Brain Growth There are two peaks of brain growth, about 26 weeks of gestation and around birth.

In the brain stem, DNA synthesis ontinues at a s!ow but steady rate unti! at !east " year of age. In most regions of the brain, the tota! number of e!!s present in adu!ts is !arge!y determined by the end of the first year of !ife Infants who weighed 2000 gr or less at birth and who died of severe undernutrition during the first year of life have a reduction of 60% total brain cell number In #e$i o and Guatema!a psy ho!ogi a! tests was found to be re!ated to dietary pra ti e and not to differen es in persona! hygiene, housing, ash in ome, rop in ome, proportion of in ome spent on food, parenta! edu ation, or other so ia! or e onomi indi ators. %erforman e of both pres hoo! and s hoo! hi!dren on the Terman and Goodenough draw&a&man tests was positi'e!y orre!ated with body weights and heights Be ause the shorter hi!dren did not ome from fami!ies signifi ant!y !ower in so io&e onomi fa tors, housing, and parenta! edu ation than those of the ta!!er hi!dren, it was on !uded that the most important 'ariab!e ref!e ted by the short stature was poor nutrition during ear!y !ife and that this a!so !ed to the !ag in de'e!opment of sensory integrati'e ompeten e . In a study done in Jamaica, all of the children from a low-income group undernourished at any time during the first 2 years of life had significant behavioral abnormalities at school age study was conducted to a population of !orean children" some were severely undernourished during the first year of life and then adopted by families in the #$. ll of the infants were adopted before their second birthday by merican families. They were then !assified as ma!nourished, moderate!y ma!nourished, and we!! nourished. By the time they rea h ( years of age, there were no differen es in a'erage weight among the three groups and a!! rea hed norma! )orean standards. *hanges in height were simi!ar to those in weight e$ ept that the undernourished hi!dren remained s!ight!y but signifi ant!y sma!!er. The mean I+ of the pre'ious!y undernourished groups was ",2.,-. The margina!!y nourished hi!dren a hie'ed a mean I+ of ",-..-. This is not a statisti a!!y signifi ant differen e. The pre'ious!y we!!&nourished hi!dren rea hed a mean I+ of """.6/, whi h does represent a signifi ant differen e from the undernourished hi!dren. The data a!so suggest that when we!!&nourished hi!dren are p!a ed in a more stimu!ating en'ironment they do e'en better. In a!! pre'ious studies, when the hi!d was returned to his or her pre'ious en'ironment, the I+ was (, or be!ow at s hoo! age. In a study in *o!ombia, se'ere!y undernourished hi!dren after re o'ery ha'e been p!a ed in an enri hed en'ironment at about 2 years of age. The hi!dren are e$posed to a!! types of stimu!ating !earning and p!ay e$perien es. Their nutrition has been kept ade0uate. %re!iminary resu!ts show that the test !e'e!s of the stimu!ated undernourished hi!dren are higher than those of the hi!dren from the higher so io& e onomi group who were not stimu!ated. 1esu!ts show that the we!!&nourished and stimu!ated hi!dren ha'e the highest !earning apa ity. %ryptophan and $erotonin Tryptophan is the pre ursor of 2erotonin. It is an essentia! amino a id and is found in a!! high& 0ua!ity proteins.

"

2erotonin is needed to regulate sleep, secrete pituitary hormones, and perceive pain. %he levels of serotonin in the brain can be altered by ingestion of tryptophan. 3n a high&protein mea! is eaten, on!y a sma!! amount is on'erted to serotonin. It is be ause tryptophan must ompete with other amino a ids to enter the brain. 4hi!e after a arbohydrate&ri h mea!, insu!in auses these ompeting amino a ids to !ea'e the b!ood and enter mus !e tissue. #ore tryptophan enters resu!ting drowsiness. %eop!e who eat a high& arbohydrate !un h are !ess a!ert fo!!owing the mea! than peop!e who eat a sma!!, high&protein !un h &ecithin, 'holine, and cetylcholine *ho!ine is deri'ed most!y from !e ithin in eggs, !i'er, soybeans, and food additi'e of mayonnaise and ho o!ate. The effe t that ho!ine has on a ety ho!ine N5613T1AN2#ITT51 is !ess dramati than that in the tryptophan&serotonin onne tion. Anima!s in7e ted with ho!ine ha'e in reases in a ety! ho!ine !e'e!s in the brain, though not as high as the tryptophan&serotonin rea htion. It is due to the fa t that transport of ho!ine from the b!ood into the brain and the subse0uent synthesis of a ety! ho!ine are more omp!e$ omparing to the tryptophan&serotonin system. *ho!ine supp!ementation has produ ed some promising resu!ts in treating tardi'e dyskinesia. *ho!ine has a bitter taste and auses an ob7e tionab!e fishiy body odor in peop!e who take it, making it an unp!easant treatment. Gi'ing !e ithin instead of ho!ine resu!ts a simi!ar su ess in treating tardi'e dyskinesia without the same drawba ks. %ure !e ithin is, howe'er, a bu!ky, wa$y substan e that must be taken in !arge amounts to be effe ti'e and added a nine a!ories a gram to a person8s diet. %eop!e with A!9heimer8s disease :who tend to be defi ient in a ety! ho!ine; gi'en supp!ementation ha'e no dramati resu!ts and suggest that this approa h is not effi a ious in A!9heimer8s disease or in enhan ing memory

%yrosine and the 'atecholamines The *ate ho!amines in !udes epinephrine, norepinephrine, and dopamine. 5ating a high&protein mea! in reases the amount of tyrosine in the b!ood fo!!owed by the !e'e!s in the brain. A more effe ti'e means is ingestion of a pure tyrosine supp!ement with arbohydrates that stimu!ates insu!in se retion. In rease in brain tyrosine wi!! in rease the !e'e!s of ate ho!amines, parti u!ar!y dopamines. This strategy has a potentia! benefit for patients suffering from %arkinson8s disease. The effe t of !e'odopa e'ident!y has a simi!ar effe t to that of tyrosine. Tyrosine has a!so been used with !imited su ess to treat depression, probab!y by in reasing the !e'e!s of norepinephrine. But tyrosine has not been appro'ed by the <DA for use as a drug be ause !itt!e is known about the possib!e harm of !ong&term use at high&dosage !e'e!s (itamins 3ne prob!em that was aused by 'itamin defi ien y is pe!!agra, with symptoms ranging from physi a! and psy hiatri . 2erious defi ien ies of thiamin, 'itamin B6, B"2, 'itamin *, and fo!i a id an a!so pro'oke psy hiatri symptoms. Thiamine defi ien y auses )orsakoff8s psy hosis and 4erni ke8s syndrome. =itamin B6 defi ien ies !ead to infant menta! retardation, and mood hanges :in some ases, psy hosis; in adu!ts.

=itamin B"2 defi ien ies auses anemia and neuro!ogi damage whi h in turn damages menta! fun tion. <o!i a id defi ien ies auses mega!ob!asti anemia that is sometimes pre eded or a ompanied by menta! disturban es in !uding irritabi!ity, mood swings, and paranoid beha'ior. =itamin * defi ien ies auses s ur'y, whose symptoms may in !ude depression and hypo hondriasis. Aside from these, there is no on rete e'iden e that any other psy hiatri i!!nesses are aused by nutritiona! defi ien ies or that su h i!!nesses an be treated with diet in ountries with !ow ma!nutrition number. It has been a!!eged that mi!d 'itamin defi ien ies might ause some impairment of brain fun tion. But nutrition s ientists are autious about it and re0uire ade0uate e'iden e before rea hing a definite on !usion %race )inerals There has been onsiderab!e resear h into the ro!e of tra e minera!s in brain and ner'e fun tion. Iodine defi ien y may !ead to thyroid defi ien y and retinism whi h is hara teri9ed by menta! retardation and serious prob!ems in growth and de'e!opment. Iron defi ien y is be!ie'ed to impair neuropsy ho!ogi a! fun tion in hi!dren, manifesting itse!f in part as !a k of attention and a!ertness in s hoo!. This is probab!y aused by inade0uate o$ygen rea hing the brain, sin e it is essentia! to proper o$ygen transport in the body. >in is another minera! that is essentia! in a number of ma7or bio hemi a! pro esses that affe t brain fun tion. *opper is a!so essentia! to norma! fun tioning of the entra! ner'ous system. Diseases su h as #enkes8 disease whi h auses inade0uate intestina! absorption of opper !eads to brain and growth retardation in infants. 3n the other hand, 4i!son8s disease is the resu!t of gradua! a umu!ation of opper in the body tissues, in !uding the brain. The resu!t, o'er time, is a deterioration of menta! fun tion. The minera! #anganese is essentia! for norma! brain fun tion. It appears to be in'o!'ed in the on'ersion of !e'odopa to dopamine in the brain. But e$ esses of manganese in the brain is found in %arkinson8s disease and some forms of dementia, a!though no know!edge is a'ai!ab!e on its ro!e in the de'e!opment of these onditions ?igh !ead and mer ury !e'e!s resu!t in entra! ner'ous system abnorma!ities that may !ead to persona!ity hanges, irritabi!ity, and s!eep disturban es. *a! ium and magnesium a!so p!ay a ro!e in some brain fun tions. ?ypo a! aemia an produ e menta! aberrations. *rthomolecular and )egavitamin %herapy 3rthomo!e u!ar therapy is defined as the @treatment of menta! disease by the pro'ision of the optimum mo!e u!ar en'ironment for the mind, espe ia!!y the optimum on entration of substan es norma!!y present in the human bodyA. The word @optimumA !e'e! appears to be a synonym for megadoses of 'itamins.. The therapy in !udes nia in, 'itamin *, B6, B"2, fo!i a id, minera!s, hormones, diets that redu e b!ood&g!u ose !e'e!s, and diets free of foods a!!eged to ause a!!ergies. In ".(B, A%A found no e'iden e to support the pra ti e of it, and hara teri9ed the under!ying therapy as superfi ia!, in onsistent, and ontradi tory. #ost !aims that !arge doses of 'itamins are usefu! in treating brain&fun tion disorders !a k support from ontro!!ed studies. %re!iminary resear h a!!eges that !arge doses of 'itamin B6 might be benefi ia! in treating some autisti hi!dren. In two studies of autisti hi!drean C both of whi h ha'e been a!!ed into 0uestion in terms of their 'a!idity C impro'ement was seen with administration of 'itamin B6. <urther tests are needed, howe'er, before !arge doses of 'itamin B6 an be re ommended as treatment. They an be harmfu!

+yperactivity in 'hildren The use of diet therapy to treat hypera ti'e hi!dren has a!ways been 0uestionab!e. Dr. Ben7amin <eingo!d proposed that sa!i y!ates, artifi ia! food o!ors, and artifi ia! f!a'ors aused hypera ti'ity. The restri ting diet works, but the su ess has nothing to do with the diet itse!f. 6nder <eingo!d8s dietary restri tions, ommon foods that are genera!!y hi!dren8s fa'orites are a!most omp!ete!y e!iminated. Dr. <eingo!d8s !aims of su ess in treating hypera ti'e hi!dren were ane dota!. Doub!e&b!ind s ientifi studies gathered at onsiderab!e e$pense o'er the years ha'e been unab!e to substantiate his !aims. These studies !ear!y showed that the belief a <eingo!d diet was being used was what worked. 1esponsib!e s ientifi studies ha'e fai!ed to find any re!ation between 'itamin megadoses therapy and !essened hypera ti'ity, and some ha'e found that hi!dren re ei'ing !arge doses of 'itamins a tua!!y be ame more hypera ti'e, ompared to hi!dren re ei'ing a p!a ebo. 2ome studies reported that the more sugar a group of hypera ti'e hi!dren onsumed, the more destru ti'e, rest!ess, and aggressi'e they were. ?owe'er, se'era! other studies ha'e shown that sugar a tua!!y an ha'e a a!ming effe t on hi!dren, whi h was arried out at the Nationa! Institute of #enta! ?ea!th and was high!y redib!e. 2in e onsuming sugar dire t!y enhan es serotonin produ tion, it is more !ogi a! that sugar wou!d ha'e a a!ming effe t *affeine has been !aimed to ause hypera ti'ity. The truth is affeine auses in reased motor a ti'ity and fidgetiness in pre&ado!es ent boys )alnutrition and ,ehavior 4hi!e most !inks between diet and beha'ior are weak, there is no 0uestion that se'ere ma!nutrition an ha'e a signifi ant impa t on beha'ior, parti u!ar!y in hi!dren. #a!nourished hi!dren tend to ha'e diffi u!ties in !earning to speak, in adapti'e and moti'ationa! beha'ior, interpersona! re!ationships, and de'e!opment of motor ski!!s ,rea-fast and $chool .erformance <ar more subt!e are the !earning diffi u!ties that may or may not re!ate to fasting in s hoo!& hi!dren. In genera!, it was found that hi!dren who ate breakfast performed better throught the morning on different measures of ogniti'e performan e than those who skipped it. The optima! breakfast was one that was ba!an ed in protein, arbohydrates, and fats /ood llergies and ,ehavior A!!ergi rea tions to spe ifi foods are be!ie'ed by many peop!e to ause beha'iora! abnorma!ities, but ob7e ti'e !ini a! tria!s ha'e fai!ed to show that they do so, or that they an a ount for neuro!ogi a! or psy hiatri prob!ems. 1esponsib!e immuno!ogists and a!!ergists genera!!y find that true food a!!ergies are un ommon, and beha'iora! prob!ems aused by a!!ergies are e$ eptiona!!y rare. 2e'era! studies of peop!e who !aimed that food a!!ergies were ausing su h symptoms as !ethargy, depression, mood swings, irritabi!ity, poor on entration, an$iety, and s!eep!essness found that on!y a sma!! per entage suffered from genuine food a!!ergies.

a-&inolenic cid 0 & 1 AEA is known as "/FB n&B, with a hain !ength "/ arbons !ong and three bonds that are unsaturated. It is found in f!a$ and f!a$seed oi!, ano!a oi!, soybeans, and peri!!a, as we!! as in se'era! 'arieties of nuts and their oi!s. It an fun tion as a pre ursor for the n&B fatty a ids ei osapentaenoi a id :5%A; and do osahe$aenoi a id :D?A;, with a !ow on'ersion e'en in the most optimum nutritiona! onditions, and !imited 'ariety of 'itamins and minera!s further !imits it. This has made most e$perts do not re ommend the re!ian e of AEA as a sour e of 5%A and D?A. 2icosapentaenoic cid 02. 1 and 3ocosahe4aenoic cid 03+ 1 5%A :2,F- n&B; is primari!y found in fish. 6nder onditions of tissue D?A saturation, D?A an @retro on'ertA into 5%A. D?A :22F6 n&B; is a!so primari!y found in fish, whi h obtain it by eating marine a!gae. D?A is stored in the fish8s mus !e tissue and an a!so be obtained from marine a!gae as supp!ements. 3#5GA&B <ATTG A*ID2 AND B1AIN <6N*TI3N D?A is the brain8s bui!ding b!o k, pro'iding stru ture to neurons and is an an hor point for neurotransmitter re eptor. In rats fed a D?A&defi ient diet, neuron atrophy was obser'ed in the parieta! orte$ :!ogi a! thinking enter;, hippo ampus :memory enter;, and hypotha!amus :hormone enter; D?A a!so has an antio$idant effe t. Ade0uate D?A is important for maintaining hea!thy neurotransmitter fun tion, in !uding for dopamine and serotonin. This has been shown in anore$ia patients, where antidepressant is not effe ti'e for promoting the i!!ness :when the body fat is sti!! minima!; but effe ti'e in re!apse pre'ention :after the patient has regained fat; D?A has the abi!ity to raise the sei9ure thresho!d of the ner'ous system. By redu ing ner'ous system a ti'ity, fish oi!s ha'e been found to ha'e therapeuti 'a!ue in diseases that tent to worsen under stress. The effe t of D?A and 5%A on sei9ure a ti'ity may partia!!y be e$p!ained by their effe t on neuron e$ itabi!ity or neura! hypera ti'ity 3BTAINING AD5+6AT5 D?A AND 5%A 3btaining and retaining D?A and 5%A depend on ade0uate intake, as we!! as important !ifesty!e and @ma roAnutritiona! hoi es. It is often what is eaten in addition to D?A and 5%A that determines whether o'era!! essentia! fatty a id !e'e!s are ade0uate 3uring .regnancy and &actation Go'ernmenta! warnings about fishes to$i !e'e! of mer ury :that is harmfu! to feta! growth; an be a'oided by taking fish&oi!&supp!emented margarine and omega&B eggs, as we!! as wi!d aught sa!mon, sardines, herring, ha!ibut, and tuna. *urrent!y D?A and 5%A are appearing in foods in four different formsF #enhaden, #i roen apsu!ated <ish 3i! %owder, D?A and 5%A %rodu ed by 3ther Ei'esto k and #arine A!gae H #enhaden is a pe!agi , surfa e feeding fish that is not typi a!!y onsumed by huans be ause its bony stru ture doesn8t render mu h edib!e f!esh. ?owe'er the oi! of this fish was designed by the <ood and Drug Administration to be on the Genera!!y 1egarded As 2afe :G1A2; !ist, pro'ided that ma$imum intake did not e$ eed B gIpersonIday. The produ t then was used as additi'e on other produ ts

#i roen apsu!ated <ish 3i! %owder is produ ed by for ing fish oi! through a sie'e and reating sma!! f!akes that an be in orporated into food produ ts su h as bread. In 2,,- a new heat&stab!e powder produ t was introdu ed in the 62, pro'iding an a!ternati'e to fish and fish oi!s H 3ther sour e produ ed by !i'esto k with higher 5%A and D?A ontent in !udesF 5ggs of hi kens fed a suffi ient amount of f!a$seedJ #i!k from ows fed with grasses high in omega&B fatty a idsJ #eat of anima!s feed primari!y on grasses. H #arine A!gae is the primary sour e of D?A and 5%A. They are eaten by fishes and thus rise up in the food hain to humans. It is important to note that Eggs and marine algae-based products contain DHA only 3uring Infancy 3ne of the most important sour es of D?A and 5%A is mother8s mi!k. 1edu ed time spent between mother and babies has redu ed the a'ai!abi!ity of omega&B fatty a ids to babies. 2ome baby formu!as were made with marine a!gae as the sour e. This had made them ontain on!y D?A. 3uring dulthood Eong& hain fatty a id patho!ogy. They shou!d be used and are thus effe ti'e. %atients a! oho!ism, tardi'e dyskinesia supp!ementation

:E*<A; supp!ements wi!! often impro'e depression and its re!ated with 'itamin 5 supp!ementation to make sure that they are not o$idi9ed with bipo!ar disorder, postpartum depression, s hi9ophrenia, dementia, and other psy hiatri onditions may a!so impro'e with E*<A

N6T1ITI3N 15*3##5NDATI3N2 5oal 67 'onsumption of 3ietary 3+ and 2. The dai!y needs of omega&B fatty a ids re ommended by Internationa! 2o iety for the 2tudy of <atty A ids and Eipids :I22<AE; is 22, mg ea h of both D?A and 5%A. ?owe'er, the needs may be mu h higher. I22<AE does not !arify whether its re ommendations are spe ifi a!!y for an apparent!y hea!thy popu!ation, or if this is what is needed in a popu!ation su h as in the 6nited 2tates with !ess fish intake and a pandemi defi ien y of omega&B fatty a ids. It is important to know that a!! seafood is benefi ia! with regard to omega&B ontent. 5oal 27 )aintenance of a 3iet with a &ow %otal 3aily *mega-6 to *mega-8 9atio A high n&6Fn&B ratio :K",; appears to promote inf!ammation and o$idation, and if it happens to the brain and ner'ous system !eads to an in rease in menta! i!!ness. A benefi ia! ratio is probab!y !ose to 2F". 4hen onsidering a re ommendation of fish or fish oi! supp!ements, onsider that the in !usion of fish in a mea! impro'es the o'era!! ba!an e of fat, saturated fat, and po!yunsaturated fat in addition to in reasing the n&B intake. It is the n&6Fn&B ratio that is important, not the tota! amount of n&B. Ironi a!!y, in 'egan 'egetarian diets was found to ha'e some of the highest ratio. =egan 'egetarians ha'e been found to ha'e !ower tissue D?A on entrations than non'egetarians. 2upp!ementations of D?A may he!p in menta! i!!ness of 'egan 'egetarian, as the high DNA on entrations may be retro on'erted to 5%A. 5oal 87 voidance of 9estrictive 3iets that 2ncourage 9apid :eight &oss

Dietary manipu!ation and restri tion annot spe ify whi h type of fat is !ost. 5'en an omega&B AEA supp!ementation during a weight !oss diet has been found not to preser'e n&B stores in tissue. Two or more generations of D?A defi ien y : aused by restri ti'e eating; affe t brain fun tion, spe ifi a!!y spatia! !earning and o!fa tory& ued re'ersa! !earning task.

5oal ;7 Increased ntio4idant Inta-e #aintenan e of hea!thy fatty a id !e'e!s ha'e 2 goa!s F to in rease the !e'e!s through dietary hoi es and to pre'ent their o$idation through dietary food hoi es. A!though D?A is an antio$idant, another antio$idant may preser'ing these fats, so a good supp!ement shou!d ontain 'itamin 5. A diet ri h in fruits and 'egetab!es is an important strategy. In addition, when prepared with 'inaigrettes and marinades, they an be important arriers of omega&B fatty a ids. C Anore$ia Ner'osa :AN; C Bu!imia Ner'osa :BN; C 5ating Disorders Not 3therwise 2pe ified :5DN32; C Binge 5ating Disorder :B5D; The treatment of eating disorders re0uires a mu!tidis ip!inary approa h in !uding psy hiatri I psy ho!ogi a!, medi a!, and nutritiona! inter'ention. The nutritiona! rehabi!itation in !udes nutrition assessment, medi a! nutrition therapy :#NT;, nutrition ounse!ing, and nutrition edu ation. A!though the eating disorders are distin t i!!ness, simi!arities e$ist in nutritiona! onse0uen es and nutritiona! management. Nutrition assessment routine!y in !udes a diet history and the assessment of bio hemi a!, metabo!i , and anthropometri indi es of nutrition status DI5T ?I2T31G In diet history, the assessment of energy intake, ma ro L mi ronutrient onsumption, eating attitudes L beha'iors shou!d be in !uded in the guide!ines. 6sua!!y an AN patient onsume !ess than ",,, k a! per day, and they usua!!y o'erestimate their food and energy intake. Assessing typi a! energy intake wi!! pre'ent o'erIunderfeeding at the start of rehabi!itation and open a dia!ogue regarding a!ori re0uirements during the refeeding and weight maintenan e phases BN patients energy intake may be unpredi tab!e due to the a!ori ontent of a binge, the degree of a!ori absorption after a purge, and the e$tent of a!orie restri tion between binge episodes. Though they assume that 'omiting may e!iminate a!ories onsumed during the binge episodes, a study of "( BN sub7e ts onsuming a mean of 2"B" k a! during binge, the a!orie e!iminated during the 'omit was on!y .(. k a!. This !eads to a on !usion that energy e!imination is be!ow energy onsumption. Another assumption is that the a!orie onsumed during a binge an be omp!ete!y purged is a!so a mis on eption. As a ru!e of thumb, M-,N energy onsumed during a binge is retained after purging. Inade0uate intake resu!ts in de reased onsumption of arbohydrate, protein and fat. AN patients tend to a'oid arbohydrate and fat ontaining foods. And as a!orie intake drops, the amount of arbohydrate, fat, or protein intake is a!so redu ed, a!though the re!ati'e to tota! a!ori onsumption may not. It is be ause the per entage ontributed is re!ati'e to tota! amount of a!ori intake, and this may be in the a'erage to abo'e&a'erage range. This, with !imited 'ariety and poor food group representation, wi!! resu!t in inade0uate 'itamin and minera! onsumption. In genera!, mi ronutrient intake para!!e!s

ma ronutrient intake :fat fatty a id L fat so!ub!e 'itamins;. 2o it is important to ompare the a!ori intake with D1I. #any AN patients fo!!ow 'egetarian diets. This affe ts the 0ua!ity and 0uantity of protein intake. Assessment of the patient8s diet history before AN and the fami!y diet may be re0uired. It is important to know whether the patient fo!!owed 'egetarianism before or after she de'e!op AN. Be ause of day&to&day 'ariabi!ity in eating disorder, a 2D&hour re a!! is not parti u!ar!y usefu!. It is better to estimate dai!y food onsumption o'er the ourse of a week. <irst, determine the number of non& binge days :either restri ti'e or norma! intake; and appro$imate their a!ori ontentJ determine the binge days and appro$imate a!ori ontent and dedu t -,N :purged;J then a'erage them. Typi a! f!uid intake shou!d a!so be determined be ause abnorma!ities in f!uid ba!an e are pre'a!ent in this popu!ation. 5$treme f!uid restri tion or onsumption may re0uire monitoring of urine spe ifi gra'ity and serum e!e tro!ytes. 5ATING B5?A=I31 AN and BN patient ommon!y de'e!op food a'ersions. They tend to regard foods as abso!ute!y @goodA or abso!ute!y @badA. This shou!d be identified and ha!!enged throughout the treatment pro ess. In addition, determine a!so unusua! or ritua!isti beha'iors :ingestion of food in atypi a! manner, with nontraditiona! utensi!sJ unusua! food ombinationsJ e$ essi'e use of spi es, 'inegar, !emon 7ui e, and artifi ia! sweeteners;, mea! spa ing and !ength of time a!!o ated for a mea!. #any BN patients eat 0ui k!y, ha'e a @binge&triggering food@ and de'e!ops an a!!&or&nothing approa h towards it. A!though they may prefer a'oidan e, assistan e with reintrodu tion of ontro!!ed amounts of these foods at regu!ar times and inter'a!s is he!pfu!. In AN, the patients eat in an e$ essi'e!y s!ow manner, often p!aying with their food and utting it into sma!! pie es. These may be regarded as a ta ti to a'oid food intake or an effe t of star'ation EAB31AT31G A22522#5NT A!though patients tend to onsume a !ow a!orie diet, but some present with e!e'ated serum ho!estero! !e'e!s. But this does not warrant the ontinuation of a fat& and ho!estero!&restri ted diet during nutritiona! rehabi!itation =ITA#IN AND #IN51AE D5<I*I5N*I52 Despite the !ow intake diets, true defi ien y diseases are un ommon. The de reased need for mi ronutrients in a atabo!i state, use of 'itamin supp!ements, and se!e tion of mi ronutrient&ri h foods may be prote ti'e. Iron defi ien y anemia is a!so un ommon in AN due to de reased re0uirements. The true pi ture may be masked by hemo on entration resu!ting from dehydration in ear!y treatment. 3n e refeeding has been initiated, ?b may de rease from base!ine 'a!ues ?yper arotenemia, ommon!y found in AN though e$ essi'e dietary intake of arotenoids is !ess ommon, shou!d be norma!i9ed during the ourse of nutrition rehabi!itation. 5N51GG 5O%5NDIT615

1esting energy e$penditure :155; is hara teristi a!!y !ow in ma!nourished AN patients, basa! metabo!i rate fa!!s as mu h as ",N&"-N to onser'e energy, and refeeding wi!! in rease it. ?owe'er, in some ases the in rease in 155 is e$ essi'e and presents as metabo!i resistan e to weight gain. BN patients an ha'e unpredi tab!e metabo!i rates. Dietary restraint may p!a e them in a state of semistar'ation :a hypometabo!i rate; and binge&purge an in rease the metabo!i rate se ondary to a preabsorpti'e re!ease of insu!in. ANT?13%3#5T1I* A22522#5NT A goa! of nutritiona! rehabi!itation is restoration of body fat and fat&free mass. Body weight is assessed and routine!y monitored in patients with eating disorders. In AN, weight gain is ne essary whi!e in BN, weight maintenan e is the short&term goa!. In genera!i9ation, a hange of B-,, k a! in a!ori intake is fo!!owed by a hange of " !b in body weight. A!though the tota! body fat norma!i9es after short&term weight restoration, the distribution may not be norma!. T?5 #5DI*AE N6T1ITI3N T?51A%G AND *36N25EING
Outpatient Outpatient

Intensive Outpatient

Intensive Outpatient Day Treatment (Day Hospital)

Day Treatment (Day Hospital)

Inpatient

Inpatient

Anorexi a Nervosa

Bulimia Nervos a

AN315OIA N51=32A Treatment of AN may begin at one of four !e'e!s of are depending on the se'erity of ma!nutrition, degree of medi a! and psy hiatri instabi!ity, duration of i!!ness, and growth fai!ure. 2ome begin with inpatient hospita!i9ation and stepped down, others may begin on an outpatient basis and may step up. 5oals of <utritional 9ehabilitation o *orre tion of bio!ogi and psy ho!ogi a! se0ue!ae of ma!nutrition o 1estoration of body weights o Norma!i9ation of eating patterns, eating beha'iors, and hungerIsatiety ues ?ospita!&based programs or residentia! treatment is warranted when the AN patient is medi a!!y unstab!e, se'ere!y ma!nourished, or growth retarded. 6nder these ir umstan es, the a!ori pres riptions are determined by the medi a! do tor or treatment team. The proto o! for menu p!anning may 'ary. The patient may either parti ipate in menu p!anning from the beginning of treatment or when her weight is restored. 2ometimes the patient may need to omp!y guide!ines in menu p!anning

There are no out ome studies to suggest that one method is better than others, and despite the differen e, AN patients onsistent!y find it diffi u!t to make food hoi es, and the 1egistered Dietitian :1D; an be e$treme!y he!pfu!. In an outpatient setting, the team has !ess ontro! o'er the hoi es, so the 1D must use ounse!ing ski!!s to begin the p!an de'e!opment. AN patients are typi a!!y pre ontemp!ati'e or ambi'a!ent about making hanges in eating beha'ior, diet, and body weightJ some are defiant and hosti!e on initia! presentation the nutrition ounse!or an he!p to reso!'e the ambi'a!en e. %reatment .lan and 'aloric .rescriptions The treatment p!an shou!d in !ude an e$pe ted rate of weight gainF about 2&B !bIweek for hospita!i9ed patient and ,.-&" !bIweek for the outpatient. *a!ori pres riptions in the range of ",,,&"6,, k a!Iday are suffi ient to initiate weight gain, and must progressi'e!y in rease :about ",,&2,, a!ories per 2&B days; to promote ontro!!ed weight gain. Aggressi'e refeeding of se'ere!y ma!nourished AN patients may pre ipitate !ife&threatening omp!i ations of the refeeding syndrome during the first week of ora!, nasogastri , or intra'enous refeeding. %ara!!e! to weight gain, the a!orie intake shou!d a!so be in reased, with a measure of (,&",, k a!Ikg of body weight, as we!! as an in rease in a ti'ity shou!d a!so be in !uded. In genera!, the pres ription is about B,,,&D,,, k a!Iday, and D,,,&D-,, k a!Iday for ma!e. After the goa! is a hie'ed, a!ori pres ription may be s!ow!y de reased to promote weight maintenan e. *a!ori pres ription in ado!es ents may remain higher due to growth and de'e!opment. 5uidelines for )edical <utrition %herapy o Dietary fat intake F 2-N&B,N J en ourage sma!! in reases in fat intake unti! goa! an be attained J pro'ide sour e of essentia! fatty a id o %rotein intake F "-N&2,N, minimum F 1DA in gIkg idea! body weight J high bio!ogi 'a!ue sour es o *arbohydrate F -,N&--N J en ourage inso!ub!e fiber for treatment of onstipation o =itamin and minera! supp!ementation to rea h ",,N 1DA o *a! ium and =itamin D due to in reased risk of osteopenia and osteoporosis o Iron& ontaining preparations may aggra'ate onstipations Important <otes o %ossibi!ity of food dis arding, 'omiting, e$er ising, and e$ essi'e physi a! a ti'ity in !uding fidgeting o De!ayed gastri emptying, abdomina! distention and dis omfort di'ide mea!s with afternoonIe'ening sna ks o %atient fear to be a ustomed to !arge food amount use !i0uid supp!ement B6EI#IA N51=32A Treatment of BN typi a!!y begins and ontinues on an outpatient basis. 3n o asion a BN patient may be dire t!y admitted to an intensi'e outpatient or day treatment program. ?owe'er, inpatient hospita!i9ation is re!ati'e!y un ommon and genera!!y is of short duration and for the spe ifi purpose of f!uid and e!e tro!yte stabi!i9ation. The 1egistered Dietitian :1D; is an essentia! part of the treatment team at a!! !e'e!s of are.

",

5oals of <utritional 9ehabilitation o Interruption of the binge&and&purge y !e o 1estoration of norma! eating beha'ior o 2tabi!i9ation of body weight %reatment .lan and 'aloric .rescriptions Assessment of 155 a!ong with !assi signs of a hypometabo!i state :su h as a !ow T B !e'e! and o!d into!eran e; is usefu! in determining the a!ori pres ription. If a !ow metabo!ism is suspe ted, a a!ori pres ription of "-,,&"6,, a!ories dai!y is a reasonab!e p!an to start. The goa! in monitoring goa! is weight stabi!i9ation. If the weight is stabi!i9ed on a !ower&than& a'erage a!ori intake, sma!! but onsistent in reases in the a!ori intake shou!d be pres ribed e'ery "&2 weeks. This wi!! indu e in rementa! in reases in the metabo!i rate. Bingeing, purging, and restrained intake often impair re ognition of hunger and satiety ues. The essation of purging beha'ior oup!ed with a reasonab!e dai!y distribution of a!ories at three mea!s and pres ribed sna ks an be instrumenta! in strengthening these bio!ogi ues. %atien e and support are essentia! in this pro ess of making positi'e hanges in their eating habits. 2stimating Initial 'aloric .rescriptions o <or a typi a! week, ask patient to estimate the number of bingeIpurge days, bingeInonpurge days, moderate&intake days, and restrained&intake days. o ?a'e the patient des ribe a typi a! food on a bingeIpurge days, bingeInonpurge days, moderate& intake days, and restrained&intake days. o 5stimate -,N of the a!ori intake on the bingeIpurge days, and ",,N on the bingeInonpurge days, moderate&intake days, and restrained&intake days. o *a! u!ate the tota! a!ori intake o'er the (&day period o *a! u!ate an a'erage dai!y intake. The 1egistered Dietitian an than formu!ate an initia! eating and mea! p!an based on this estimated a'erage dai!y intake 5uidelines for )edical <utrition %herapy o <at F 2-N&B,N J pro'ide sour e of essentia! fatty a ids o %rotein F "-N&2,N, minimum F 1DA in gIkg idea! body weight J high bio!ogi 'a!ue sour es o *arbohydrate F -,N&--N J en ourage inso!ub!e fiber for treatment of onstipation o #u!ti'itamin&minera! preparation to ensure ade0ua y, parti u!ar!y in the initia! phase 'ognitive ,ehavioral %herapy 0',%1 *BT is the treatment of hoi e in BN. 4hen app!ied to an eating disorder, *BT is typi a!!y a 2,& week inter'ention that onsists of three distin t and systemati phases of treatmentF o 5stab!ishing a regu!ar eating pattern o 5'a!uating and hanging be!iefs about shape and weight o %re'enting re!apse 4hen the BN patient is re ei'ing *BT, the 1D an be instrumenta! in he!ping the patient to estab!ish a regu!ar mea! pattern. The 1D and the psy hotherapist must maintain a it'e ommuni ation to a'oid

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o'er!ap in the ounse!ing sessions. If the BN patient is engaged in a type of psy hotherapy other than *BT, the 1D shou!d in orporate more *BT ski!!s into the nutrition ounse!ing sessions. BING5&5ATING DI231D51 o 2trategies for treatmentF nutrition ounse!ing and dietary management, indi'idua! and group psy hotherapy, and medi ation. o Goa! of treatmentF 2e!f&a eptan e, impro'ed body image, in reased physi a! a ti'ity, and better o'era!! nutrition.

N6T1ITI3N 5D6*ATI3N Though patients tend to ha'e know!edge about food and nutrition, nutrition edu ation is sti!! an essentia! omponent of the treatment p!an. The patients may re ei'e from unre!iab!e sour es or ha'e distorted interpretation. And remember to hoose the information arefu!!y. A sour e that indi ates a !ow& fat !ow& a!orie intake for pre'enting hroni disease is not orrespondent to the treatment p!an. %13GN32I2 1e!apse rates after weight restoration in AN is high, as many as -,N patients re0uiring rehospita!i9ation within " year of inpatient treatment. Two thirds of AN wi!! ha'e enduring food and weight preo upation. Ado!es ents ha'e better out omes than adu!t, and younger ado!es ents is better than o!der ado!es ents. #orta!ity rates in AN is among the highest in psy hiatri i!!ness. AN women are "2 times more !ike!y to die than women of simi!ar ages in the genera! popu!ation. Appro$imate!y ha!f of these deaths are due to the effe ts of e$treme ema iation and about ha!f to sui ide :%a!mer, "..,;. BN patients ha'e a short&term su ess rate of -,N&(,N, and a re!apse rates of B,N&/-N.

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