Nutrition therapy for eating disorder

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Nutrition in Clinical Practice
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DOI: 10.1177/0884533610361606
2010 25: 122Nutr Clin Pract
Christina Scribner Reiter and Leah Graves
Nutrition Therapy for Eating Disorders
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122
Volume 25 Number 2
April 2010 122-136
© 2010 American Society for
Parenteral and Enteral Nutrition
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Background
Eating fulfills basic biological needs and supports life.
Unfortunately, fear and distrust about eating contribute
to eating disorders, disordered eating, or concerns about
possible food addiction.1
The actual prevalence of eating
disorders is likely far underestimated2
as many people are
reluctant to disclose information about their eating
behaviors3
or do not meet the strict diagnostic criteria for
an eating disorder.2
Furthermore, prevalence and inci-
dence data for eating disorders are confounded by diffi-
culty in recognizing early signs of eating disorders,
variability in screening and referral practices, choice to
not seek medical treatment if afflicted with an eating
disorder, and variance in interpretation of diagnostic cri-
teria.4
As a result, up to 90% of those with an eating dis-
order may go untreated.3
Disordered eating and eating disorders that are char-
acterized by serious dysfunctional response to hunger
and satiety signals5
are considered commonplace,6
par-
ticularly among adolescent girls and young adult women.
Eating disorders result in impaired function and morbid-
ity with mortality rates that rank among the highest of all
From 1
Metropolitan State College of Denver, Denver, Colorado;
2
Laureate Eating Disorders Program, Tulsa, Oklahoma
Christina Scribner Reiter, MS, RD, CSSD, Metropolitan
State College of Denver, Denver, CO; e-mail: reiterc@mscd
.edu.
mental disorders.4,6
More than 7 million girls and women
in addition to 1 million boys and men in the United
States are expected to suffer from an eating disorder dur-
ing their lifetime.7
Eating disorders strike early in life,
with 10% being diagnosed prior to age 10 and about one-
third being diagnosed during the preteen and adolescent
years. Eighty-six percent of all eating disorders are diag-
nosed before children leave their teen years.7
The preva-
lence of eating disorders among athletes appears to be
growing, with data revealing rates 10-50 times higher
than previously thought.8
As shown in Table 1, anorexia nervosa (AN) and
bulimia nervosa (BN) share most clinical features9
as
described by the American Psychiatric Association in
its Diagnostic and Statistical Manual of Mental
Disorders, fourth edition, text revision (DSM-IV-TR).10
The outcome on body weight of the balance of undereat-
ing to overeating is the major feature distinguishing AN
from BN.9,10
In addition, patients may migrate across
diagnostic categories, “crossing over” from one disorder
to the other.9
Within all ages and genders, the diagnosis
of AN or BN pales in contrast to a diagnosis of an
“atypical” eating disorder, defined as “eating disorder
not-otherwise-specified” (EDNOS). EDNOS includes
patients with binge eating disorder (BED)10
and who do
not meet the specific criteria for AN or BN or are
unable to describe or comprehend their disordered eat-
ing behavior.4
The same or similar processes apparent
in AN and BN promote or maintain the EDNOS.9
Thus, treatment goals are similar, and patients with
Nutrition professionals are essential members of the multidis-
ciplinary clinical team treating individuals with eating disor-
ders. They possess knowledge and expertise that includes
nutrition, physiology, and skills for promoting behavior change
relative to the psycho-socio-cultural aspects of eating. This
review provides an overview of the current state of the art in the
practice of nutrition therapy for eating disorders, providing
guidance in nutrition assessment, interventions, monitoring
and interpretation of information and data, awareness of
emerging roles for nutrition, and important considerations
regarding professional boundaries practiced in the field of eat-
ing disorders. Training and experience in nutrition therapy
specific to eating disorders promote a positive outcome in
patients. Nutrition professionals are involved in all levels of
care, including individual and group treatment in inpatient
hospitalization or residential programs, partial hospitalization,
and outpatient programs. It is beyond the scope of this article
to address specific nutrition considerations relevant to individ-
uals. Additional research is needed to delineate the most effec-
tive strategies for nutrition therapy in the treatment of eating
disorders. (Nutr Clin Pract. 2010;25:122-136)
Keywords: nutrition therapy; eating disorders; eating; anorexia;
anomxia nervosa; bulemia; bulimia nervosa
Nutrition Therapy for Eating Disorders
Christina Scribner Reiter, MS, RD, CSSD1
; and
Leah Graves, RD, LD, FAED2
Financial disclosure: none declared.
Invited Review
at Aston University - FAST on August 22, 2014ncp.sagepub.comDownloaded from

Nutrition Therapy for Eating Disorders / Reiter, Graves 123
various diagnoses are frequently treated together in
group settings.
Eating disorders are thought to arise from the inter-
play of genetics, biology, and psycho-socio-cultural fac-
tors.11
A strong link between psychological problems and
food selection and eating behavior has long been recog-
nized.5
Poor nutrition has been postulated as both a con-
tributor to the development of eating disorders, as well as
a consequence. Evidence from the classic Keys semi-
starvation study, in which malnutrition was imposed on
psychologically healthy men, illustrates the development
of dramatic emotional changes with food restriction that
include depression, anxiety, and attitudes and behaviors
related to food, some of which persisted after refeed-
ing.7,12
In addition, more recent studies on quality and
composition of the diet suggest that nutrition may be
implicated in the development and treatment of mood
disorders seen in eating-disordered patients.7
Depression
coupled with negative emotions and altered appetite regu-
lation is associated with impaired physical activity and
increased appetite,13
which may lead to binge eating.
Obesity is associated with poor nutrition,14
alcohol abuse,
and mood, anxiety, and personality disorders that include
major depression, dysthmia, and obsessive-compulsive
disorder, among others.15
Alcohol consumption among
eating-disordered individuals may pose problematic and
potentially life-threatening consequences, even if alcohol
consumption is not more frequent or in higher quantities
than in non–eating-disordered individuals.16
Obesity is coded as a medical condition and is not
included in the DSM-IV. As such, psychological issues5
included in the etiology,10
maintenance, or response to
obesity may not be fully addressed in treatment.17
In fact,
although “binge eating” is defined by DSM-IV, clinicians
specializing in eating disorders recognize that loss of con-
trol over eating is more related to psychological distress
than is the actual amount of food consumed.18
Song and
Fernstrom13
review psychological issues following bariat-
ric surgery, reporting that about 10% of obese individuals
have BED, about 27% have a lifetime incidence of BED,
and 66% have a lifetime history of an Axis I diagnosis.
Clearly, all people who are underweight or obese do not
have an eating disorder; obese individuals with BED are
in a distinct category of obesity.19
Among the obese, those
with BED have a higher incidence of severe psychopa-
thology and impairement of social functioning than obese
individuals who do not exhibit BED.19,20
Although many
patients may believe that weight loss will improve
Table 1. Types of Eating Disorders
Anorexia Nervosa Bulimia Nervosa Eating Disorder Not Otherwise Specified
Unwillingness to maintain body
weight at a minimally normal
weight for age and height
Self-evaluation unduly influenced
by body shape and weight
A sense of lack of control during
This “other” category may include any of the following:
Subsydromal Binge eating Individuals of
eating disorders: disorder: normal weight
Intense fear of gaining weight or
becoming fat that does not
diminish with weight loss
Disturbance in the way in which
one’s body weight or shape is
experienced, undue emphasis on
body weight or shape on self-
evaluation, or denial of the
seriousness of the low body weight
Absence of at least 3 consecutive
menstrual cycles
Subtype
Restricting type: lack of regular
binge eating or purging
behavior
recurrent episodes of binge
eating, which occur at least twice
a week for at least 3 months
Use of compensatory behaviors to
prevent weight gain (eg, self-
induced vomiting; misuse of
laxatives, diuretics, enemas, or
other medications; fasting; or
excessive exercise) at least twice
a week for at least 3 months
The disturbance does not occur
exclusively during episodes of
anorexia nervosa
individuals who
exhibit most but
not all of the
DSM-IV-TR
criteria for
anorexia nervosa
or bulimia
nervosa
Recurrent binge
eating less
frequent than
described for
bulimia nervosa
without regular
compensatory
behavior; this
behavior causes
distress and may
be accompanied
by obesity, body
image
dissatisfaction,
low self-esteem,
or depression
who:
a. purge after
eating
b. chew and spit
out food rather
than swallowing
it to prevent
weight gain;
eating disorder
Psychiatric
impairment
related to the
abuse of diet
pills and
diuretics
Obsessive
preoccupation
with cosmetic
surgery to deal
with issues of
shape and
weight
Subtype
Binge eating/
purging type:
regular binge
eating or
purging
behavior
Purging type: use
of self-induced
vomiting or the
misuse of
laxatives,
diuretics, or
enemas
Nonpurging
type: use of
compensatory
behaviors other
than regular
use of purging,
such as fasting
or excessive
exercise

124 Nutrition in Clinical Practice / Vol. 25, No. 2, April 2010
psychological function, the improvement appears to be
transient,12
with existing psychiatric disorders persisting
after bariatric surgery.21
Ifland et al22
suggest that overweight and obesity
may be the result of food addiction for many people.
Obesity may be resistant to treatment due to the myriad
of factors that appear to contribute to its etiology,
including genetics, metabolism, biological pathways in
the brain, behavior, food habits, physical activity, envi-
ronment,20
and the use of pharmacotherapies that
promote weight gain, such as atypical antipsychotic
medications21
that promote weight gain. Functional neu-
roimaging suggests that obese individuals may have a
delayed awareness of satiety and altered chemical neuro-
mediators that contribute to a sense of loss of control in
eating, appetite drive, and craving similar to addiction.20
Neurobiology further suggests that obsessive-compulsive
and impulsive traits may be common to BN and BED.
Shared neurobiology and psychosocial factors suggest
that treatments for substance abuse may be effective for
overeating that leads to obesity,20,22
as evidenced by com-
parison of the 7 core features of substance dependence,
defined in the DSM-IV, to overconsumption of refined
foods.22
Recently, a single broad diagnostic category encom-
passing all eating disorders has been suggested,6
as there
are more similarities than differences among core features
of eating disorders.23
Etiological factors; physical, medical,
and laboratory findings; and prevalence data for eating
disorders are available at http://www.psychiatryonline.
com.10
Treatment guidelines for AN and BN are delineated
by the American Psychiatric Association (APA).24
Both the
APA24
and the National Institute for Clinical Excellence
(NICE)25
in the United Kingdom recommend nutrition
rehabilitation for eating disorders and the treatment of
subthreshold eating disorders based on the eating disorder
most similar to the patient’s presentation.
Nutrition Therapy
The National Institutes of Health defines nutrition coun-
seling as “a process by which a health professional with
special training in nutrition helps people make healthy
food choices and form healthy eating habits.”26
Varying
levels of nutrition advice may be provided by physicians,
nurses, psychotherapists, athletic trainers, strength and
conditioning coaches, and “nutritionists.” Yet, registered
dietitians (RDs) are considered to be the most uniquely
qualified and trained to provide nutrition therapy across
the full continuum of disordered eating and at various
levels of care.27
Nutrition professionals, specifically RDs,
are integral team members in the treatment of eating
disorders.
All healthcare team members should recognize the
risk factors and signs for development of eating disorders:
•• Dietary habits including avoidance of specific
foods or food groups, picky eating
•• Exercise habits or athletes involved in sports
that emphasize thin body build, body building,
or body appearance
•• Sociocultural values, including perception of
health or beauty, that influence drive for thin-
ness, negative body image, and/or body dissatis-
faction
•• Perceived pressure to perform such as in aca-
demics or athletics
•• Psychological factors, including temperament,
anxiety disorders, low self-esteem, self-regulation,
attachment issues, and history of abuse
•• A more complete description can be found in the
APA’s practice guideline for treating patients with
eating disorders.24
The nutrition professional assists with medical
monitoring, understanding medications and pharmaco-
therapies, and using medical nutrition protocols toward
providing optimal nutrition and the normalization of
eating.27
Nutrition professionals who identify themselves as
being an advanced or specialty-level practitioner may
work in various practice settings (eg, hospitals, residen-
tial treatment programs, private practice, community/
public health, education, or research) and are expected
to implement scientific evidence-based practice that
extends beyond entry-level knowledge and experience. A
“specialist” in nutrition therapy for eating disorders con-
centrates on this aspect of the nutrition profession and
often works in a position requiring skills and training that
expand beyond those expected of a generalist. The
American Dietetic Association (ADA) has approved prac-
tice-specific Standards of Practice (SOP) and Standards
of Professional Performance (SOPP) for some areas in
dietetics,28
but at the time of this writing, there is no
SOP or SOPP for the specialist in eating disorders. The
Behavioral Health Nutrition (BHN) ADA practice group
has recommended that the SOP and SOPP for Behavioral
Health Care (originally published in 2006) be reviewed
and revised to include eating disorders as 1 of 4 distinct
practice areas.29
Many different approaches to the treat-
ment of eating disorders, including nutrition therapy,
have been and continue to be used, some with more
empirical evidence than others.
The nutrition professional may be the first profes-
sional to be consulted by a patient and identify signs and
symptoms of an eating disorder (ED). Although a variety

of healthcare providers may contribute to the assessment,
diagnosis and coding are made by qualified medical and
mental health professionals in accordance with the most
current DSM criteria.10
Thus, ethical guidelines29
exclude
the RD from diagnosing an eating disorder. An interdisci-
plinary team approach is recommended for treatment of
eating disorders.24
The nutrition professional should dis-
close his or her qualifications and philosophical approach,
seek appropriate counsel, and make referrals as part of
the management team. The patient will benefit from
being engaged as a valued collaborator in making informed
decisions regarding goal setting and methods employed in
his or her treatment.5,30
Psychotherapeutic Considerations
in Nutrition Therapy
The competent nutrition counselor helps the patient rec-
ognize and understand the complex role an eating disor-
der plays in his or her life. As such, the nutrition therapist
assists patients in recognizing that disordered eating may
meet their need for safety or the relief of pain.5
Nutrition
counseling guides patients in identifying problematic
behaviors and setting realistic and achievable nutrition-
related goals to support clients in making behavior
changes.5,31
Nutrition education includes conversations
about discrepancies between knowledge, beliefs, and
behaviors, ultimately empowering the patient to normal-
ize eating and make healthier decisions.5
The goal of nutrition therapy is nutrition rehabilita-
tion. Recovery indicators include reaching and maintaining
a healthful body weight, normalization of eating patterns
and perceptions of hunger and satiety, and the correction
of malnutrition-affected biological and psychological func-
tion.24
To this end, the nutrition therapist assesses the cur-
rent and past patterns of dietary intake, including timing of
meals, portion size, and food- or body-related rituals.
Nutrition therapy assists clients in making changes related
to food intake, supplement use, compensatory behaviors,
physical activity, and the patient’s relationship with his or
her body. Strategies include exploring potential solutions to
problems, taking risks, assertiveness, getting needed sup-
port, and setting boundaries. More specifically, patients
become competent in eating in various social situations
and selecting food from all food groups in appropriate
amounts to meet nutrition needs. Nutrition needs and
dietary patterns consider physical activity, growth and/or
development, achieving and maintaining a healthful weight
range,32,33
and attending to coexisting conditions that may
affect food selection, such as allergy, intolerance, meta-
bolic syndrome, polycystic ovary syndrome, disabilities, or
family history for risk of disease. It is imperative that the
nutrition therapist consider the multitude of factors that
affect food intake, including lifestyle and socioeconomic
factors, personal values, interpersonal relationships and
skills, trauma history, body image, self-esteem, substance
abuse, and participation in sports. The success of nutrition
therapy is affected by identifying and taking advantage of
resources. Those resources might include access to healthy
food, knowledge of food selection and preparation, and
sources of support such as family, friends, and the work-
place.
In acting as an agent of change, the nutrition thera-
pist must initially establish a therapeutic alliance by seek-
ing to fully understand and empathize with the various
aspects of the client’s struggle.5
Development of a strong,
mutually trusting, and nonjudgmental relationship begins
at the initial assessment.4
A helping model puts the coun-
selor in the position of teaching and coaching, focusing
on developing a greater sense of competence through
positive regard, reassurance, and support as patients and
family members explore potential solutions.4,5,34
Blonna
and Watter34
have identified 3 sets of individual skills that
are the basis of effective healthcare counseling: “attend-
ing skills” (culturally appropriate body language) are
essential to establishing a safe and open counseling rela-
tionship; “responding skills” keep patients involved, allow-
ing the nutrition counselor to understand issues from the
client’s perspective; and “influencing skills,” which are
imperative in facilitating change.
A number of counseling approaches to develop or
expand personal5
or coping skills33,35
that are supported by
evidence, primarily from the psychological literature, are
employed.5
For the majority of cases, the application of
therapeutic modalities that are useful for an eating disor-
der will apply as patients migrate from one diagnostic
classification to another.9
Behavioral approaches offer an
opportunity for change that can potentially extend beyond
the “physical” changes of food selection or body weight to
emotional and relational changes (eg, sense of self-confi-
dence or safety with food). Unfortunately, it is common
for patients to receive treatment from clinicians who are
not trained in therapeutic modalities.36
Unless the nutri-
tion therapist is specifically trained or credentialed in
counseling, he or she may not have adequate knowledge
and skill to succeed in facilitating change,5
particularly
among eating-disordered patients who experience extreme
fear and anxiety related to distrust, disgust, or a sense of
loss of control. The fundamental goal in applying psycho-
therapeutic strategies is that clients will recognize and
understand conscious and unconscious thoughts and
beliefs, as well as the moods or behaviors that affect eat-
ing and physical activity.
The “stages of change” model by Prochaska et al37,38
guides treatment to facilitate change in thoughts, feel-
ings, and behaviors based on a concept known as the
“processes of change.” Motivational interviewing (MI) is
a counseling style that is designed to promote motivation
to change. MI has been show to be effective in eating

disorders and obesity treatment.20
Implementation of the
principles of cognitive behavior therapy (CBT) and social
cognitive theory/social learning theory facilitate change in
diet for weight management, diabetes, and cardiovascular
disease.37
CBT was identified as effective for BN and
“similar syndromes” by the 2004 Cochrane review of psy-
chotherapy for eating disorders.39
CBT is considered a
stronger approach than others when used alone.40
CBT
has been specifically adapted for application to eating
disorders25
and has been shown to be effective when
administered by dietitians in a group setting for reducing
binge eating and improving depression, body image, and
self-esteem among obese women.17
However, the efficacy
of CBT alone for eating disorders is limited,6
and CBT
combined with other counseling approaches is likely nec-
essary for some, if not most, patients.41
Incorporation of individual or group CBT, dialectical
behavior therapy (DBT), or psychoeducation in nutrition
therapy is intended to promote greater understanding of
the mental, emotional, spiritual, and medical aspects
of the eating disorder. Self-monitoring, therapeutic repeti-
tion/clarification, role-play, modeling, imagery, and real-life
performance may be used to enhance skill and reduce
anxiety and guilt.5
Many clinicians describe their approach
as a mixed (eclectic) approach and may include narrative
therapy, self-disclosure, or a feminist approach.42
Nutrition
therapy groups are routinely offered along with individual
therapy in treatment centers, and pose advantages as well
as the possible disadvantages of contagion and exposure to
competition, which is undesirable. The nutrition therapist
balances education with collaboration and interaction
among group members to provide new or increased under-
standing and experimentation. Patients then go outside to
practice before returning to process the experience back in
the group.5
Some faith-based inpatient programs have shown
superior results when spirituality oriented CBT was used
as compared to secular CBT.43
Supporting and using one’s
spirituality in reducing mealtime anxiety and disorders
related to food, particularly among spiritually devout
patients, can promote successful outcomes.
Individuals with eating disorders are often ambivalent
and resistant to treatment,25
and severe eating disorders
are known for their protracted course.9
Among some
patients, “maintaining processes” that include clinical
perfectionism, pervasive low core self-esteem, mood
intolerance, and interpersonal difficulties interact with
the core psychopathology of eating disorders and contrib-
ute to treatment resistance.9
For these reasons, nutrition
therapy should be coordinated and concurrent with men-
tal health professionals33
who use psychological assess-
ments related to motivation, mood, anxiety, personality,
and substance use disorders that influence the clinical
course and outcome24
of nutrition therapy. In fact, assess-
ment of personality and temperament may be key to
implementing a treatment approach (eg, dialectical
behavior therapy) that is likely to promote positive change
as well as develop realistic expectations regarding the
course of illness and recovery.23
Expanded Responsibilities
The expanded responsibilities of the nutrition profes-
sional do not include counseling for complex psychologi-
cal and interpersonal issues such as trauma. However,
nutrition professionals may find themselves in a position
to counsel eating-disordered patients on physical activ-
ity or dental health. Nutrition deficiencies; purging
behaviors; use of caffeinated, carbonated, or sweetened
drinks; and the use of vinegar and lemon to reduce hun-
ger level are examples of relational links between nutri-
tion, oral health, and the eating disorder. Referrals to oral
healthcare providers experienced in eating disorders for
oral hygiene and treatment of discomfort or pain should
be considered when applicable. Attention to oral health is
important in dealing with altered oral aesthetics, body
image, and self-esteem, and affects the patient’s choice in
food/beverage and ultimately nutrition status. Thus, a
bidirectional relationship exists between nutrition and
oral health.44
Patients, families, and other members of the multidis-
ciplinary treatment team frequently look to the nutrition
therapist for guidance on balancing physical activity and
energy intake. Although nutrition professionals do not
develop exercise prescriptions unless specifically certified
to do so,45
it is appropriate to discuss the use and misuse of
activity among patients with inadequate energy intake, oste-
oporosis, or related bone disorders to reduce health risk.25
Again, referral to a physical therapist or athletic trainer
knowledgeable about eating disorders may be appropriate.
Addiction Models
For years, nutrition therapists and their patients have
operated on the premise that people respond to foods dif-
ferently and benefit from a personalized nutrition plan.
Evidence is emerging to suggest that manipulation of
both macronutrients and micronutrients may affect cog-
nition, mood, and behavior. Although not currently stan-
dard, some eating disorder units follow routine nutrient
supplement plans. More evidence is needed to determine
optimal levels of macronutrients and micronutrients
within this population.
Some weight management and treatment programs
for BN and BED operate from an addictions model based
on evidence that food affects the same neuronal systems
as do substances typically associated with abuse.
Specific food and environmental conditions may result in

physiological and behavioral responses similar to sub-
stance dependence (addiction).1,20,22
Nutrition choices may affect body mass index (BMI)
and influence mood through the serotonergic system.46
It
is known that binge eating increases in response to per-
ceived stress and associated negative mood.46
Munsch
et al46
suggest that binge eating may be the result of a
complex relationship between mood and the influence of
that mood on loss of control over eating and nutrition or
vice versa. Furthermore, they urge caution in interpreta-
tion of studies on nutrition and mood because naturally
occurring, chronic negative mood may illicit a different
response than that induced in a laboratory setting.
Corwin and Grigson1
compare DSM-IV-TR criteria
for substance dependence to the concept of food addic-
tion using the following:
•• Progressive use over time
•• Withdrawal symptoms
•• Use more than intended
•• Tried to cut back
•• Time pursuing, using, recovering
•• Missed important activities
•• Continued despite the consequences
According to the authors of this article, it appears that
concern related to highly palatable foods being inherently
addictive in and of themselves is without support, but the
pattern of intake of these foods (repetitious, intermittent,
“gorging”) may increase the likelihood of eliciting loss of
control in eating. Animal studies offer insight regarding
potential for food addiction related to neuropathways acti-
vated by highly palatable diets (fat and sugar) and key
reward pathways.22,47
Others identify environments that
mimic classic conditioning48
or associate problems in inter-
personal relationships, sense of not belonging or lack of
fulfillment, not being loved, feeling afraid or incompetent,
and the drive to feel nurtured and safe as driving forces to
becoming dependent on foods to meet needs.49
Overall, it
appears that treatment which includes attention to quality
and availability of food, inclusion of family members,
behavioral strategies that include motivation and readiness
to change, and physical activity are all components of a
program that recognizes potential influences of neuro-
psycho-social underpinnings of food on reward pathways.20
Patients frequently present concerns regarding the
effect of psychotropic medications and weight change to
the nutrition therapist. Although medications may be
related to weight change in scientific literature, the actual
risk for and magnitude of weight change is influenced by
individual characteristics of patients, course of illness or
treatment, or effects of past medications. Furthermore,
the mechanisms of actions related to medications and
weight change are largely unknown.18
Population Factors
Athletes
The prevalence of disordered eating among athletes is
debated, with reports that range from 1% to 62% among
female athletes and 0%-57% among male athletes.50
Athletes may be at higher risk for developing an eating
disorder because of the very traits that make them good
at their sport (perfectionism, competitiveness, concern
with performance) and emphasis on leanness.51
There is
also a possibility that individuals with preexisting eating
disorders may gravitate toward sports that support their
desire to achieve a certain physique.8
Although the extent
of disordered eating among athletes is unclear, a wide
variety of maladaptive eating, attitudes, and behaviors
have been reported among athletes attempting to alter
body weight or composition. Athletes pose an added chal-
lenge to healthcare providers and athletic personnel in
identifying either subclinical or full-syndrome eating dis-
orders. Some dietary and weight control maneuvers prac-
ticed by athletes are transient and safely managed as part
of the physiologic demands of the sport. However, others
are persistent and pose a threat to health, performance,
and even life.52
The nutrition therapist working with ath-
letes must be knowledgeable about dietary regimens prac-
ticed within various sports, as well as identifying nutrition
issues and challenges that affect health and performance.
The primary goal of dietary counseling for the athlete is
to provide for optimal food and fluid intake.53
An eating-
disordered athlete is at risk of inadequate energy and
nutrient intake to meet the demands of the sport, even if
weight is within a desirable range.52
The Female Athlete
Triad identified by the American College of Sports
Medicine describes a complex interrelationship between
“energy availability,” menstrual status, and bone
health.50,52,53
Low energy availability among female ath-
letes who present with the female athlete triad may sim-
ply reflect the challenge to eat enough to meet the energy
needs of their sport rather than an actual eating disor-
der.50
The deleterious effect of the triad on bone mineral
density is analogous to that in AN.54
When working with
an eating-disordered athlete, collaboration with the med-
ical and coaching staff and using medical nutrition proto-
cols to advance recovery is recommended. For more
information about managing disordered eating in ath-
letes, see the National Athletic Trainers’ Association posi-
tion statement.52
Pregnancy
An individual with AN, BN, or EDNOS may become
pregnant and experience unfavorable outcomes related to
inadequate nutrition and purging behaviors such as exces-
sive exercise and use of laxatives, diuretics, or appetite

suppressants. However, as many as 70% of pregnant
women with eating disorders report a reduction or full
remission of eating disorder symptoms during pregnancy.
One of the most predictive factors in pregnancy outcome
is weight gain during pregnancy.55
In May 2009, the
Institute of Medicine (IOM) updated guidelines for
weight gain during pregnancy that are based on prepreg-
nancy BMI rather than the Metropolitan Life Insurance
tables (Table 2).56
These new guidelines may present a challenge for
individuals whose coping mechanisms include an eating
disorder. After birth, data regarding breast milk produc-
tion and lactation by women with EDNOS, or with a his-
tory of EDNOS, are lacking. Mothers with AN are at risk
of underfeeding their infants either by diluting the for-
mula or prolonged breastfeeding and delayed introduc-
tion to solids.55
Some women may exacerbate their symp-
toms to avoid weight gain with pregnancy. Nutrition
professionals should collaborate with obstetrical practi-
tioners in reinforcing nutrition intake to support weight
gain and enable the mother to differentiate her own nutri-
tion needs from those of her infant, as well as making
appropriate referral to other healthcare professionals (see
Table 3).55
Target Weights
Determining a target body weight range for undernour-
ished eating-disordered patients is a challenging aspect in
the treatment plan. Outcome research has yet to provide
an empirically supported guide for target weight. For
the underweight patient, there is disagreement in the
literature regarding weight criteria considered “remis-
sion.” Recent data suggest that beginning weight restora-
tion early in treatment yields a better outcome.57
Failure
to achieve complete weight restoration increases risk for
relapse, with patients struggling with symptoms of their
disorder for a longer period of time.32,58-60
Nutrition therapists are often consulted to recom-
mend target weight ranges (also referred to as expected
body weight [EBW] or ideal body weight [IBW]) to the
treatment team. The nutrition therapist is uniquely qual-
ified to evaluate weight goals in the context of a patient’s
nutrition state and developmental stage.25
However, team
consensus is essential in providing a consistent message
about recommendations and treatment goals. If a team
does not show unity, one of the most compelling meas-
ures to push compliance with treatment is lost, with
potential to disempower caregivers and increase the risk
that the eating disorder will interfere with weight restora-
tion. Unity can be achieved in structured treatment set-
tings by including the patient as a member of goal setting
within the treatment team. The outpatient setting may
require greater coordination among treatment team mem-
bers who are not geographically close or can be achieved
by a conference call.
It is important to remember that there is wide varia-
tion of normal weight within the population, including
both children and adults. Some patients may meet “nor-
mal” weight parameters and actually be underweight
given their biological heritage. As a result, most clinicians
are making recommendations considering family history,
patient growth and development, patient weight history,
and actual patient functionality. Unfortunately, patients
or family members often engage in negotiation to limit
the weight restoration process. The extent of weight res-
toration may be limited by a patient’s willingness to
accept recommendations, current care environment, and
treatment resources.
Numerous and complex factors may be included in
determining a target weight range. Although BMI is com-
monly considered a screening tool for risk of weight-
related disease61
and monitoring growth,62
it is not
considered a tool for rigidly predicting an individual’s
healthiest weight at any given life stage or lifestyle or for
determining level of care needed. Many treatment groups
reach consensus among the team based on a patient’s abil-
ity to function both biologically and psychologically.
Biologically, patients would need to achieve a body weight
that supports body processes (eg, patient has normal hor-
mone function, reproductive function, and laboratory
values). Biological functionality limits the risk of bone
loss and other medical complications.33
Psychologically,
patients need to maintain mood stability and cognitive
processing adequate to make use of psychotherapy. Many
therapists identify when a patient is weight restored by the
quality of the patient’s work in psychotherapy. Other fac-
tors included in determining and reassessing the
target weight range may include pelvic ultrasound to
Table 2. Institute of Medicine Guidelines
for Weight Gain During Pregnancy
Prepregnancy BMI
Weight Category
BMI, kg/m2
(World
Health Organization)
Weight Gain
Recommendation
Underweight (BMI <18.5) 28-40 pounds
Normal weight 18.5-24.9 25-35 pounds
Overweight 25-29.9 15-25 pounds
Obese ≥30 11-20 pounds
Reprinted from Institute of Medicine. Weight Gain During
Pregnancy: Reexamining the Guidelines. Reprinted with permis-
sion from National Academies Press, Copyright 2009, National
Academy of Sciences.
BMI, body mass index.

assess ovarian and uterine size and function in female
patients, prior weight history before the eating disorder,
family norms, physical activity, and eating in response to
body cues. Finally, for female patients, the weight at
which healthy menstruation occured prior to the eating
disorder is only an indicator, as ovulation and menstrua-
tion may not resume until a higher weight is attained.24,63
Ultimately, target weight ranges are goals that are informed
but not necessarily a fixed number. The only way to truly
know if rehabilitation is achieved is to have a patient pur-
sue the recommended goal(s), and to reevaluate target
weights throughout the treatment process.
One school of thought is to recommend a target
weight as if the patient has the ability to remain in treat-
ment until full recovery is achieved. If treatment time is
limited, a goal for the episode of care can be determined.
The value in this approach is to support the patient
through multiple levels of care by not colluding with avoid-
ance of recommendations. Coordination among treatment
teams is essential when a patient is in a structured treat-
ment setting, such as an inpatient or a residential setting,
and then transitioning to the outpatient setting.
Energy Requirements
Determining energy needs for patients with eating disor-
ders presents a challenge. For patients with eating disor-
ders, attempts to correlate energy requirements using
equations typically used for determining energy expendi-
ture in hospitalized patients and general populations have
been unsuccessful.64-66
Indirect calorimetry is the most
accurate method for determining energy requirements in
patients with AN and BN.64,67,68
However, most clinicians
do not use indirect calorimetry. The cost, availability, and
portability of state-of-the-art equipment limit its use in
many settings. Lower cost, handheld, indirect calorime-
ters offer an affordable option, but research in a healthy
population is very limited,69
and these units have not been
studied in an eating-disorder population.
One possible limitation in using the handheld units
for determining resting metabolic rate (RMR) among
eating-disorder patients is their reliance on using a con-
stant for respiratory quotient (RQ), a comparison of
oxygen consumption and carbon dioxide output. The RQ
is used to verify valid measurements with the traditional
indirect calorimeters. The respiratory metabolic compen-
sation that occurs in eating disorders may affect both
components of RQ. A technology that assumes RQ, in
contrast to measuring it, may limit accuracy of data.
Clinicians may take a thorough nutrition history and then
develop an eating/feeding plan to meet the treatment
goal(s). For example, while working toward either weight
restoration or weight maintenance, the nutrition therapist
edits the meal plan to achieve treatment goals or adapts
the equations used to predict energy needs based on clini-
cal experience.
Many factors must be considered in determining how
much energy to recommend or provide for patients.
Overly aggressive feeding can be lethal to the chronically
malnourished patient. Underweight patients must be
carefully rehabilitated to prevent complications from
refeeding. Overfeeding a patient whose body has down-
regulated in response to negative energy balance can
result in refeeding syndrome,70
a constellation of chal-
lenges to multiple body systems that can be dangerous
early in care. Patients may experience hypophosphatemia,
hypokalemia, hypocalcemia, hypomagnesemia, and fluid
retention as well as thiamine deficiency. Judicious moni-
toring and cautious provision of energy can limit the like-
lihood of refeeding syndrome.70
The general practice is to
begin the refeeding process cautiously. Inpatient programs
often start feedings on reduced calorie regimens, typically
30-40 kcal/kg/d (often 1000-1200 kcal among low-weight
patients),24
with the initial goal being medical stabilization
and safety rather than weight recovery. This phase of treat-
ment may last 1-3 weeks.33
A balance of energy nutrients
and supplementation of vitamins and minerals is essential
to ease the patient out of a catabolic state and into an
anabolic one without electrolyte disturbance.
As carbohydrate intake increases among chronically
calorie-restricted patients, metabolism suddenly shifts
from fat utilization (low insulin environment) to an
increase in plasma insulin. Insulin drives an influx of
Table 3. Making a Referral of a Client With an Eating
Disorder for Continuation of Care
Consider Resources for Making a Referral
Credentials
and experience
Professional listservs and member lists:
The Academy for Eating Disorders
(http://www.aedweb.org)
National Eating Disorder Association
(http://www.nationaleatingdisorders.
org)
International Association of Eating
Disorder Professionals (iaedp.com)
The American Dietetic Association
(http://www.eatright.org)
Availability Colleague and Treatment Center
Recommendations
Philosophy Referral lists:
Eating Disorder Referral and
Information Center (http://www
.edreferral.com)
Something Fishy (http://www
.something-fishy.org)

phosphorus to meet the demands for phosphorylated
intermediates in glycolysis. The use of phosphorus to
build high-energy compounds (eg, adenosine triphos-
phate [ATP]) also increases, with resultant hypophos-
phatemia. In addition, potassium and magnesium enter
the cell while sodium is driven extracellularly. Plasma
expansion increases risk of heart failure.71
Interestingly, a
cooperative patient with adequate appetite and reasona-
ble food tolerance may require limited access to food,
sodium, and fluid to provide safe progression in rehabili-
tation without complication. Patient access to sodium
and simple sugars (gum, candy, breath mints, and even
cough drops) may therefore need to be limited to reduce
risk of refeeding syndrome.71
This can prove to be chal-
lenging in orally fed patients who have relied on personal
control of oral intake and whose psychological tolerance
of the process may be limited.
An experienced nutrition therapist can skillfully pro-
vide feeding with inclusion of all energy nutrients, limiting
the risk of refeeding syndrome. Nutrition education assists
the patient in understanding the need for caution at this
stage of care and expecting more flexibility in eating dur-
ing the next phase of care. The risk of refeeding syndrome
increases with more invasive feeding methods. Thus, the
goal is to provide balanced eating using the oral route as a
first preference, enteral route as a second preference, and
parenteral route as a last preference.70
Patients who need
enteral intervention often tolerate continuous drip feed-
ings better than bolus feedings, especially early in the
rehabilitation process. Carefully monitoring the patient’s
therapeutic response via laboratory data, vital signs, daily
weights per protocol, and fluid intake and output is essen-
tial to manage refeeding risk. Once medical stability is
achieved, weight restoration at a rate of 2-3 lb per week
for hospitalized patients and 0.5-1 lb per week for patients
in outpatient treatment is generally accepted and desire-
able.24,25,33
Forced treatment and feeding should be con-
sidered a life-saving rescue effort.25,32,33
Body weight gain among AN patients may be difficult to
achieve, particularly in the outpatient setting. Tolerance for
a low body weight is lower when treating children and teens
compared with adults; inpatient care may be recommended
even though weight loss is not severe enough to avert irre-
versible impacts on growth and development.24
Rapid weight
restoration is likely to carry greater psychological distress for
the patient, although it may meet demands of insurers.32
The literature suggests that structured treatment pro-
grams provide a secure and consistent environment that
imparts the “key ingredients” of “predictability and confi-
dence.”32
Underfeeding in this population can slow treat-
ment progress for a variety of reasons. Downregulation of
metabolic rate continues, resulting in limited growth,
endocrine impairment, and ability to use psychotherapy.
Furthermore, children and adolescents who have reached
a healthy weight will benefit from a meal plan that
includes increased energy necessary to support future
growth and development.25,72
Patients with anorexia nervosa may require more
energy than expected to achieve weight restoration, with
energy needs at 70-100 kcal/kg/d for some patients.24
One
explanation is that patients are compelled to sabotage
efforts, fearing loss of the eating disorder and becoming
overweight or obese.73
Patients may interfere with the
weight restoration process through dishonesty, discarding
food, exercising, or vomiting. Conversely, some patients
will actually have a higher than expected energy demand.
An increased thermic effect of food73,74
and challenges
with absorption of nutrition have been postulated as con-
tributors to the increased energy demand.
The focus of nutrition rehabilitation in normal-weight
BN patients is on normalization of eating behavior, estab-
lishing a consistent eating pattern, and consumption of a
diet that is energy neutral. Research suggests that BN
patients may be more metabolically efficient, requiring
fewer calories than their non–eating-disordered peers.75
Although indirect calorimetry is the most accurate method
of determining energy needs,76
most clinicians use
adjusted energy equations, a thorough diet history, and
clinical skill to establish energy goals.
For patients who have not used binging or purging
behaviors, increased energy needs may persist for a period
after weight restoration is complete.77,78
This need is
thought to be related to slow normalization of neuroendo-
crine processes. Thus, consistent nutrition therapy to
assist the patient with weight maintenance is recom-
mended to consolidate progress and prevent relapse.
How, when, and to what degree one should intervene
in the treatment of excess adiposity is controversial. Risks
that should be considered include hypertension, impaired
glucose tolerance or diabetes, dyslipidemia, cardiovascular
disease, and obstructive sleep apnea.79
Although osteoporo-
sis is not included in this list, there is emerging evidence
that higher levels of body fat mass are related to chronic
systemic inflammation and accelerated bone resorption.80
Cognitive limitations induced by malnutrition include
potentiating of mood disorders as well as limitation in
executive function. Patients often note poor attentiveness
that resolves when adequate energy is available. This pro-
vides the clinician with a positive outcome of the renutri-
tion process that is not weight related.
Macronutrient Composition
Currently, there is no recommendation for macronutrient
distribution specific to the eating-disordered population.
Nutrition therapy includes individualized planning to
assist each patient in addressing cognitive distortions
with regard to the nutrition quality of food, specifically
carbohydrate, protein, and fat. Meal planning should

include adequate carbohydrate with a focus on energy
utilization throughout the day. Although many patients
focus only on the nutrition relevance of each food,
achieving dietary quality can be complicated. The nutri-
tion therapist will assist patients in attending to personal
taste preferences and the inclusion of discretionary calo-
ries within the realm of a balanced diet with the goal of
promoting flexibility, limiting dietary restraint, and achiev-
ing satiation.
Although most patients know that dietary protein
provides the amino acid substrates important for lean tis-
sue synthesis and repair, roles for protein and amino acids
in multiple metabolic roles, including thermogenesis and
glycemic regulation, are emerging.81
Evidence of the role
of precursor amino acids in neurotransmitter synthesis
can assist the nutrition therapist in helping patients
include quality sources of protein in the diet.82
Several
researchers have investigated the role of amino acids in
the treatment of depression.82-86
Although dietary manip-
ulation studies have indicated promise, to date, effect on
mood appears to be limited.87
More research is necessary
to apply this science to actual food prescriptions. However,
an explanation of the effect that energy and protein insuf-
ficiency play in the bioavailability of amino acid building
blocks for the synthesis of neurotransmitters such as
serotonin and dopamine underscores the potential for
nutrition to exacerbate mood disorders and is an effective
construct for nutrition therapy. Inclusion of dietary pro-
tein at each meal plays an important role in achieving
satiety81
and a more sustained energy curve, which can
appeal to patients struggling with frank binge eating or
fear of binge eating.
Dietary fat is frequently avoided in the eating-
disordered population; however, it is essential to a bal-
anced eating plan. ω-3 Fatty acids have gained much
recent attention. ω-3 Intake alters the structure and
functional integrity of membranes in central nervous
tissue.87
The precise mechanisms by which cognitive
function is influenced by ω-3 fatty acids is unclear, but
most theorhetical mechanisms involve neurotransmit-
ters.85
Evidence suggests that limited ω-3 fatty acid
intake may be linked to mental disorders, primarily
depression, in the general population.87-91
For the
patient at risk of cardiovascular disease, 250-1000 mg
of eicosapentaenoic acid (EPA) and docosahexaenoic
acid (DHA) may be effective,92
whereas the recom-
mended dose for treating mental disorders such as
depression ranges from 1.5-9.6 g daily.89
Thus, although
ω-3 fatty acids have not specifically been implicated in
the treatment of eating disorders7
and the optimal
intake remains under investigation, ω-3 fatty acids may
be useful in treating some symptoms (eg, elevated
serum triglyceride levels, insulin sensitivity, mood dis-
orders) and are frequently included in the treatment
plan for individuals with eating disorders.7
ω-3 Fatty
acids remain in tissue membranes for weeks.92
Given
the health benefits of inclusion of ω-3 fatty acids in the
diet, ω-3-rich foods as sources of fat are routinely
incorporated into meal planning.
In addition, the inclusion of dietary fat limits the
respiratory load for severely malnourished patients89
and provides a protein-sparing effect. However, dietary
fat intake must be carefully balanced with the issue of
early satiety in the eating-disordered population. The
satiety effect of dietary fat can be helpful to some
patients who are experiencing impulses to binge eat as
an aid in the prevention of overeating. Introduction of
fat in the diet as an antibinge nutrient can assist
patients with fat phobia.
Micronutrients
Eating-disordered patients often have limited intake of
vitamins and minerals,93-95
potentially leading to micronu-
trient deficiency,24
although frank deficiency occurs less
often than expected. Various micronutrient deficiencies
have been found among patients who restrict food intake.7
An association between B vitamin deficiency and mood
disorders typical of eating disorders has led to supplemen-
tation with niacin, vitamin B12, and folic acid and reported
improvement in appetite and mental state.7
A thorough
diet history can evaluate insufficiency of micronutrient
intake. It is common practice to routinely supplement
patients with a complete multivitamin/mineral prepara-
tion during treatment. Many treatment teams routinely
evaluate serum vitamin and mineral levels supplementing
additional micronutrients, including folic acid, thiamine,
vitamin B12, zinc, vitamin D, and calcium. Evidence of
sustained deficiency of folic acid and zinc after weight
recovery96
suggests supplementation may be recom-
mended beyond the rehabilitation phase of treatment.
Bone health is of concern due to overwhelming evidence
of bone loss in this population.54,97,98
To date, vitamin D
and calcium intake do not appear to be primary predictors
of bone mineral density among adolescents with AN.54
Annual bone density scans have become standard with
most treatment teams for patients who have experienced
a 6-month or greater interruption in menses.54
Vitamin D
supplementation should be in response to actual labora-
tory evaluation of serum 25-hydroxyvitamin D. Many
experts now recommend a dose of 1000 IU (25 mcg) per
day to maintain normal vitamin D levels; greater doses are
needed to promote vitamin D repletion for individuals
with levels reflecting vitamin D deficiency or insuffi-
ciency.99
Consensus among researchers is that a target
level of 35-40 ng/mL is an ideal serum level for health and
the prevention of a variety of concerns, including bone
health, dental health, muscle strength, and a variety of

other conditions.99
Thus, vitamin D status is routinely
assessed in the eating-disordered population.
Meal Plans
Nutrition therapy addresses variety in food selections,
desensitization to binged and/or purged foods, and normal-
ization of eating behavior, including social eating. The use
of structured eating plans to establish consistent intake
allowing for provision of essential nutrition and satiety and
limiting dietary restraint and fluid loading is common prac-
tice, although to our knowledge, research has not identi-
fied the most effective type of plan for any individual.
Two common foundations for developing meal plans
are MyPyramid and Exchange Lists for Meal Planning.
Although MyPyramid is not intended as a “therapeutic
diet,” it may be appropriate for improving eating habits
among eating-disordered individuals. However, Krebs-
Smith and Kris-Etherton100
point out that the professional
must be aware of certain issues related to its use. MyPyramid
is a product of the US Department of Agriculture and was
designed to guide the general public in food selection to
provide nutrient adequacy and reduce risk of chronic dis-
ease. The Exchange Lists were developed as a joint effort
between the American Diabetes Association and the
American Dietetic Association. Foods within each nutrient-
dense food group can be traded (or “exchanged”) with
another food within that group, plus additional tallying of
added fats, energy-supplying sweeteners, and alcohol to
achieve a specified energy and macronutrient intake.100
MyPyramid offers both opportunities and drawbacks
for the eating-disordered patient. MyPyramid emphasizes
that nutrients should come from nutrient-dense foods, as
foods provide a variety of healthful benefits in addition to
nutrients. MyPyramid reinforces moderation and variety
in food choices as well as balance between energy intake
and physical activity.
If using MyPyramid eating plans, nutrition profes-
sionals should consider that 12 energy levels up to 3200
kcal/d are provided. Food group recommendations
assume limited processed foods, no added salt, and
selection of foods in their most nutrient-dense form that
are free of any added fat or energy-containing sweeten-
ers; meats are the leanest, trimmed cuts, and milk prod-
ucts are the lowest in fat (eg, skim milk was used in
calculating energy provided rather than regular
cheese).100
Many individuals with eating disorders will
need a meal plan at some point in the recovery process
that provides more than 3200 kcal/d; RDs possess the
skills to modify existing plans to meet individual needs.
The discretionary energy allowance provided is minimal
relative to the typical American’s intake of fats
and added energy-containing sweeteners, and may
not support the notion that “all foods can fit” without
explanation.100
Energy intake is the basis of the 12 food
patterns provided. This is generally not helpful to the
eating-disordered patient as it may reinforce calorie
counting and monitoring body weight.100
Guidelines are
available from national organizations (such as the Clinical
Guidelines on Overweight and Obesity,American Diabetes
Association, American Heart Association, American
Institute for Cancer Research, and the National
Cholesterol Education Program) that outline macronutri-
ent recommendations (eg, 15%-21% of calories from
protein, 28%-31% from fats, and 53%-58% from carbohy-
drate) similar to the MyPyramid recommendations.100
Whatever system the nutrition therapist uses for
guiding food intake toward normal, updates to treatment
plan and reassessment must be ongoing.
Emerging Research
Exposure to internal and environmental stress interrupts
the development of gut flora, with increasing stress
resulting in more pronounced damage and increased risk
of inflammatory and allergic disease.101
The body’s natu-
ral gut flora are affected by various factors, including
stress, chronic constipation, antibiotics, and excess alco-
hol use.7
Studies of adolescents under challenging life
circumstances, including those with AN, suggest that
including probiotics such as those in yogurt can result in
beneficial effects on immunologic markers.101
Lactic acid
derived from milk, other dairy products, or capsules is
well tolerated and improves absorption of minerals,7
improves immune function,7,101
and reduces the inflam-
matory response102
and severity of constipation7
such as
that related to irritable bowel syndrome (IBS). Individuals
with an eating disorder may be at higher risk of develop-
ing IBS.103
Long-Term Complications
The literature indicates a long course of illness for many
patients with eating disorders.104
Prompt and adequate
intervention is affiliated with improved clinical out-
comes.104
Long-term complications of eating disorders
involve growth interruption, bone loss, cardiovascular
abnormality, compromised reproductive function, gastro-
intestinal challenges, and death,24,105,106
which are caused
in part by ongoing nutrition disturbances. Patients require
consistent medical monitoring and ongoing care to man-
age any lingering effects of the eating disorder.107
Nutrition
status is challenged over a significant period of time;
therefore, therapy with an experienced nutrition therapist
is recommended to limit risk24,27
and minimize long-term
complications of the eating disorder. Clinical complica-
tions of eating disorders affect the following24
:

•• Electrolyte balance
•• Cardiovascular system
•• Gastrointestional system
•• Reproductive system
•• Metabolism
•• Nutrition status
•• Skeletal and dental health
•• Muscular strength
•• Body weight and composition
•• Cognition
•• Growth
Sudden death related to eating disorders cannot be
predicted by length of illness. Low serum albumin and BMI
lower than the 60th percentile (BMI ≤12) are the strongest
risk factors. Additional considerations include electrolyte
imbalance, excessive exercise with low body weight,
hematemesis, frequent attempts to purge by vomiting or
laxative use, inadequate (or excessive) fluid intake, rapid
weight loss, and presence of and type of food restriction
(high protein and low carbohydrate).33
Interpretation of
vital signs, anthropometric measurements, systems func-
tion, and evidence of self-injurious behavior, family interac-
tions, and attitudes regarding food, exercise, and appearance
requires collaboration with other professionals.24
Prevention
Because most eating disorders develop during adoles-
cence,7
timing is critical to successful prevention efforts.
Registered dietitians hold positions where they may
contribute to eating disorder prevention in a variety of
settings. It is well known that changes in knowledge do
not necessarily translate into change in attitude or behav-
ior and that there is evidence that providing information
about eating disorders may increase risk.51
Shaw et al101
reviewed eating disorder prevention programs and identi-
fied the following as successful characteristics of pro-
grams reducing the risk of eating pathology: (1) target
high-risk individuals (vs universal), (2) include interactive
programs (such as those that include cognitive behavioral
strategies, guided discovery, and active dissonance-
induction11,102
) and promote internalization of concepts,
and (3) consist of multisession interventions delivered by
trained professionals to participants 15 years or older.
Health professionals have been concerned that efforts
to prevent or treat overweight or obesity among children
may inadvertently contribute to the development of eating
disorder behaviors, poor body image, weight bias, or
unhealthy weight gain.102,103,105
Recent research suggests
that moderate calorie restriction does not pose a psycho-
logical risk among children105
or adults,103
but this conclu-
sion is preliminary as an abundance of evidence suggests
that emphasizing appearance and weight can promote
eating disorder symptoms.102
Neumark-Sztainer106
describes
recommendations for both preventing obesity and eating
disorders, all of which are directly applicable to the exper-
tise of dietitians: (1) discourage dieting and encourage
sustainable eating and physical activity programs, (2) pro-
mote a positive body image, (3) encourage frequent and
enjoyable family meals, (4) encourage families to avoid
“weight talk” and do more at home to facilitate healthy
eating and physical activity, and (5) address weight mis-
treatment among overweight teens and their families.
Although preliminary evidence suggests that highly
palatable, energy-dense foods may promote loss of control
regarding food intake among some people or condi-
tions,22,47
nutrition therapists can safely manage the food
addiction theory and counsel patients and parents by
emphasizing (1) that overrestriction of these foods
increases preference and eating in the absence of hun-
ger108
and (2) that science supports the principles of a
balanced diet, including a variety of foods in moderation.
The media have a powerful influence on adolescent
desire for change, including change of eating behavior.
Including media literacy in nutrition education will help
teens gain knowledge of factors that influence their food
choice and eating behaviors.109
Nutrition services and
classroom nutrition education are vehicles for integrating
obesity and eating disorder prevention.110
Coordination Across the Continuum of Care
An RD experienced in the treatment of eating disorders
is integral to a complete course of care.27
The nutrition
professional working with eating-disordered patients
should begin with a proper medical diagnosis and then
provide the patient with a clear description of treatment
options.110
Although most eating-disordered patients can
be treated in an outpatient setting,33
the availability of
treatment, evidence of symptom improvement or lack
thereof, and medical–psychiatric risk are important to
the decision to recommend a higher level of care.32,33
At
all treatment levels, utilization of a stepwise approach
should move the patient from a high level of structure,
providing predictability and confidence, toward greater
flexibility and self-trust as one moves toward recovery.32
Criteria for level of care is provided by the American
Psychiatric Association.24
Eating disorders are complex, multifactorial ill-
nesses that are difficult to successfully treat. A coordi-
nated, well-planned approach by a multidisciplinary
treatment team that includes a protocol for transition
between levels of care and providers is recommended for
optimal care.13,14,24,32
Transition to a lower level of care
is fraught with opportunities that pose a risk for, and
contribute to, relapse.32
Continued care beyond the
rehabilitation phase is required to assist patients
with establishment of new lifestyle habits with regard
to nutrition and general health practices. It is the

responsibility of clinicians to make appropriate referrals
and maintain communication.
Recommendations for the Future
Nutrition professionals treating individuals with mental
disorders, including eating disorders, must be willing to
stay current regarding the use of nutrition as both a first
line of defense and adjunct treatment. It is essential that
the nutrition therapist treating eating disorders stay
abreast of, and contribute to, emerging evidence and
therapeutic strategies that prove to be effective.
Workshops, seminars, formal or self-education, and infor-
mal or formal supervision are all routes to gaining knowl-
edge and enhancing counseling skill.
Clearly, treatment involves decisions in terms of select-
ing appropriate treatment regimens. The first principle of
medicine is primum non nocere (above all, do no harm).111
The potential benefits, as well as risks, in all aspects of
nutrition therapy—from assessment, to intervention, and
even to prevention—to reduce the risk of causing uninten-
tional harm must be considered by all healthcare practi-
tioners. Thus, the effective nutrition therapist will be in a
position to model calculated risk-taking by using strategies
that are based on good decision making with the goal of
making each experience the best it can be.112
The state of treatment knowledge related to eating
disorders is limited, and additional empirical evidence is
needed to identify effective nutrition strategies. We
encourage clinicians to publish research, including single
case studies, as these may further understanding of treat-
ment acceptance, relapse, and recovery rates.40
Acknowledgments
The authors acknowledge Cindy Heiss, PhD, RD,
and Ovidio Bermudez, MD, FAED, for review of this
manuscript.
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315
Volume 25 Number 3
June 2010 315
© 2010 American Society for
Parenteral and Enteral Nutrition
10.1177/0884533610374593
http://ncp.sagepub.com
hosted at
http://online.sagepub.com
Erratum
Rollins MD, Scaife E, Jackson W, Mulroy C, Book L, Meyers R. Elimination of Soybean Lipid Emulsion in Parenteral
Nutrition and Supplementation With Enteral Fish Oil Improve Cholestasis in Infants With Short Bowel Syndrome.
Nutr Clin Pract. 2010;25:199-204. (Original DOI: 10.1177/0884533610361477)
In the above article, on page 202, 2 amounts in Table 2 appear incorrectly. Under “20% soybean lipid emulsion,” in the
“linoleic” line, the amount should be 0.1 g/mL instead of 1.1 g/mL. In the “total fat(kcal/ml)” line, the amount should
be 2.0 g/mL instead of 0.2 g/mL.

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