5)
Snack Handful of almonds
(week 6)
Dinner apple, salad, 1 TBS olive
oil, 2 crackers
2 crackers (week 5)
Snack Yogurt 2%, 8 oz Protein bar (week 6)

Step 5:
Week 7 -onwards
Breakfast apple, cheese stick, 1 slice bread, 1
TBS peanut butter
CONTINUE TO WORK
TOWARDS “REAL
MEALS” OVER TIME
Snack Banana
Lunch carrots, 1 TBS hummus, 5 pita
chips
Snack Handful of almonds
Dinner apple, salad, 1 TBS olive oil, 4
crackers
Snack Yogurt 2%, 8 oz, Protein bar

Step 6:
“REAL MEALS”
Breakfast 2 slices toast, 1 TBS peanut butter,
apple
1. VARIETY
Snack Banana, cheese stick 2. DIFFERENT
CUISINES
Lunch Sandwich with cheese, ham,
tomato, lettuce, yogurt
3. “NORMAL”
PORTIONS
Snack Handful of almonds, apple 4. MORE NEUTRAL
WITH FOOD
Dinner Chicken pesto with vegetables and
rice
Snack Yogurt 2%, 8 oz, Protein bar
*Work towards ‘Rule of 3’

Neutrality...Road to Recovery
HUNGER / FULLNESS /
SATIETY CUES
TRUST IN BODY
LESS ANXIETY
NEUTRALITY

Orthorexia
❖ Coined in 1997 by Steven Bratman, MD
❖ Defined as an obsession with "healthy or
righteous eating.”
❖ It often begins with someone's simple and
genuine desire to live a healthy lifestyle.
❖ The severe restrictive nature of orthorexia
could easily morph into anorexia.
❖ How does one separate out what is or is
not disordered?

Bulimia Nervosa(BN): Relationship
with Food

Bulimia Nervosa
An illness characterized by repeated episodes of
binge eating followed by inappropriate
compensatory methods
- Purging, including self-induced
vomiting or misuse of laxatives,
diuretics, or enemas
- Non-purging including fasting or
engaging in excessive exercise

Bulimia Nervosa APA Criteria
• Characterized by recurrent episodes of
binge/purge eating
• Average ≥ 2 binge/purge cycles/week
-Uncontrollable eating during binge
-Purge regularly
• Continues at least 2x/wk for ≥3 months

Bulimia Nervosa Prevalence
• 5% of college women
• 20% of college women exhibit symptoms (Sx)
• 50% of those with anorexia nervosa develop bulimia nervosa
• Gorging and purging/vomiting
• Susceptible populations—athletes, actors, dancers, wrestlers,
runners

BN: Physiology of Eating Patterns
Restriction & blood sugar levels:
Separate out physiological binge/overeating urges vs
emotional urges
OVERFULL
Purge Event
STARVING
AM PM

BN: Physiology of Eating Patterns
GOAL: Re-establish blood sugar levels by
balancing out food intake and distribution
Eat Eat
Eat
Decrease in blood
sugars=HUNGRY
Increase in blood sugar
= FULL
= FULL
Decrease in blood
sugars=HUNGRY
Decrease in blood
sugars=HUNGRY

Nutrition Treatment of BN
Meal Event MONDAY
Breakfast
Snack Coffee (24 oz)
Lunch
Snack
Dinner apple, salad, carrot sticks, bread, more
bread, pasta, more pasta, cupcakes,
chocolate.
Snack

Breakfast Cheese stick (week 1)
Snack Coffee (12 oz) Reduce coffee = appetite
suppressor
Lunch Yogurt, apple (week 1)
Snack
Dinner apple, salad, carrot sticks,
bread, more bread, pasta,
more pasta, cupcakes,
chocolate...
Begin awareness journal
Snack
Step 2: Meet the
client where they
are at….
“Add on’s” week 1-
2...safe, low risk,
“doable”

Step 3: Week 3-4;
“Mark” meal
times with some
food items, and
then snacks
Breakfast cheese stick 2 eggs (week 3)
Lunch Yogurt, apple 2 TBS granola (week 3)
Snack
Dinner apple, salad, carrot sticks,
bread, more bread, pasta,
more pasta, cupcakes,
chocolate...
Dinner Substitution: “safe
meal”
Grilled chicken,
vegetables, rice
Snack “Safe Snack”: frozen yogurt

Step 4: Week 5-6
Attempt re-
exposure to
higher risk
foods as able
(portioned
pasta)
Breakfast 2 eggs, cheese stick 1 slice toast, with 1 tsp
butter
Snack Coffee (12 oz) 2 graham crackers
Lunch Yogurt, 2 TBS granola,
apple
Snack Banana, Handful of
almonds
Dinner Grilled chicken,
vegetables, and rice
Dinner Substitution:
“challenge meal” 2
cups pasta with sauce
Snack “Safe Snack”: frozen
yogurt

Step 5:
Week 7 -onwards
Breakfast 2 eggs, 1 slice of toast with butter, cheese stick 1. CONTINUE TO WORK
TOWARDS “REAL MEALS”
EVENLY DISTRIBUTED
OVER THE DAY
Snack Coffee (12 oz), 2 graham crackers 2. INCLUDE SNACKS TO
REGULATE HUNGER
Lunch Yogurt, 2 TBS granola, apple 3. AVOID LARGE
VOLUMINOUS MEALS
Snack Banana, handful of almonds 4. DECREASE RISK OF
OVERFULL SENSATION
AND RISK OF PURGING
Dinner Grilled chicken, vegetables, and rice
Snack 1 frozen yogurt

Nutrition Treatment of BN Step 6: “REAL MEALS”
Breakfast 2 slices toast, 2 eggs, 1 slice of cheese,
apple
1. VARIETY
Snack Coffee (12 oz), 2 graham crackers 2. DIFFERENT CUISINES
Lunch Sandwich with cheese, ham, tomato, lettuce,
yogurt
3. “NORMAL” PORTIONS
Snack Banana, Handful of almonds 4. MORE NEUTRAL WITH
FOOD
Dinner Chicken pesto with vegetables and rice 5. BALANCED MEALS
THROUGHOUT THE
DAY
Snack 2 Oreos and frozen yogurt

BINGE EATING DISORDER
AN BN BED

Binge Eating Disorder
o Recurrent episodes of binge eating with:
• Eating in discrete period of time an amount of food larger than most people would eat
• A sense of lack of control over eating during the episode (a feeling that one cannot stop eating or
control what or how much one is eating)
o The binge eating occurs at least once a week for three (3) months.
o The binge eating episodes are associated with:
• eating much more rapidly than normal
• eating until feeling uncomfortably full
• eating large amounts of food when not feeling physically hungry
• eating alone because of feeling embarrassed by how much one is eating
• feeling disgusted with oneself, depressed, or very guilty afterwards

BED: Nutritional Impact on Body
● Many BED clients struggle with weight gain
o 75% are overweight or obese
o NOTE: Therefore not all BED clients struggle with weight
concerns
● Chronic medical symptoms may occur due to weight gain over time
● Clients of a higher weight can have malnutrition
● Often BED clients have grown up on diet after diet

BED: Mental Health
•Distress, anxiety, depression
•May have a trauma history
•For clients of higher weight, there can be trauma related to
living life in a larger body
•Public comments, remarks, discrimination, judgement
•BED carries the most stigma of all eating disorders

BED: Mental Health
•Treatment therefore MUST take into consideration the
stigma and shame that our clients often experience
•Extra sensitivity is required on behalf of the clinician
•BED client is often used to a world of judgement – from
everyone – family, friends, colleagues
•You the clinician, may be the first ally they have had in
their battle with their eating disorder

BED: Physiology of Eating Patterns
Restriction & blood sugar levels:
Separate out physiological binge/overeating urges vs
emotional urges
OVERFULL
STARVING
AM PM
GUILT

BED: Physiology of Eating Patterns
GOAL: Re-establish blood sugar levels by
balancing out food intake and distribution
Eat Eat
Eat
Decrease in blood
sugars=HUNGRY
= FULL
= FULL
Decrease in blood
sugars=HUNGRY
Decrease in blood
sugars=HUNGRY

Nutrition Treatment of BED
Meal Event MONDAY
Breakfast
Lunch
Snack
Dinner Salad, chicken, mashed potatoes, bread, more bread, pasta, more
pasta, more pasta….
Snack Ice cream, oreos, cupcakes, chocolate...ice cream, oreos, nuts...

Nutrition Treatment of BED Step 6: “REAL MEALS”
Breakfast 2 slices toast, 2 eggs, 1 slice of cheese,
apple
1. VARIETY
Snack Coffee (12 oz), 2 graham crackers 2. DIFFERENT CUISINES
Lunch Sandwich with cheese, ham, tomato, lettuce,
yogurt
3. “NORMAL” PORTIONS
Snack Banana, Handful of almonds 4. MORE NEUTRAL WITH
FOOD
Dinner Chicken pesto with vegetables and rice 5. BALANCED MEALS
THROUGHOUT THE
DAY
Snack 2 Oreos and frozen yogurt

BED: Challenges in Treatment
● Slow and steady
● Often have struggled with BED since childhood
● Inadequate training of clinicians
● Weightism

•BED is very misunderstood
•General public’s belief is dieting will solve the “problem”
•Dieting worsens BED
•Psychological aspects of BED are often not seen and often
not treated
•Poor diagnosis, poor recognition, often BED clients don’t
know they have BED
•Underdiagnosed, and under recognized, means fewer
people are presenting for treatment

•Weight loss is not a goal of treatment
•Some clients will lose some weight but not all
•Biochemical changes occur in the body with weight gain,
that are irreversible
•For some clients, recovery without significant weight loss
does not seem “worth it”
•Recovery can be a difficult “buy in”

Say “No” to Dieting
...Dieting is a “gateway” behavior to an Eating
Disorder
Dieting AN BN BED
50%

Defining Weight & Health
Messages about health in the media
–Health depends on weight
•Thin = healthy
•Fat = unhealthy
–Eat better and you will be healthier
–Exercise more and you will be healthier
Health is about more than weight
Health is about more than diet and exercise

Defining Weight and Health
Diet and exercise are only two components of health
Health
Diet
Exercise
Emotional
Social
Spiritual
Intellectual
Environmental
Occupational

Intuitive Eating
● Awareness of physical and emotional cues
● Recognition of non-hunger triggers for eating
● Learning to meet other needs in more effective ways than eating
● Choosing food for both enjoyment and nourishment
● Eating for optimal satisfaction and satiety
● Using the fuel consumed to live a vibrant life
Powerful evidenced based tool for developing a healthier, happier
relationship with food

Bringing Balance Back to Eating
Nutrition therapy is an integral part of the eating disorder treatment and
recovery process. The primary role of nutrition therapy is to assist patients in
normalizing their eating patterns.
Normalized eating encompasses:
● Eating adequately to meet the body’s daily nutritional needs
● A balanced and sustainable relationship with food, free from negative or
distorted thoughts about oneself
● Listening to and trusting the body’s internal cues to determine hunger and
fullness

Transitioning from Traditional to
Intuitive Eating
● Timing and readiness is key
● Readiness Indicators:
○ Recognize the ED is about
something deeper--weight and
eating are symptoms?
○ Tolerate risk with eating?
○ Tolerate being uncomfortable?
○ Recognize needs and feelings?
○ Value Self-Care?
○ Recognize vulnerability--being too
hungry, too tired, too stressed, etc?

Case Study 1
● Adolescent female age 14
● Referred for weight concerns

Case Study 2
● 81 year old female

Case Study 3
● Type 2 Diabetes, BED
● Referred by endocrinologist due to refusal to take insulin related to fear of weight gain
● year old female

Case Study 4
● Angel
● adopted/foster homes
● using fast-food

Resources
Health At Every Size®: https://haescommunity.com/
Intuitive Eating: http://www.intuitiveeating.com/content/resources
Center for Change-Specialized Treatment for Eating Disorders:
http://centerforchange.com/research-treatment/
National Eating Disorder Association:
http://www.nationaleatingdisorders.org/

Interested in learning more?
Join me this summer and register for
FCS 496: Eating Disorders

Nutrition Assessment of Eating Disorders

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