MNT in Eating Disorders
MNT in Eating Disorders The Ideal Body Image Media promotion Social acceptance Influence and stress on young individuals Food: More Than Just Nutrients Linked to personal emotions Comfort Release of natural opioids Reward Eating Disorders (APA Diagnoses) Anorexia nervosa Bulimia nervosa Eating disorder not otherwise specified (EDNOS) Binge eating disorder (BED) Schebendach in Krause, 12th ed., p. 564) Genetic Link? Identical twins have a higher chance of eating disorders Fraternal twins are less likely Profile of Anorexia Usually occurs between the ages of 12-18 Typically white female Lifetime prevalence among women is .3 to 3.7%, depending on criteria used 5%-10% are male Middle-upper socioeconomic class Often coexists with other psychiatric disorders: major depression or dysthymia (5075%), anxiety disorders, OCD (40%) 5-20% mortality rate, mostly from heart failure or arrhythmias Schebendach in Krause, 12th Ed, p 564 Anorexia Nervosa: Psychological Features Perfectionism Harm avoidance Feelings of ineffectiveness Inflexible thinking Overly restrained emotional expression Limited social spontaneity Schebendach in Krause, 12th Ed., p. 564 Anorexia Nervosa Food rituals – Cuts food in small pieces – Rearranges food on plate Eliminates foods gradually – 300-600 calories a day – Diet pop, sugarless gum Prolonged exercise Preoccupation with food Cooks for others Hungry, but refuses to eat Diagnostic Criteria American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria are the standard AN APA Diagnostic Criteria Weight <85% standard Intense fear weight gain/fat although underweight Distorted body image Women: amenorrhea: absence of 3 consecutive periods Restricting type – Not regularly engaged in binge eating-purging behavior Binge eating/purging type – Regularly engaged in binge eating and purging behavior AN Diagnostic Criteria Weight deficit is necessary (<85% of expected) If AN develops in childhood or early adolescence, failure to make expected weight gains instead of weight loss may occur – Stunting possible in prepubertal children – Growth charts are essential Amenorrhea may not be useful in younger patients as menarche may be delayed Related Psych Disorders in AN Depression: May be due, in part, to the psychological stress of starvation Obsessive-compulsive disorder: may be exacerbated by malnutrition Comorbid personality disorders: poor impulse control, substance abuse, mood swings, and suicide tendencies Prevalence of AN More prevalent in industrialized countries that idealize a thin body type although expected to become more widely distributed Lifetime prevalence among women is .5% to 3.7%, depending on criteria used Prevalence among men is one tenth of that among women Schebendach in Krause, 12 edition, p. 564 th Risk Periods for Anorexia Nervosa Age 14 – puberty, high school Age 18 – college, full time jobs Pathophysiology of AN Physical and psychological consequences of malnutrition Pathophysiology of AN Depleted fat stores; muscle wasting Amenorrhea Cheilosis Postural hypotension; dehydration or edema Bradycardia; hypothermia Sleep disturbances Pathophysiology of AN: Osteopenia Reduced bone mineral density May result in vertebral compression, fractures Caused by estrogen deficiency, elevated glucocorticoid levels, malnutrition, reduced body mass Affects males and females Pathophysiology of AN Low body temperature/cold intolerance Lower metabolism: low thyroid hormone Bone marrow hypoplasia (50% of AN patients) results in leukopenia, anemia, thrombocytopenia Pathophysiology of AN: Cardiovascular Decreased heart rate <60 bpm – Fatigue, fainting Decreased blood pressure <70 mm/Hg systolic; orthostatic hypotension Reduction in heart mass Mitral valve prolapse related to hypovolemia or cardiomyopathy – Death from CHF Pathophysiology of AN Iron deficiency anemia Increased infections Dry skin, hair Yellow skin due to hypercarotenemia Desquamation, hair loss, alopecia Hirsutism Lanugo: fine body hairs Pathophysiology of AN: GI Bloating, abnormal fullness after eating Constipation Digestive enzymes low Pathophysiology of AN Electrolyte imbalance → heart failure, death – Low intake potassium – Loss in vomiting, diuretics – Refeeding syndrome: electrolyte imbalances caused by too-rapid refeeding 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 binges/purge cycles/week – Uncontrollable eating during binge – Purge regularly: vomiting, laxatives, diuretics, strict dieting, fasting, vigorous exercise Continues at least 2x/wk for ≥ 3 months American Psychological Association. DSM-IV-TR, ed 4, Washington DC, 2000 Bulimia Nervosa Prevalence Lifetime prevalence of BN among young adult women is 1% to 3% Rate of occurrence in males is 10% of that in females Rarely seen in childhood Schebenbach, in Krause, 12th edition, p. 565 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 Profile of Bulimia Young (usually female) adults (college students) May be predisposed to becoming overweight Usually at or slightly above normal weight Tried frequent weight-reduction diets as a teen Impulsive Often goes undiagnosed Profile of Bulimia Nervosa Other psychological disorders, including major depression, dysthymia, anxiety disorders, personality disorders, substance abuse Low self esteem Guilt Preoccupied with food Recognize behavior is abnormal Binge Definition Eating, in a discrete period of time (e.g., within any 2-hour period) an amount of food that is definitely larger than most people would eat under similar circumstances A sense of lack of control over eating during the episode Binge Relieves stress Common binge foods: – High carbohydrate, high fat – Convenience foods – Cakes, cookies, ice cream – Soft, easier to purge High food bills Purge Laxatives, enemas – Act on large intestine – 90% of calories are absorbed in small intestine – Damages large intestine → constipation Vomiting Most commonly used compensatory behavior (80%-90% of BN) 33-75% of calories still absorbed Fingers down throat – Damaged knuckles Syrup of Ipecac – Toxic to heart, liver, kidneys – Poison if taken repeatedly Vomiting Teeth – Stomach acid erodes enamel – Pain, decay Diuretics Water loss Electrolyte loss NO fat loss! Hypergymnasia: Excessive Exercise Compulsive exercise: that which significantly interferes with life activities Occurs at inappropriate times or in inappropriate settings Continues despite injury or other medical complications Symptoms of BN Usually normal weight and secretive in behavior Scarring of the dorsum of the hand used to stimulate the gag reflex, known as Russell’s Sign Parotid gland enlargement Erosion of dental enamel with increased dental caries resulting from gastric acid in the mouth Pathophysiology of BN: Vomiting Dehydration Alkalosis Hypokalemia Sore throat, esophagitis, mild hematemesis Abdominal pain Pathophysiology of BN: Vomiting Subconjunctival hemorrhage Mallory-Weiss esophageal tears Esophageal ruptures (rare) Acute gastric dilatation or rupture Salivary gland infections Pathophysiology of BN: Laxative Abuse Dehydration Elevation of serum aldosterone and vasopressin levels Rectal bleeding Intestinal atony Abdominal cramps Pathophysiology of BN: Diuretic Abuse Dehydration Hypokalemia Pathophysiology of BN Cardiac arrhythmias related to electrolyte and acid-base imbalance caused by vomiting, laxative, and diuretic abuse Ipecac may cause irreversible myocardial damage and sudden death Menstrual irregularities Vicious Cycle of Bulimia Eating Disorder Not Otherwise Specified (EDNOS) A diagnostic category for eating disorders that fail to meet full criteria for either anorexia nervosa or bulimia nervosa May have partial symptoms of either AN or BN For example, all criteria for AN may be met except patient has regular menses OR significant weight loss but wt still Physical Manifestations of Eating Disorders Treatment of Eating Disorders AN: Treatment Nutrition Increase food intake to raise the BMR Prevent further weight loss Restore appropriate food habits Ultimately weight gain Some weight restoration and treatment of malnutrition may make psychotherapy more effective AN: Treatment Psychological Cognitive behavior therapy Determine underlying emotional problems Reject the sense of accomplishment associated with weight loss Family therapy, support group Nutrition Assessment in Eating Disorders Assessment of Intake in Eating Disorders Calories compared with DRI Evaluate macronutrient mix (carbohydrate, protein, fat) Evaluate micronutrient intake compared with DRI Estimate fluids and compare with needs Evaluate alcohol, caffeine, drugs, dietary supplements Dietary Intake in AN Generally inadequate caloric intake, <1000 kcals/day Tend to avoid fat Many follow a vegetarian lifestyle – Identify whether vegetarian lifestyle coincided with onset of disease Dietary Intake in BN Highly variable; in one study mean intake of 4446 kcals; 44% overeating, 19% undereating When not binge eating may follow a low fat diet Eating Behavior in AN/BN Unusual or ritualistic behaviors Unusual food combinations Nontraditional utensils Excessive spices, vinegar, lemon juice, noncaloric sweeteners Meal spacing, length of time allocated for a meal BN: may eat quickly AN: may eat in excessively slow manner AN/BN Eating Attitudes Food aversions “Safe” foods Magical thinking Binge trigger foods Ideas on appropriate amounts of food Misconception that purging eliminates all calories from a binge episode Lab Assessment Visceral proteins: generally normal in AN Lipids: elevated cholesterol and abnormal lipid profile; may be due to hepatic dysfunction, decreased bile acid secretion, hypothalamic dysfunction, eating patterns – Does not warrant prescription of low fat, low cholesterol diet Lab Assessment Serum glucose: low due to lack of precursors for gluconeogenesis and production Low T3 syndrome: low levels of active form of thyroid hormone; resolves with refeeding Vitamin-Mineral Abnormalities Hypercarotenemia: in AN restrictors; mobilization of lipid stores, catabolic changes, metabolic stress; normalizes with rehab Deficiency diseases rare in AN, possibly due to use of supplements, catabolic state, use of nutrient-dense foods Osteopenia and osteoporosis are common Metabolic Changes AN: low metabolic rates (REE 62-70% of expected, or 700-1000 kcals) Refeeding causes increases in REE Elevated diet-induced thermogenesis (DIT) and ↑ REE may require high calorie prescriptions in nutritional rehab BN: unpredictable metabolic rate Helpful to measure REE using indirect calorimetry Anthropometric Assessment AN patients meet criteria for marasmus (depleted adipose and somatic protein stores but intact visceral proteins) Body composition: underwater weighing or DEXA; BIA of questionable validity Skinfolds from 4 sites (triceps, biceps, subscapular, suprailiac crest) MAMC Body Weight Assessment Goal weight determined by various methods (NCHS growth tables to age 18) Daily preprandial early morning weight in hospital Gowned weight on the same scale once a week in outpatient (pt should void and urine specific gravity checked or patient examined to determine if bladder is full) Management of Eating Disorders Multidisciplinary team including physicians, nutritionists, psychotherapists May include inpatient medical or psychiatric hospitalization, partial hospitalization and residential treatment, intensive outpatient, or outpatient programs Treatment Goals AN: weight gain and correction of malnutrition disorders; normalization of eating patterns and behaviors BN: weight maintenance in the short term even if patient is overweight until eating habits are stabilized Factors Affecting Weight Gain in AN Fluid balance – Polyuria seen in starvation – Edema from starvation or refeeding – Hydration ratio in tissues Metabolic rate – Resting energy expenditure – Postprandial energy expenditure Factors Affecting Weight Gain in AN Energy cost of tissue gained – Lean body mass – Adipose tissue Previous obesity Physical activity Nutritional Care in AN Often require hospitalization to begin refeeding Some require enteral feedings, but most can be rehabbed with oral feedings Goal is increase in energy intake with weight gain Energy intake must be increased gradually while minimizing caloric expenditure Nutritional Care in AN Initial calorie prescriptions 1000-1600 kcals, or 30-40 kcals/kg Increase 100 to 200 kcals q 2-3 days; may be as high as 70-100 kcal/kg/day Hospitalized patients: goal is 2-3 lb/week Outpatients: 1 pound/week APA Practice Guidelines for the Treatment of Eating Disorders, January, 2006 Refeeding Syndrome Refeeding malnourished patients with AN can result in life-threatening hypophosphatemia, cardiac arrhythmia, and delirium May be precipitated by high-calorie feeding regimens Patients weighing less than 70% desirable body weight at greatest risk Serum phos, mg, K+, calcium must be closely monitored and supplements provided as needed Energy Needs in AN 70-100 kcals/kg may be needed for continued weight gain (depends on REE and type of tissue gained) AN more physically active than controls; require ↑ kcals for weight maintenance May require 3000-4000 kcals/day later in wt restoration (males 4000-4500) Energy Needs in AN If unsuccessful in weight gain, evaluate for discarding food, vomiting, exercising, increased motor activity, metabolic resistance Use indirect calorimetry in fasting and postprandial state Once at goal rate, 40-60 kcals/kg should promote wt maintenance and continued growth and development in adolescents Macronutrient Mix Fat intake of 25%-30% of calories is recommended as added fat or less obvious sources (whole milk or peanut butter) Protein: 15%-20% of calories; RDA for age and sex in grams/kg of IBW; high biological value sources; vegetarian diets should be discouraged during rehab Carbohydrate: 50%-55%; include sources of insoluble fiber to relieve constipation Micronutrients Vitamin-mineral supplements: may have increased need in anabolism; 100% RDA multivitamin with minerals (iron may ↑ constipation) Encourage calcium-rich foods and Vitamin D MNT in AN Early treatment: caloric intake usually low, can be provided in 3 meals per day; snacking may relieve some physical discomfort Later treatment: as caloric prescription increases, snacks become unavoidable Defined formula liquid supplements may be helpful; patients may be more willing to accept them than large volumes of food MNT in BN Immediate goal interruption of the binge and purge cycle with weight maintenance Rarely hospitalized except for electrolyte disturbances Energy Needs in BN May be hypocaloric; poor correlation between predicted and actual REE Measured REE preferable; provide calories at 120%-130% measured REE – Signs of low metabolism: history of chronic dieting, low T3 level, cold intolerance – In presence of low metabolism, provide 1500-1600 kcals/day) or determine average calories/day based on current intake Energy Needs in BN Monitor anthropometric status and adjust caloric prescription for weight maintenance Avoid weight reduction diets until eating patterns and body weight are stabilized May be on low-calorie intakes for longer periods than anorectic patients Monitoring of BN Patients Bingeing, purging, restrained intake impair recognition of hunger and satiety cues Many patients with BN are afraid to eat early in the day as they might binge later May digress from meal plan after a binge, attempting to compensate Macronutrients in BN Protein: 15-20% of calories; meet RD in g/kg IBW; HBV sources Carbohydrate: 50%-55% of calories; encourage insoluble fiber Fat: 25%-30% of calories – Provide source of essential fatty acids MVI: multivitamin with minerals Cognitive Behavioral Therapy Structured psychotherapeutic method alters attitudes and problem behaviors Identifies and replaces negative, inaccurate thoughts Typically a 20-week intervention that – Establishes a regular eating pattern – Evaluates and changes beliefs about shape and weight – Prevents relapse Female Athlete Triad Three Components Eating disorder Lack of menstrual periods Osteoporosis – Bones like 60-year-old – Caused by low estrogen – Often irreversible – Early warning: stress fractures Also meet criteria for EDNOS Female Athlete Triad Female athletes participating in appearance-based and endurance sports Seen in 15% swimmers, 62% gymnasts, and 32% of all other sport Female Athlete Triad Performance thinness: the commonly held belief that achieving a lower weight and percentage of body fat will enhance performance Appearance thinness: trend to reward thinner athletes in adjudicated sports such as gymnastics and figure skating Treatment for Female Athlete Triad Reduce preoccupation with food, weight, and body fat Increase meals and snacks gradually Rebuild body to healthy weight Establish regular menses Decrease training Binge-Eating Disorder (Compulsive Overeating) Complex and serious eating disorder Occurs in ~30% -50% of subjects in weight control programs (40% are males) More common with obese individuals with history of restrictive dieting ~50% exhibit clinical depression Not preoccupied with body shape Onset adolescence or early 20s Binge Eating Disorder Diagnostic Criteria (APA) Recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of BN At least 2x week over 6 month period Distress, disgust, guilt, depression Binge-Eating Disorder (Compulsive Overeating) Eat more rapidly than usual Eat until uncomfortable Eat when not hungry Cannot control binges Embarrassed, guilty after binge Binge Eating Process Precondition Trigger phase Maintenance phase Ending phase Post-binge phase (consequences) Characteristics of a Binge-Eater Consider self as hungrier than normal Isolate self to eat large quantities Triggered by stress, depression, anxiety, loneliness, anger, frustration Usually binge on “junk” foods Eat without regards to biological need Food is used to reduce stress, provide feeling of power and well-being Treatment for BingeEating Learn to eat in response to hunger Learn to eat in moderation Avoid restrictive diets which can intensify problems Increase activity Treatment for BingeEating Increase self-acceptance and improved body image Address hidden emotions Overeaters Anonymous Antidepressants Baryophobia “The fear of becoming heavy” Children are given a low-fat, restricted diet in hopes to ward off obesity or heart disease Detrimental to children; affect growth and development Self-imposed restrictive diets by young adults to avoid obesity Lack of appropriate nutrition information Treatment for Baryophobia Nutrition education Nutrition required for proper growth Appropriateness of sweets and fats in the diet Childhood Eating Disorders DSM criteria not appropriate in young children Cases of AN reported in children as young as 8 years old BN rare in childhood C/o nausea, abdominal pain, difficulty swallowing, concerns about weight, shape, and body fatness Five Warning Signs of Childhood Eating Disorder Decreasing weight goal Increasing criticism of the body Increasing social isolation Disruption of menstruation Reports of purging in the context of dieting Eating Disorders in Dietetics Students There is some evidence that the prevalence of disordered eating is higher in dietetics students than in other majors, though the research has been mixed Eating Disorders in UG College Students Worobey and Schoenfeld surveyed 165 undergraduate women (mean age 21.6+4.9 years and 46 men (22.4+6.6 years) from dietetics, exercise science, dance, psychology, and biology/nursing Worobey J, Schoenfeld D. Eating disordered behavior in dietetics students and students in other majors. JADA 1999;99:1100-1102 Eating Disorders in UG College Students Nursing/biology majors had significantly higher BMI and weight Dietetics students scored highest on Cognitive concerns and binge/purge behavior Worobey J, Schoenfeld D. Eating disordered behavior in dietetics students and students in other majors. JADA 1999;99:1100-1102 Eating Disorders in College Students Dietetics and dance majors scored highest on Life Interference Dance students scored highest on Excessive Exercise Worobey J, Schoenfeld D. Eating disordered behavior in dietetics students and students in other majors. JADA 1999;99:1100-1102 Eating Disorders in College Students Fredenberg et al surveyed 5 groups of students in DPD dietetics, CP dietetics, non-food home economics curricula, college basketball or volleyball 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. Eating Disorders in College Students Fredenberg and colleagues found no significant differences among the groups of college women surveyed in EAT scores (Eating Attitude Test.) However, 17.7% of DPD students had EAT scores symptomatic of eating disorders compared with 3.3% and 2.9%, respectively for CP and home economics students (NS) This was lower than in a previous study (24%) (Drake et al, JADA, 1989) Worobey J, Schoenfeld D. Eating disordered behavior in dietetics students and Prognosis Mortality has declined for AN from 10% to 2%. 20% to 30% will have a lifelong struggle with food Bulimics may need long-term counseling to correct underlying philosophies and beliefs. Family counseling is useful for both AN and bulimia. High relapse rate after treatment Topics for Nutrition Education Impact of malnutrition on growth and development Impact of malnutrition on behavior Set-point theory Metabolic adaptation to dieting Restrained eating and disinhibition Causes of bingeing and purging 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. Topics for Nutrition Education —cont’d Impact of exercise on caloric expenditure Ineffectiveness of vomiting, laxatives, and diuretics in long-term weight control Portion control Food exchange system Social dining and holiday dining Food Guide Pyramid Hunger and satiety cues Interpreting food labels Nutrition misinformation Modified from Schebendach J, Nussbaum MP: Nutrition management in Adolescents with eating disorders. Adoles Med: State Art Rev 3 (3): 556, 1992. Dying To Be Thin Normal to be concerned about diet, health, and body weight Weight normally fluctuates Treat physical and emotional problems early Discourage restrictive diets Correct misconception about foods Thin is not necessary better Summary Nutritional intervention supports psychologic strategy
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