JanetE.
Schebendach,
MAb RD
KEYTERMS
amenorrheaabsence of threeconsecutive menstrualperiods
when otherwiseexpectedto occur
anorexianervosa(AN) a disease characterized by (l) refusal
to maintain a minimally normal body weight, (2) intense
fear of gaining weight, (3) body image distortion, and (4)
amenorrheain posffnenarchealfemales;it may be one of
two subtypes:restricting or binge eating/purging
binge an episodeof eating marked by three particular fea-
tures:(1) the amount of food eatenis larger than most per-
sonswould eat under similar circumstances;(2) the exces-
sive eating occurs in a discrete period, usually less than
2 hours; and (3) the eating is accompaniedby a subjective
senseof lossof control
bingeeatingdisorder(BED) a disordercharacterized by the
occurrenceof binge eatingepisodesat leastmricea weekfor
a 6-month period
body imagedistortion a significantdisturbancein the per-
ceptionofbody shapeor size
bulimia nervosa(BN) an illnesscharacterized by repeated
episodesof binge eatingfollowed by inappropriatecompen-
satory methods such as parging including self-induced
vomiting or misuseof laxatives,diuretics, enemas,or nln-
purging,including fastingor engagingin excessive exercise
cognitivebehavioraltherapy(CBT) a highly stmcturedpsy-
chotherapeuticmethod usedto alter attitudesand problem
behaviorsby identifying and replacingnegative,inaccurate
thoughtsand changingthe rewardsof the behavior
Sections of this chapter were written by Pamela Reichert-Anderson, MA,
RD, for the previous edition of this text.
Diagnosticand StatisticalManual of Mental Disorders,
TR-IV (DSM-TR-IV)a manualpublishedby the American
Psychiatricfusociation that establishesdiagnostic criteria
for anorexianervosa,bulimia nervosa,eating disorder not
otherwisespecified,and binge eating disorder
dysthymiachronic,mild depression
eating disordernot otherwisespecified(EDN0S)a diag-
nostic categoryfor eating disordersthat fail to meet firll
criteria for anorexianervosa,bulimia nervosa,or binge eat-
ing disorder
femaleathlete triad a patrernin strenuouslyexercisingath-
letesof esffogendeficiencyand athletic amenorrhea,disor-
deredeatingand low body fat, and lossof bone mass
hypercarotenemia an elevation of serum carotene,fre-
quently encounteredin patientswith eatingdisorders;most
likely attributableto an acquireddefectin carotenemetabo-
lism, secondaryto semistarvation
lanugo soft, downy hair growth
low T3 syndromea low metabolic state characteristicof
anorexianervosa,in which thyroid hormone production
tends to be normal but the peripheral deiodination of
thyroxin favors formation of the lessmetabolically active
reduced uiiodothyronine (rT3) rather than T3; resolves
with refeeding
night eatingsyndrome(NES) conditionin which the indi-
vidual delayseatingfor severalhours after arising;consumes
more than half of daily energyintake during and after din-
ner but beforebreakfast;may haverelationshipwith depres-
sion and elevatedcortisol and stresslevels
purging methods intended to reversethe effectsof binge
eating;self-inducedvomiting is the most common purging
method, but additional methods include laxative, enema.
and diuretic abuse
563
564 PART4 i Nutritionfor HealthandFitness
Eating disordersare debilitating psychiatricillnesseschar-
acterizedby a persistent disturbanceof eating habits or
weight control behaviorsthat resultin significantlyimpaired
physical health and psychosocialfunctioning. American
Psychiatricfusociation (APA) diagnosticcriteria are avail-
able for anorexianervosa(AIrl), bulimia nervosa(Bl$), eat-
ing disordernot otherwisespecified(EDNOS), and binge
eating disorder (BED). Nght eating slmdrome (I.JES),
childhoodeatingdisturbances, and the femaleathletetriad
are alsocharacterizedby disorderedeatingandweight con-
trol behaviors(seeChapters2l and23).
DIncNosrrc GnrrERrA
Anorexia
Nervosa
A core clinical feature ofanorexia nervosa(AN) is voluntary
self-starvation resulting in emaciation. The reported life-
time prevalence of AN among women is 0.3 to 3.7o/", de-
pending on how strictly diagnostic criteria are defined
(APA, 2006). Among males estimated prevalence is about
one tenth that of femalesffager and Andersen,2005). AN is
more prevalent in Westernized, postindustrializedsocieties;
however, transnational migration and modernization are
expected to result in a moie global distribution of eating
disorders (Becker, 2004), including third world countries
(Miller and Pumariega, 2001).
Initial presentation of AN typically occurs during adoles-
cence or young adulthood; howeveq later onset (i.e., initial
onset at age 25 or older) may develop in responseto adverse
life events.Incidence rates for AN among middle-age women
(over age 50) account for less rhan 17" of newly diagnosed
AN patiens (APA, 2006 ). Etiology varies for this disorder,
but there seems to be a genetic component, as well as envi-
ronmental and psychosocialfactors (Bulik et al., 2006).
Criteria for the establishment of a diagnosis of AN were
first publishe d in 1972 by Feighner and associates.The APA
first published criteria for the diagnosis of AN in 1980;
however, it was not until 1987 that the APA recognized AN
and BN as two separateand distinct clinical entities. SeeBox
22-I for the most current diasnostic criteria for AN.
The Diagnosticand Statistical Manual of Mental Disor-
ders, TR-IV (DSM-TR-IV) specifies "refusal to maintain a
body weight at or above a minimally normal weight for age
and height (e.g., . . . body weight less than 85o/oof that ex-
pected)." The weight deficit may occur secondary to pur-
poseful weight loss or manifest as failure to gain weight
during periods of linear growth in children and adolescents.
Growth records should be obtained to determine if the child
has fallen off his or her growth curve. If stunting has oc-
curred, the weight deficit should be calculated using the
premorbid height percentile.
Determination of "minimally normal weight" is problem-
atic. Metropolitan Life Insurance Company weight standards
are often used; however, recofirnended weight for height dif-
fers between the 1959 and 1983 tables.Dietitians often calcu-
late desirable body weight using the Hamwi method (see
Chapter l4). This is not recornmended in patients with an
eating disorder @D) becauseit calculates a "normal" body
weight much lower than other standards. For children and
adolescentsages1l to 17 years,normal bodyweight should be
determined from the National Center for Health Statistics
weight and height tables (seeAppendices 12 and 16) and the
Body Mass Indices @MI) for age in Appendtx23.
Patients with AN have body image distortion, causing
them to feel fat despite their often cachectic state. Some
individuals feel overweight all oveq whereas others are
overly concerned about the fatness of a specific body part
such as the abdomen, buttocks, or thighs.
Amenorrhea. defined as the absenceof at least three con-
secutive menstrual cycles in postmenarcheal women, is not
an ideal criterion for AN becausesome patients continue to
menstruate ^t a very low body weight (Mitchell et al., 2005).
Development of AN during prepubescence may result in
arrested sexual maturation and delayed menarche (primary
amenorrhea). Young adolescent males with AN may have
estrogen and testosterone deficiency and arrested grow"th
and sexual development.
AN can be categorized into two diagnostic subtypes: re-
stricting and binge eating/purging. The restricting type is
characterized by food restriction without binge eating or
purging (self-inducedvomiting or misuse of laxatives,ene-
mas, or diuretics). The binge eating/parging is characterized
by regular episodesofbinge eating or purging behavior. AN
may initially present as the restricting subtype; howeveS
migration to binge eating/purging subtype may occur as
duration of illness progresses.
Psychological features associated with AN include per-
fectionism, compulsivity, harm avoidance, feelings of inef-
fectiveness, infl exible thinking, overly restrained emotional
expression, and limited social spontaneity (APA, 2000). Sev-
eral psychiatric conditions may also coexist with AN, and
these include major depression, dysthymia (chronic mild
depression), arxiety disorders, obsessive-compulsive disor-
der, personality disorders, and substance abuse. Lifetime
comorbid depression and dysthymia have been reported in
50Y" to 75% of AN patients (APA, 2006).
Symptoms of depression may remit during the course of
nuffition rehabilitation and weight restoration. However, the
suicide rate is greater among individuals with AN than in the
general population; thus ongoing psychiatric assessmentis
essential (APA, 2006). More than 40"/o of AN patients also
have obsessive-compulsivedisorder (OCD). Onset of OCD
frequendy predatesAN, and many patients remain symptom-
atic despite weight restoration (APA 2006).
Five percent to twenty percent of patients with an-
orexia nervosa die from their illness; halfofthose patients
die of medical complications (Steinhausen, 2002). Malnu-
trition, dehydration, and electrolyte abnormalities may
precipitate death by inducing heart failure or fatal ar-
rhythmias (McCallum et a1.,2006).
Bulim iaNer vosa
Bulimianeryosa(BN) is a disordercharacterizedby recur-
rent episodes
of bingeeatingfollowedby one or more inap-
propriate compensatorybehaviorsto prevent weight gain.

AmericanPsychiatricfusociation Diagnostic Criteria
AnorexlaNervosa(AN)
A. Refusalto maintain body weight at or above a minimally
normal weight for age and height (e.g.,weight loss
leading to maintenanceof body weight lessthan 85% of
that expected;or failure to make expecredweight gain
during period of growth, leading to body weight less
than 85% ofthat expected)
B. Intense fear of gaining weight or becoming fat, even
though underweight
C. Disturbance in the way in which one'sbody weight or
shapeis experienced,undue infuence of body weight
or shapeon self-evaluation,or denial ofthe seriousness
of the current low body weight
D. In postrnenarchealfemales,amenorrhea(i.e., the absence
of at least three consecutivemenstrual rycles)
l. Restriaingtype:Dwing the current episodeof AN,
the person has not regularly engagedin binge earing
or purging behavior.
2 . Binge eating/purging type:Dving the current episode
of AN, the person has regularly engagedin binge
eating and purging behavior.
Bullmla Nervosa (BN)
A. Recurrent episodesof binge eating. An episodeof binge
eating is characterizedby both of the following:
1. 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 during a similar
period of time and under similar circumsrances
2. A senseoflack ofcontrol over eating during the
episode(e.g., a feeling that one cannot stop eating
or control what or how much one is eating)
B. Recurrent inappropriate compensatorybehavior to
prevent weight gain, such as self-inducedvomiting;
misuseof laxatives,diuretics, enemas,or other
medications;fasting; or excessiveexercise
C. The binge eating and inappropriate compensatory
behaviorsboth occur, on average,at least twice a week
for 3 months
D. Self-evaluationis unduly influenced by body shapeand
weight.
These behaviors include self-induced vomiting, laxative
misuse,diuretic misuse,compulsiveexercise,or fasting.The
lifetime prevalenceof BN amongyoung adult womenin the
United Statesis lo/oto 3o/o. The rateof occurrencein males
is approximatelyone tenth that in females(APA,2000).
Unlike AN patiens with binge andpurge subtype,patiens
with BN are typically within the normal weight range, al-
thoughsomemaybe slighdyunderweightor overweight.Like
their AN counterparts,theseindividualsplace considerable
imporance on body shapeand size,and they are often frus-
trated by their inability to attain an underweightstate.
22 ! Nutritionin EatingDisorders565
CHAPTER
E. The disturbancedoesnot occur exclusivelyduring
episodesof AN.
| . Purging type:Dnring the current episode of BN, the
person has regularly engagedin self-inducedvomiting
or the misuseof laxatives,diuretics, or enemas.
2. Nonpargingtype:Dwng the current episodeof BN,
the person has used other inappropriate compensatory
behaviorssuch as fasting or excessiveexercisebut has
not regularly engagedin self-inducedvomiting or the
misuseof laxatives,diuretics, or enemas.
Eating Disorder Not (Xherwise Specified (EDNOS)
This category is for disorders of eating that do not meet
criteria for any specific eating disorder.
For example:
1. For females,all of the criteria for AN are met except
that the individual has regular menses.
2. All of the criteria for AN are met except that, despite
significant weight loss,the individual's crurent weight
is in the normal range.
3. All of the criteria for BN are met except that the
binge eating and inappropriate compensatory
mechanismsoccur at a frequency of lessthan twice a
week or for a duration of lessthan 3 months.
4. The regular use of inappropriate compensatory
behavior by an individual of normal body weight
after eating small amouns of food.
5. Repeatedlychewing and spitting out, but not
swallowing, large amounts of food.
Binge Eating Disorder (BED)
A. Recurrent episodesof binge eating in the absenceof the
regular use of inappropriate compensatorybehaviors
characteristicof BN
B. Binge episodesmust occur at least 2 day'sper week for a
period of 6 months.
From American Psychiatric fusociation: Diagnonic and swtistial manual of
DSM-IV-TR, ed 4, (text revision) Washington, DC,2000,
mennl tlisord.erc,
American Psychiatric fusociation.
It is commonly thought that vomiting is the predominant
feature of BN; however, it is the binge eating behavior that
is central to the diagnosis. A binge is consumption of an
unusually large amount of food in a discrete period (usually
<2 hours). There is a senseof lack of conuol over the eating
episode. Although the amount of food and caloric content
of a binge vary binges are often in the range of 1000 to 2000
calories (Fairburn and Harrison, 2003). Patients with BN
typically binge on foods that are otherwise avoided such as
snack foods and desserts;however, some binge on extremely
large portions of low calorie foods such as fruit and salad.
566 PART4 I Nutrition for Health and Fitness
Patients may report a binge episode when the amount of
food consumed is clearly not excessive. Although these
"subjective binges" may not support a diagnosis of BN,
clearly these individuals have feelings about their eating
behavior that merit further exploration.
BN patients engage in compensatory behaviors intended
to offset food binges. The choice of compensatory behav-
iors further classifies BN into purging and nonpurging
subtypes. Patients wirh purging type BI,l regularly engage in
self-induced vomiting or the misuse of laxatives, enemas, or
diuretics. Those with nonpurging type BN do not regularly
engage in purging behaviors but rather fast or excessively
exercise to compensate for their binge. To meet full
DSM-TR IV criteria for BN bingeing, both binge eating and
recurrent inappropriate compensatory behaviors must oc-
cut on aver^ge, at least twice a week for 3 months. Current
APA diagnostic criteria for BN are listed in Box 22-1.
Adverse emotional statessuch as labile mood, frustration,
arxiety, and impulsivity are often found in patients with BN.
Psychiatric comorbidities, including major depression,dys-
thymia, anxiety disorders, personality disorders, substance
abuse,and self-injurious behaviors,are also common in BN.
Compared to AN, BN patients are usually embarrassedand
distressedby their syrnptoms, making it easier ro engage
them in treatment.
Etiologies proposed for the development of BN include
addictive, family, socio-cultural, cognitive-behavioral, and
psychodynamic models (APA, 2006). BN, with or without
comorbid psychiatric illness, should be treated and moni-
tored by a mental health professional. However, only a mi-
nority of individuals with BED are actually treated in men-
tal health services(Hoek, 2006).
E a t i n gD i s o r d eNr o t 0 t h e r w i sS
ep e c i f i e d
Approximately half of the individuals with eating disorders
fall into the eating disorder not otherwise specified
(EDN0S) diagnostic group. Essentially these individuals
meet most, but not all, of the criteria for AN or BN (e.g., a
female meeting all diagnostic criteria for AN except amen-
orrhea; a previously obese patient who, despite extreme
weight loss, pathologic eating behavior, and amenorrhea
fails to meet the AN criterion of body weight lessthan 85%
of expected; a person who binges and purges, but with less
frequency or for a shorter period of duration, than is speci-
fied for BN; or the individual who does not binge but vomits
after eating a normal-size meal or snack). Clinically the
EDNOS patient should receive treaftnent consistent with
reasonable and customary care for either AN or BN. Inade-
quate treatrnent may lead to the development of fuIl-criteria
AN or BN. In addition, patients who meer criteria for BED,
a diagnostic group for research purposes only, would be
clinically diagnosedwith EDNOS. See Box 22-l for APA
diagnostic criteria for EDNOS.
B i n g eE a t i n gD i s o r d e r
Researchcriteria for binge eating disorder(BED) are
listed in Box 22-1. Binge eating, similar to that seenin
BN, is characteristicof BED; however,there are no inap-
propriate compensatorybehaviorsafter the binge. Binge
episodesmust occur at least2 daysper week for a period
of 6 months.
Personswith BED experiencea feeling of powerlessness
over their eating, similar to that felt by BN patients.Sig-
nificant emotional distresscharacterizedby feelingsof dis-
g-ust,grrilt, and depressionoccurs after a binge. Onset of
BED generally occurs in late adolescenceor in the early
twenties,with women being 1.5 times more likely to de-
velop this disorderthan men.
Most patients with this disorder are overweight,with
l5o/o to 50% prevalenceamong participants in weight-
control programs(APA,2000).Patientswith BED may have
a higher lifetime prevalenceof major depression,substance
abuse,andpersonalitydisorders.In addition,somealsohave
night eatingsyndrome(NES),consumingmore thanhalf of
daily energy intake during and after dinner but before
breakfast,and sleep disorders.Many of these individuals
seekbariatricsurgery(Allisonet al., 2006).
E a t i n gD i s o r d e ri ns C h i l d h o o d
Onset of eating disorders most typically occurs during
adolescenceand young adulthood. When an eating disor-
der is suspectedin a child or young teen, use of DSM cri-
teria may be problematic becauseclinical presentation of-
ten differs from that seen in older adolescentsand young
adults. Complaints of nausea, abdominal pain, and diffi-
culty in swallowing may coexist with concerns about
weight, shape, and body famess. Food avoidance, self-
induced vomiting, and excessive exercise may occur, but
laxative misuse is uncommon.
Any child or adolescent practicing unhealthy weight-
control practices or thinking obsessivelyabout food, body
weight or shape, or exercise may be at risk for an eating
disorder. Other obsessive behaviors and depression may
coexist in these children as well. Early onset AN may re-
sult in delayed or stunted growth, osteopenia, and osteo-
porosis (APA, 2006). AN has been reported in children as
young as 7 years of age. The male-to-female ratio may be
higher in this younger age-group, and it appears in many
different cultures and ethnic groups. BN in children is
rare (APA, 2006).
The relationship between problematic childhood eating
behaviors and subsequent development of eating disorders
in later life is of concern. A l7-year longitudinal study of
800 children showed that eating conflicts, struggles with
food, and unpleasant meals were risk factors for the devel-
opment of an eating disorder in adolescenceor young adult-
hood (Kotler et al., 2001). However, other childhood eating
problems such as not eating, disinterest in food, picky eat-
ing, eating too litde, and eating too slowly failed to predict
subsequent development of an eating disorder.
There is a need for developmentally appropriate diagnos-
tic criteria, screening instruments, and validated treaffnents
for children and younger adolescents.The term eatingdistar-
bance versus eating disorder has been suggested @ryant-
Waugh, 2000). See Table 22-l for descriptions of childhood
eating disturbances, including childhood AN and BN.
 22 1 Nutritionin EatingDisorders567
CHAPTER

EatingDisturbances
Childhood
EatingDisturbance Gharacteristlcs
Anorexianervosa Determined food avoidance
Weight loss or failure to gain weight during the period of preadolescentgrowth
(10-14 yr) in the absenceof any physical or other mental illness
Any two or more of the following:
Preoccupationwith body weight
Preoccupationwith energy intake
Distorted body image
Fear offanress
Self-inducedvomiting
Extensive exercising
Laxative abuse
Bulimia nervosa Binge eating followed by purging, restricting, excessiveexercise,or laxative abuse
rarely seenin childhood
Food avoidanceemotional disorder A primary emotional disorder resulting in avoidanceof food
Weight loss, or failure to gain developmentallyappropriate amounts of weight
No preoccupationwith weight and shape
Absenceof body image distortion
May have comorbid medical disorders/diseases
Selectiveeatins Food intake limited to a very small number of foods
May be rigid about the brand of food, or its place of purchase
Food choicestend to be carbohydrates
Selectiveeating hinders participation in social situations that include eating
Attempts to increasevariety in diet are met with extreme resistance
Age-appropriate gains in weight and height
No preoccupationwith weight and shape
Absenceof body image distortion
No fear of choking or gagging (seefunctional dysphagia)
Restrictive eating Characteristicallyeatsa smaller than normal amount of food
Disinterested in eating
No intentional food restriction
Normal balanceof carbohydrates,protein, and fats in diet
Absenceof mood disorder
Height and weight within normal limits but at the lower end of percentiles
May have difficulty meeting increasedenergy requirement during puberty
No preoccupationwith weight and shape
Absenceof body image distortion
Foodrefusal Episodic, situational, or intermittent food refusal
No preoccupation with weight and shape
Absenceof body image distortion
Emotional issues,such as unhappinessor worry, may be the underlying cause
Functional dysphagia Food avoidance,particularly foods ofa certain type or texture
Fear of swallowing, vomiting, choking
An aversiveevent may precipitate the disorder
No preoccupationwith weight and shape
Absenceof body image distortion
Pervasiverefusal s1'ndrome Profound and pervasiverefusal to eat, drink, walk, talk, or engagein self-care
May be underweight and dehydrated
May be a form of posttraumatic stressdisorder
Rare but potentially life threatening
Usually requires hospitalization
From Bryant-Waugh R: Overview of eating disorders. In Lask B, Bryant-Waugh R, editors: Anoreria nertsosaand.related enting disord'ersin chihlhood
ed 2, East Sussex,Utrl 1000,PsychologyPress.
and ad.olescence,
568 PART4 | Nutritionfor HealthandFitness
E a t i n gD i s o r d e ri ns A t h l e t e s
Competitive athletes are at great risk for the development
of eating disorders. Females who participate in activities
that emphasize a lean body rype (e.g. gymnastics, figure
skating, distance running, crew, and ballet dancing) and
male bodybuilders and competitive wrestlers may be par-
ticularly vulnerable.
Internal and external pressures to achieve or maintain an
unrealisticallylow body weight underlie the development of
the female athlete triad (seeChapter 2 3). The triad is a seri-
ous ry.ndrome consisting of disordered eating, amenorrhea,
and osteoporosis. Disordered eating may present in the
form of chronic undereating and episodic bouts of fasting,
binge eating, and purging. Parents, trainers, and coaches
who are overly invested in the athlete's performance may
ignore or even encourage disordered eating and dieting
behaviors. Although t}re exact relationship between the triad
and clinical eating disordersis not fully understood, athletes
meeting criteria for the triad would also meet criteria for
EDNOS (APA,2006).
E a t i n gD i s o r d e ri ns I n d i v i d u a l s
w i t h D i a b e t eMsellitus
When an individual with type 1 or rype 2 diabetesmellitus
(DM) developsan eating disorder,complexmedical,nutri-
tional, and psychologicalmanagementis required.Those
with type I DM are more likely to haveAN, BN, or ED-
NOS, whereasthosewith type 2 DM aremore likely to have
BED (APA, 2006).Binge eating,purging, and intermittent
periodsof food restricrionmakeit difficult to stabilizeblood
glucoselevelsin individualswith type I DM, resulting in
increasedoccurrenceof medicalcrisesand medicalcompli-
cations.Furthermore,insulin omissionand underdosingfor
the purposeof weight lossmay representa specificsubtype
of purging behaviorin insulin-dependentpatientswith eat-
ing disorders(APA, 2006).
TneATMENTAppRoAcH
Tleatrnent of eating disorders requires a multidisciplinary ap-
proach that includes psychiatric/psychological, medical, and
nutrition interventions. Tleatrnent, provided at several levels
of care depending on severity of illness, includes inpatient
hospitalization, residential rreatment, day hospitalization, in-
tensive outpatient treafinent, and outpatient treaffnent.
Inpatient treatment can be provided on a psychiatric or
medical unit, and a behavioral protocol developed specifi-
cally for the management of eating-disordered patients is
highly recommended. Residential eating disorder treat-
ment facilities also provide 24-hour carel however, they are
usually not equipped to manage medically or psychiatri-
cally unstable patients. Day treatment programs provide
specialized multidisciplinary care, including meals. Pa-
tients initially attend day treatment for 6 to 8 hours a day,
5 to 7 days per week.
The least intensive form of treaunent is outpatient care;
however, this still requires the ongoing, coordinated effort
of physicians, psychotherapists, and nuuitionists. Intensive
outpatient trea0nent programs provide several hours of
multidisciplinary care several times per week.
The Practice Guideline for the Tieatment of Patients with
E ating D isorders(APA, 2 006) provides comprehensive guide-
lines for the formulation and implementation of treatment
plans in patients with AN, BN, EDNOS, and BED. These
guidelines provide specific treatrnent recommendations
(e.g., nutritional rehabilitation, medical management, psy-
chological interventions, medication management) and level
of care guidelines for patients with eating disorders. In ad-
dition, the Society for Adolescent Medicine (SAM, 2003),
the American Academy of Pediatrics (AAP, 2003), and the
American Dietetic fusociation (ADA, 2001) have published
poliry statements and positions regarding guidelines for ef-
fective treatrnent of eatine disorders.
GlrnrcAL HARAcrERrsrrcs
AND MCOICAL OMPLICATIONS
Although eating disorders are classified as psychiatric ill-
nesses,they are associatedwith significant medical compli-
cations, morbidiry and mortality. Numerous physiologic
changes result from the weight-conffol habits of patients
with AN and BN (Thble 22-2). Some are minor changes that
occur secondary to reduced energy intake; some are patho-
logic alterations that may have long-term consequences;
and a few represent potentially life-threatening conditions.
Anorexia
Nervosa
Patients with AN have a typical and distinctive appearance
(Figure 22-l).Their cachectic and prepubescent body habi-
tus often makes them look younger than their age. Com-
mon physical findings include lanugo, soft, downy hair
growth, dry and britde hair, hypercarotenemia,cold intoler-
ance, and ryanosis of the extremities.
Protein-energy malnutrition with resultant loss of lean
body mass is associatedwith reduced left ventricular mass
and systolic dysfunction in AN. Cardiovascular complica-
tions include bradycardia (heart rate less than 60 beats/
min), orthostatic hypotension, and cardiac arrhythmias
(Romano et al., 2003).
Gastrointestinal complications secondary to starvation
include delayed gastric emptying, decreased small bowel
motility, and constipation. Complaints of abdominal bloat-
ing and a prolonged sensation of abdominal fullness compli-
cate the refeeding process.
A serious medical complication found in both male and
female patients is osteopenia (reduced bone mineral density
[BMD]), the precursor of osteoporosis.A cross-sectional,
community-based study of 214 adult females with AN
showed rhat 52"/" had osteopenia,34o/"had osteoporosisin
 22 { ttutritlonin EatingDisorders569
CHAPTER

of EatingDisorders
MedicalGomplications
AN BN
Restdctlng BingeEatingPurginE Puging Nonpurging
Fluid and Eleetrolyte lmbalance
Hypokalemia ^/
Hlryonatremia "/
Hypochloremic alkalosis ./
Elevated BUN .i
Inability to concentrateurine i
Decreasedglomerular filtration rate ./ ^/
Ketonuria ./
Cardiovascularand ElectrocardiographicAbnormalities
Bradycardia
Orthostatic hlpotension ./
Arrhythmias
Prolonged QT interval "l
T wave abnormalities
Conduction defects ./
Ipecac cardiomyopathy ./
Mitral valve prolapse ^i
Congestive cardiac failure
Pericardial effusion
Gastrointestinal
Parotid hypertrophy
^/
Perimolysis and increasedincidence of dental caries {
Constipation
Bloody diarrhea
Delayed gastric emptying
Intestinal atony {
Esophagitis
^/
Mallory-Weiss tears
Esophagealor gastric rupture
Perforation/rupture of stomach
Barrett esophagus
Fatry infiltration and focal necrosisof liver
Superior mesentericartery syndrome {
Gallstones
Skeletal
Osteopenia
Fractures
Dermatologic
Acrocyanosis
Yellow dry skin (hypercarotenemia)
Britde hair and nails
Lanugo
Russellsign (callusesover the knuckles)
Pittins edema
From Fisher M et al.: Eating disorders in adolescents:a background paper, J AdalescHeahh 16:420, 1995.
lN, Anorexia nervosa;BN, bulimia nervosa;B[A/, blood urea nitrogen; T3 triiodothyronine.

Continued
 570 PART4 I Nutritionfor HealthandFitness

MedicalComplications
of EatingDisorders-cont'd
AN BN
Restricting BingeEatingPurging Purging Nonpurging
Endocrine
Growth retardation and short stature
Delayed puberty
Amenorrhea
Low T3 syndrome
Decreasedcapacityto concentrateurine 2"
to J vasopressinsecretion
Hlpercortisolism
Hematologic
Mild anemia
Leukopenia
Thrombocytopenia
Low sedimentation rate
Impaired cell-mediatedimmunity
Neurologic
Seizures
Myopathy
Peripheral neuropathy
Cortical atrophy

one or more skeletalsites,and 30% had self-reported histo-
ries of fractures (Miller et al., 2005). Other studies suggest
that reduced BMD occurs in more than 90./o of adolesient
and young women with AN (Golden, 2005). Hormone re-
placement therapy and biphosphonatessuch as alendronate
have no proven effrcacy in underweight females with AN
(Golden et al., 2005). At present, the recommended treat-
ment is weight gain and supplementation with calcium and
vitamin D (APA,2006).
Children and adolescentswith AN develop unique medi-
cal complications that affect normal grouth and development
such as growth retardation, reduction in peak bone mais, and
structural abnormalities in the brain (SAM. 200i).
dominal pain, and subconjunctival hemorrhage. More serious
gastrointestinal complications include Mallory-Weiss esopha-
geal tears, rare occurrence of esophagealrupture, and acute
gasric dilation or mpture. Ipecac, used to induce vomiting,
may causeirreversible myocardial damage and sudden death.
Laxative abuse may lead to dehydration, elevation of se-
rum aldosterone and vasopressin levels, rectal bleeding, in-
testinal atony, and abdominal cramps. Diuretic abuse may
lead to dehydration and hypokalemia. Cardiac arrhythmias
can occur secondary to electrolyte and acid-base imbalance
caused by vomiting, laxative, and diuretic abuse. Although
the profound amenorrhea associaredwith AN is uncommon
in BN, menstrual irregularities may occur (Figure 22-1).

B u l i m i aN e r v o s a
Clinical signs and s'.rnptoms of BN are more difficult to
detect becausepatients are usually of normal weight and
secretive in behavior. When vomiting occurs, there may be
clinical evidence such as (l) scarring of the dorsum of the
hand used to stimulate the gag reflex, known as Russell,s
sign;
(2) parotid gland enlargement; and (3) erosion of dental
enamel with increaseddental caries resultins from the fre-
quent presenceof gastricacid in the mouth.
Chronic vomiting can result in dehydration, alkalosis,and
hypokalemia. Common clinical manifestations include sore
throat, esophagitis, mild hematemesis (vomiting blood), ab-
Eating disorders are complex psychiatric illnesses that re-
quire psychological assessment and ongoing treatment.
Evaluation of the patient's cognitive and psychological stage
of development, family history family dlmamics, and psy-
chopathology is essential for the development of a compre-
hensive psychosocial treatment program.
The long-term goals of psychosocial interventions in AN
are (1) to help patients understand and cooperatewith their
nutritional and physical rehabilitation; (2) to help patients
 C H A P T E R2 2 i N u t r i t i o ni n E a t i n gD i s o r d e r s 5 7 L

BULIMIANERVOSA ANOREXIANERVOSA more distressed by their illness and are typically more ac-
cepting of psychological interventions.
Dizziness,confusion
Psychotherapy can help the patient understand and
Salivarygland Dry,brittlehair change core dysfunctional thoughts, attitudes, motives,
enlargement
Lanugo{ypehair conflicts, and feelings related to his or her eating disorder.
Enamelerosion
Associated psychiatric conditions, including deficits in
Low blood pressure, mood, impulse control, and self-esteem,as well as relapse
Anythmias pulse,ECG voltage prevention, should be addressedin the psychotherapeutic
Orthostasis treatment plan.
Normalweightor Cognitive behavioral therapy (CBT) is considered the
underweight Cachexia
or overweight most effective single intervention in the treatment of acute
Biochemicalchanges s).rrnptomsof BN, but clinicians often combine elements of
JWBC
severalpsychotherapeutic approachesthroughout the course
JGlucose
tCholesterol of treatrnent (APA, 2006). Adjunctive family therapy and
lCarotene marital therapy may be beneficial in some cases.
Stool retention Psychological measures,including validated questionnaires
and interview instruments, are often used to evaluate individu-
Callus
Acrocyanosis alswith (suspected)eating disorders. Self-repors are generally
Biochemicalchanges Loss of menses used for the purpose of screening, whereas structured inter-
Musclewasting
view instruments are used to determine a diagnosis.Represen-
1co2
TAmylase tative instruments for assessmentof eating disorders include
DiminishingDTRs
the Eating Attitudes Test @AI), Eating Disorder Inventory
Diarrhea Osteoporosis
@DI-ID, Eating Disorder Examination @DE and EDE-Q4),
Dry skin Eating Disorders Questionnaire (EDQ), and the Yale-Brown-
Edema Cornell Eating Disorder ScaleffBC-EDS).
Growth retardation
Hypothermia

Binge eating Weightloss and N UTRITION EHABILITATION

and purging malnutrition
FIGURE 22-1 Physicaland clinical signsand slnnptomsof
bulimia nervosaand anorexianervosa.DTRs, Deep tendon
reflexes;ECG, electrocardiogram; WBC, white blood cell.
understand and change behaviors and dysfunctional atti-
tudes related to their eating disorders;(3) to improve inter-
personal and social functioning; and (4) to address psycho-
pathology and psychological conflicts that reinforce or
maintain eating-disordered behaviors. In the acute stage of
illness, malnourished AN patients are typically negativistic
and obsessional, making it difficult to conduct formal psy-
chotherapy. At this stage of treatment, psychological man-
agement is often focused on positive behavioral reinforce-
ment of weight restoration. This includes praise for positive
efforts, reassurance,coaching, and encouragement.
Inpatient treatment programs often use behavioral rein-
forcers that link attainment of privileges such as physical
activity (versus bed rest), off-unit passes,visitation privi-
leges, and phone privileges with attainment of targeted
weight gain and improved eating behaviors. Once acute
malnutrition has been corrected and weisht restoration is
underway, the AN patient is more likely to benefit from
psychotherapy.
Psychotherapeutic treatrnent is frequently required for at
least 1 year and in some cases for several years. Family
therapy may be more beneficial than individual therapy in
adolescentswho have been sick for 3 years or less. Com-
pared with AN patients, individuals with BN are generally
AND OUNSELING
Nutrition rehabilitation includes nutrition assessment,
medical nutrition therapy (MNT), nutrition counseling,
and nutrition education (see Pathophysiologtand Care Man-
agementAlgoritbm: Anorexia Nervosa). Although the eating
disorders are distinct illnesses, similarities exist in nutri-
tional consequencesand nutritional management.
N urRrrroN ASSESSMENT
Nutrition assessment routinely includesa diet history and
the assessment of biochemical,metabolic,and anthropo-
metric indicesof nutrition status(Figure22-2).
D i e tH i s t o r y
Guidelines should include assessment of energy intake,
macronutrient and micronutrient consumption, eating atti-
tudes, and eating behaviors (Box 22-2). Patients with AN
generally consume less than 1000 kcal per day. They often
"calorie count," but generally overestimate their food and
energy intake. Assessmentof typical energy intake will pre-
vent overfeeding or underfeeding at the inception of nutri-
tional rehabilitation and will open a dialogue regarding
caloric requirements during the refeeding and weight main-
tenance phasesof nutritional rehabilitation.
Energy intake in BN can be unpredictable. The caloric
content of a binge, the degree of caloric absorption after a
 572 PART4 I Nutritionfor Healthand Fitness

Anorexia Nervosa

. Fluidandelectrolyte
imbalances
. Cardiovascular
disorders
. Gastrointestinal
disorders
. Restricting . 0steopenia
type .
. Bingeeating/purging Dermatologicdisorders
type . Endocrine
disturbance
. Hematologicdisorders
. Neurologic
disorders

. Monitororganfunction (especially
cardiovascular) . Nutritionassessment
. Monitoranthropometric status . Correctmalnutrition if possible;
with oral feedings
. Monitorelectrolytes tubefeedingif necessary
. Psychological
counsel ing . Appropriate vitaminandmineralsupplementation
. Monitorandtreatfluidandelectrolyte
imbalances . Nutrition,counseling,
andeducation
. Antidepressant
or otherappropriate
medication

Algorithm contentdevelopedbyJohnJ.B. Anderson,PhD, and Sanfordc. Garner,phD, 2000.

purge, and the exrent of calorie restriction between binge
episodesmake assessmentof total energy intake quite chal-
lenging. Bulimic patients assume that vomiting is an effi-
cient mechanism for eliminating calories consumed during
binge episodes;however,study of the caloric conrenr of food
ingested and purged in a feeding laboratory revealed that, as
a group, 17 BN subjectsconsumed a mean of 2l3l (1- 1154)
kcal during a binge and vomited only 979 (* 1003) kcal af-
terward (Kaye et al., 1993).
The notion that a binge, and thus calories consumed dur-
ing the binge, can be completely purged is a common mis-
conception among patients. fu a rule of thumb, patients
 22 : Nutritionin EatingDisorders573
CHAPTER

EATINGDISORDERASSESSMENT

Date of birth:

DIAGNOSIS: Hospitalizations
for eating
disorder: OTHERSUPPLEMENTS:
ft Anorexia
Nervosa E In-patient
Q BulimiaNervosa E Daypatient
Q EatingDisorder
NOS E Out-patient SUGAR AND FATSUBSTITUTES:
E Intensive
out-patient

WEIGHT HISTORY Chewinggum:

MISCELLANEOUS:
Wt.loss:# lb- From- To Hard candy:
Minimum weightat currentheight Condiments:
Maximum weightat currentheight
IBW:- %lBW:- %Wtloss:- BMI%:-
BINGES:# per day # perweek
ANTHROPOMETRIC PROFILE Durationper episode:
Skinfolds(mm): Bingefoods:
Triceps:- Biceps:- Subscapular:-
Suorailiac:- Approximatekcal/binge:
Sum of sites (mm):-% Body fat:- TSF%:-
MAC (cm):- MAMC(cm):- MAMC%: SELF-INDUCED VOMITING:
Times per day:- Method:
BODYIMAGE:
LAXATIVES:
Type/brand: Amount:
of use:
Duration FrequencY
of use:
FOODALLERGIES:
DIURETICS:
Type: Amount:
of use:
Duration of use:
FrequencY
24.HOURRECALL:
EXERCISE:
Type:
-
Minutes/dav: Times/week:
Purposeof exercise:

MENSTRUALHISTORY:
Aoe of menarche:
Last menstrualperiod:

(prescription
MEDICATIONS andover-the-counter):

FLUIDINTAKE:

BOWELFUNCTION:
VITAMIN/MINERAL
SUPPLEMENTS:

form for eatingdisorders.

FIGURE 22-2 Samplenutrition assessment

should be advised that approximately 50"/" of energy con-
sumed during a binge is retained.
Inadequate energy intake results in decreasedconsump-
tion of carbohydrate, protein, and fat. Patients with AN
were historically described as carbohydrate restrictors, but
at present there is a tendency to avoid fat-containing foods
(Affenito et al., 2002; Hadigan et al., 2000). Observed food
intake in thirry patients revealedthat patients with AN con-
sumed significantly less fat (15% to 20"/" of calories) than
healthy controls (Hadigan et al., 2000).
Percent of calories contributed by protein may be in the
averageto above-averagerange, but the adequacyof intake
will be relative to total caloric consumption' For example,
the percentageof calories may remain the same, but as the
calorie intake continues to drop, the actual amount of pro-
tein falls also.
Many AN patients follow vegetarian diets' and this affects
both the quality and quantity of protein consumption. One
study found rhat 47 % of an AN population were vegetarians,
but the specific type of vegetarianism (e.g., vegan, lacto-ovo)
574 PART4 I Nutritionfor HealthandFitness

members also follow a vegetarian diet. Many nutritional re-

habilitation programs do not allow the recovering anorexic to
Assessmentof Nutrient Intake continue with vegetarianism during treaunent, whereas oth-
ers allow it, especially if the anorexic was vegetarian with
l. Calories family members before developing AN.
A. Compare intake with DRI (inside front cover) Chaotic eating, ranging from restriction to bingeing is
B. Estimate rypical intake in AN a hallmark feature of disordered eating. Because of day-
C. Determine averageintake and range of intake in BN to-day variabiliry a 24-hour recall is not particularly use-
D. Determine hidden sources(e.g., gum, hard candy) fuI. To assessenerg'y intake, it is helpful to estimate daily
2. Macronutriens food consumption over the course of a week. First deter-
A. Carbohydrate mine the number of non-binge days (which may include
(l) Determine percent kcal intake restrictive and normal intake days) and approximate their
(2) Compare inuke to DRI intake caloric content; then determine the number of binge days
(3) Simple and approximate caloric content and deduct 50% of the
(4) Complex caloric content of binges that are purged (vomited); fi-
(5) Fiber: water-solubleversuswater-insoluble nally, average the caloric intake over the 7-day period.
B. Protein Determination of this averageenerg'yintake, as well as the
(1) Determine percent kcal intake range of intake, will be useful information for the counsel-
(2) Compare intake with DRI ing process.
(3) Evaluatevegetariandiet for high biologic Inadequate caloric intake, limited variety in the diet,
value sources and poor food group representation result in inadequate
C. Fat vitamin and mineral consumption in AN and BN patients.
(1) Determine percent kcal intake In general, micronutrient intake parallels macronutrient
(2) Source ofessential fatry acid intake; thus AN patients who consistently restrict dietary
(3) Compare intake to DRI fat are at greater risk for inadequate essential fatty acid
3. Micronutriens intake and fat-soluble vitamin intake. Based on a 30-day
A Mtamins diet history Hadigan et al. (2000) found that more than
(1) Water-soluble 50% of thirty AN patients failed to meet DRI require-
(2) Fat-soluble ments for vitamin D, calcium, folate, vitamin B12,mxgne-
(3) Identifi' supplements sium, copper, and zinc. Nutrient intake in patients with
B. Minerals BN varies with the cycle of binge eating and restriction.
(l) Calcium Patients with AN and BN should be queried about the use
(2) Iron of vitamin and mineral supplements.
(3) Znc When obtaining a diet history qpical fluid intake should
(4) Identift supplements also be determined because abnormalities in fluid balance
4. Fluid are prevalent in this population. Some patients severely re-
A Determine total daily consumption strict intake because they are intolerant of feeling full after
B. Identiiz sources fluid ingestion, whereas others drink excessiveamounts, at-
5. Miscellaneous tempting to stave offhunger. Extremes in fluid restriction or
A. Alcohol consumption may require monitoring of urine specific grav-
B. Caffeine ity and serum electrolytes.
C. Amount and type of nonnutritive sweetenersand
fat substitutes
EatingBehavior
D. Other nutritional supplements(i.e., herbal Characteristicattitudes,behaviors,and eatinghabitsseenin
supplements) AN and BN are shownin Box 22-3.Food aversions, com-
From LuderE, SchebendachJ: Nutrition management of eatingdisorders, mon in this population,includered meat,bakedgoods,des-
TopClinNutr 8:53,1993. serts,addedfats,and fried foods.Patientswith eatins disor-
lN, Anorexianewosa;BN, bulimia nervosa;DRI, dietaryreferenceintake. ders often regard specific foods or groups of foods as
absolutely"good" or absolutely"bad."Irrationalbeliefsand
dichotomousthinking about food choicesshould be identi-
fied and challengedthroughout the treatrnentprocess.
was not reported (Fladigan et al., 2000). The majoriry of AN In the assessment,it is important to determineunusualor
vegetarians adopt this practice during t}re course of their ill- ritualistic behaviors,which may includeingestionof food in
ness, so vegetarianism may simply be a covert method of an at'?ical manner or with nontraditionalutensils;unusual
limiting foods, particularly those containing fat. The nutri- food combinations;or the excessive use of spices,vinegar,
tionist should determine if the adoption of vegetarian food lemon juice, and artificial sweeteners.Meal spacing and
choices predated tlle development of AN and whether family length of time allocatedfor a meal should also be deter-

Assessmentof Eating Attitudes,
Behaviors,and Habits
l. Eating attitudes
A. Food aversions
B. Safe,risky, forbidden foods
C. Magical thinking
D. Binge trigger foods
E. Ideas on appropriate amounts of food
2. Eating behaviors
A. Ritualisticbehaviors
B. IJnusual food combinations
C. Aqpical seasoningof food
D. Excessiveand atypical use of non-caloric sweeteners
E. Atypical use of eating utensils
3. Eating habits
A. Intake pattern
(1) Number of mealsand snacks
(2) Time of day meals and snacls are consumed
(3) Duration of feedings
(4) Eating environment-where and with whom
(5) How consumed-sitting or standing
B. Avoidance ofparticular food groups
C. Variety of foods consumed
D. Fluid intake-restricted or excessive
From SchebendachJ,NussbaumM: Nutrition managementin adolescents
wirlr eating disor ders,Adolesc
Metl: Stateof theAn R i l1l1tS+5, SeZ.
mined. Many patients will save their self-allotted food ra-
tion until late in the day; others are fearful of eating past a
certain time of day.
Many BN patients eat quickly, reflecting their difficulties
with satiety cues. In addition, BN patients may identifiz
foods they fear will trigger a binge episode.The patient may
have an all-or-nothing approach to "trigger" foods. A1-
though the patient may prefer avoidance, assistancewith
reintroduction of controlled amounts of thesefoods at regu-
lar times and intervals is helpful.
ManyAN patients eat in an excessivelyslow manner, often
playing with their food and cutting it into small pieces.This
is sometimes regarded as a tactic to avoid food intake, but it
may also be an effect of starvation (Keys et al., 1950).
Assessment
Lahoratory
The marked cachexia of AN may lead one to expect bio-
chemical indices of malnutrition, but this is rarely the case.
Compensatory mechanisms are remarkable, and labora-
tory abnormalities may not be observed until the illness is
far advanced.
Significant alterations in visceral protein status are un-
common in AN. Indeed, adaptive phenomena that occur in
chronic starvation are aimed at the maintenance of visceral
protein metabolism at the expenseof the somatic compart-
C H A P T E R2 2 | N u t r i t i o ni n E a t i n gD i s o r d e r s 5 7 5
ment. Serum albumin levels are generally within normal
limits but may be masked by dehydration in early treaffnent
(Swenne, 2004).
Despite consumption of a typically low fat, low-choles-
terol diet, some AN patients initially present with elevated
serum cholesterol levels (APA, 2006). Nevertheless, this
does not warrant the continuation of a fat- and cholesterol-
restricted diet during nutritional rehabilitation. If hlperlip-
idemia predated the development of AN, or if a strong
family history of hi,perlipidemia is identified, the patient
should be reassessed after weight restoration and a period of
weight stabilization. Low blood levels of essential fatty acids
may contribute to the physical and mental syrnptoms of the
disorder (Ayton, 2004).
Patients with BN may also have abnormal lipid levels.
Patients with BN are prone to eating low-fat, low-energy
foods during the restriction phase and high-fat, high-
sugar foods during binge episodes. Premature prescrip-
tion of a low-fat, low-cholesterol diet may only reinforce
this dichotomous approach to eating. Care must be taken
to balance extremes in the types and amounts of foods
consumed. An accurate lipid profile can be obtained only
after a period of dietary stabilization. Patients with BN
may also have difficulty complying with the fast required
for an accurate lipid profile.
Low serum glucose results from a deficit of precursors
needed for gluconeogenesis and glucose production. Thy-
roid hormone production tends to be normal, but the pe-
ripheral deiodination of thy'roxin favors formation of the
less metabolically active reduced triiodothyronine (rT3)
rather than triiodothy'ronine (T3) resulting in low T3 sln'
drome. This metabolic state is characteristic of AN and
typically resolves with weight restoration. Thyroid replace-
ment is not recommended (APA, 2006).
VitaminandMineralDeficiencies
Hypercarotenemia is a common finding in AN, attributed to
mobilization of lipid stores, catabolic changes caused by
weight loss, and metabolic stress.Excessivedietary intake of
carotenoids is less common. Normalizatton of senrm caro-
tene occurs during the course of nutrition rehabilitation.
Despite obviously deficient diets, reports of clinical and
biochemical findings of true deficiency diseasesare un-
common. The decreased need for micronutrients in a
catabolic state, use of vitamin supplements' and selection
of micronutrient-rich foods may be protective. Docu-
mented cases of riboflavin, vitamin 86, thiamin, niacin,
folate, and vitamin E deficiencies have been reported in
lower-weight and more chronically ill patients with AN
(Castro, 2004; Prousky,2003).
Iron deficienry anemia is also uncommon in AN. Iron
requirements are decreasedsecondary to amenorrhea and
the overall catabolic state. The true picture may be masked
by hemoconcentration resulting from dehydration in early
treatrnent (Swenne,2004). Once refeeding has been initiated,
hemoglobin concentration may decreasefrom baselinevalues
(Swenne, 2004). Zinc deficiency may also occur secondary to
576 PART4 I Nutrition for Healthand Fitness
inadequate energy intake, avoidance of red meat, and the
adoption of vegetarian food choices.
AN, past and present, is associatedwith a high preva-
lence of osteopenia and osteoporosis in both males and
females. Although low estrogen and testosterone levels
and weight loss are the primary causes,concurrent dietary
deficiencies of calcium, magnesium, and vitamin D con-
tribute to the overall pathogenesis. Dual x-ray absorpti-
ometry to determine the degree of impaired bone miner-
alization is recommended (see Chapter 24).
F l u i da n dE l e c t r o l y tBea l a n c e
Vomiting and laxative and diuretic use can result in signifi-
cant fluid and electrolyte imbalances in patients with eating
disorders. Laxative use may result in hl,pokalemia, and di--
uretic use can also cause hypokalemia and dehydration.
Vomiting may result in dehydration, hypokalemia, and alka-
losis with hypochloremia. Hyponatremia is another serious
complication but is seen less frequendy.
IJrine concentration is decreased, and urine output is
increased in semistarvation. Edema may occur in response
to malnutrition and refeeding. Depletion of glycogen and
lean tissue is accompaniedby obligatory water loss that re-
flects characteristic hydration ratios. For example, the
obligatory water loss associated with glycogen depletion
may be in the range of 600 to 800 ml. Varying degrees of
fluid intake, ranging from restricted to excessive,may affect
electrolyte values in AN patients.
E n e r g yE x p e n d i t u r e
Resting energ'y expenditure (REE) is characteristically
low in malnourished AN patients (de Zwaan et a1.,2002).
Weight loss, decreasedlean body mass,energ'yresrriction,
and decreased leptin levels have been implicated in the
pathogenesis of this hypometabolic state. Refeeding in-
creasesREE in malnourished AN patients. However. in
some casesthe increasein REE is excessiveand presents
as metabolic resistance to weight gain. Anxiety level, ab-
dominal pain, hyperactivity, and cigarette smoking may
also be associated with this phenomenon ffan Wymel-
beke et al., 2004). An exaggerated diet-induced thermo-
genesis (DIT) has also been reported in AN during the
course of refeeding (de Zwann et a1.,2002). This further
contributes to metabolic resistanceto weight gain during
the early course of nutritional rehabilitation in AN.
Patientswith BN can have unpredictable metabolic rates.
Dietary restraint between episodes of binge eating may
place bulimic patients in a state of semistarvation (resulting
in a hypometabolic rate). However, binge eating followed
by purging can increase the metabolic rate secondary to a
preabsorptive release of insulin, which activates the s).rnpa-
thetic nervous system (de Zwann et a1.,2002).
Baseline and follow-up assessmentof REE is clinically
useful throughout the course of nutritional rehabilitation of
AN and BN patients (Schebendach,2003). Recent advances
in handheld devices such as the MedGem and BodyGem
make measurement of energy expenditure possible in a
clinical setting (seeChapter 2).
Anthropometric
Assessment
Patients with AN have protein-energy malnutrition charac-
teized by significantly depleted adipose and somatic pro-
tein stores but a relatively intact visceral protein comparr-
ment. These patients meet the criteria for a diagnosis of
severe protein-energy malnutrition. A goal of nutritional
rehabilitation is restoration of body fat and fat-free mass.
Although these comparfinents do regenerate, the extent and
rate vary.
Percent body fat can be estimated from the sum of four
skin-fold measurements (triceps, biceps, subscapular, and
suprailiac crest) using the calculations of Durnin and col-
leagues (Durnin and Rahaman, 1967; Durnin and Womers-
ley,I974). This method has been validated against underwa-
ter weighing to assesspercentageof body fit in adolescent
girls with AN (Probst, 2001). A more accuratemeasurement
ofpercentage ofbody fat can be obtained from underwater
weighing or from a dual-enerry x-ray absorptiometry
(DEXA) scan equipped with body composition software;
however, these methods are not generally available in an
ofifice or clinic setting (see Chapter 14).
Bioelectrical impedance analysis (BIA) is more readily
available, but shifts in intracellular and extracellular fluid
compartrnents in patients with severe eating disorders may
affect the accuracy of body fat measurement. To improve
the validity of BIA (see Figure 14-17) measurement in AN
patients, the measurement should be done in the morning
before ingestion of all food and liquid, using a reclining
chair that is always reclined to the same position to prevent
differential pooling of fluids (Sunday and Halmi, 2001).
For practical purposes the midarm muscle circumfer-
ence, derived from midarm circumference and triceps skin-
fold measurements, can be easily obtained and compared
with sex- and age-matched population standards (see Chap-
ter l4). Baseline and follow-up measurements should be
obtained during nutritional rehabilitation.
Body weight is assessedand routinely monitored in pa-
tients with eating disorders. In AN weight gain is necessary.
In BN the short-term goal should be weight mainrenance.
Although weight loss may be warranted, tiis cannot be ad-
dressed until chaotic eating patterns are stabilized.
Rate of weight gain in AN may be affected by hydration
status, glycogen stores, metabolic factors, and changes in
body composition (Box 22-4). Rehydration and replenished
glycogen stores contribute to weight gain during the first
few days of refeeding. Thereafter weight gain results from
increasedlean and fat stores.It is generalizedthat one needs
to increaseor decreasecaloric intake by 3500 kcal to cause
a l-lb change in body weight, but the true energy cost de-
pends on the type of tissue gained. More energy is required
to gain fat versus lean, but weight gain may be a mix of fat
and lean tissue.
Although total body fat normalizes after short-term
weight restoration, it may not be normally distributed
(Mayer et al., 2005; Grinspoon 2001). When weight-
restored AN patients were compared to body mass index
(BMl)-matched normal controls, itwas found that, although
total adipose tissue did not differ significantly between the
 22 I Nutritionin EatingDisorders577
CHAPTER

two groups, body fat was disproportionately deposited
around the waist and abdominal cavity in the weight-re-
stored adult female AN patients (Mayer et al., 2005). How-
ever, central accumulation of fat after weight gain was not
observed after weight restoration in adolescents with AN
(Misra et al., 2003).
Changes in body fat distribution after long-term mainte-
nance of weight restoration and after weight restoration in
male AN patients are not known. Variables that may affect
the type of tissue gained include the stage of growth and de-
velopment, degree of baseline malnutrition, duration of ill-
ness, duration ofweight restoration, gender, genetics, physi-
cal activity, and possibly the type and rate of refeeding.
The anthropometric status of patients with eating disor-
ders should be assessedand monitored regularly (see Chap-
ter 14). The patient's goal weight can be determined by
various methods, none of which is perfect. The height,
weight, and BMI tables of the National Center for Health
StatisticsC{CHS) should be used to assessboys and girls up
to 20 years of age (seeAppendices 12 and 16). A bone age
can be obtained in adolescentswith stunted height to deter-
mine catch-up growth potential.
If a patient is hospitalized, a daily preprandial, early-
morning weight should be obtained. On an outpatient basis
a gowned weight should be obtained on the same scale,at
approximately the same time of day, at least once a week in
early treatment. Before weigh-in the patient should void,
and urine specific gravity should be checked for dehydration
or fluid loading. If the patient claims to be unable to provide
a urine specimen, the physician should examine the patient
to see whether the bladder is fuIl. Patients may resort to
deceptive tactics (water loading, hiding heary objects on
their person, and withholding urine and bowel movements)
to make a mandated weight goal.
Tieatment of AN may begin at one of four levels of care
(Figure 22-3), depending on the severity of malnutrition,
degree of medical and psychiatric instability, duration of ill-
ness, and growth failure. Some AN patients begin treatment
with inpatient hospitalization and are stepped down to a less
intensive level of treatment as weight restoration and nutri-
tional rehabilitation progress. Other AN patients begin
treatment on an outpatient basis; however' if adequate
weight restoration does not occur' they are generally stepped
up to a more intensive level of care.
In BN treatment typically begins and continues on an
outpatient basis.On occasiona BN patient may be directly
admitted to an intensive outpatient or day treaffnent pro-
gram. However, inpatient hospitalization is relatively un-
common and generally is of short duration and for the spe-
cific purpose of fluid and electrolyte stabilization' The
registered dietitian (RD) is an essentialpart of the treatment
team at all levels ofcare.
Nervosa
Anorexia
The goals of nutrition rehabilitation include correction of
biologic and psychological sequelae of malnutrition; resto-
ration of body weight; and normalization of eating patterns'
eating behaviors, and hunger/satiety cues' Hospital-based
programs or residential treatrnent is warranted when the AN
patient is medically unstable,severelymalnourished, or grovth
retarded (APA, 2006; SAM, 2003). Under these circumstances

Factors Affecting Rate of Weight

Gain in Anorexia Nervosa NERVOSA
ANOREXIA NERVOSA
BULIMIA

1 . Fluid balance
A. Polyuria seenin semistarvation
B. Edema
(l) Starvation
(2) Refeeding
C. Hydration ratios in tissues
(l) Glycogen:3-4:1
(2) Protein: 3-4:1
2, Metabolic rate
A. Resting energy expenditure
B. Postprandial energy expenditure
3 . Energy cost oftissue gained
A. Adipose tissue
B. Lean body mass
4. Previous obesity
5. Physical activity
From SchebendachJ,NussbaumM: Nutririon managementin adolescents
witlr eating disorders,AdolestMed: Stateof theAn Rn 3(3):545,1992. FIGURE 22-3 Nutrition counselingin the continuum of care
in eatinedisorders.
 578 PART4 Nutritionfor Healthand Fitness
caloric prescriptions are determined by the medical doctor
or treatment team.
Institutions vary with respect to their menu-planning
protocol. In some institutions the meal plan and food
choices are initially fixed without parient input. As treat-
ment progressesand weight is restored,the patient gener-
ally assumesmore responsibiliry for menu planning. In
other inpatient programs the patient participates in menu
planning from the beginning of trearment. Some institu-
tions have established guidelines that the patient must
comply with to maintain the "privilege" of menu plan-
ning. Guidelines may require a cerrain type of milk (e.g.,
whole vs. low fat), and the inclusion of specific types of
foods such as added fats, animal proteins, desserts,and
snacks. A certain number of servinss from the different
food groups may be prescribed at different calorie levels.
Meal-planning systems also vary among trearmenr pro-
grams. Some design their own, others use food group ex-
changesor the MyPyramid system, and some formulate an
individualized meal plan for each patient.
There are no outcome studiesto suggestthat one method
of meal planning is superior to another, and ueatment pro-
grams tend to have their own philosophy about menu plan-
ning. Despite differences in protocol, AN patients consis-
tently find it difficult to make food choices.The RD can be
extremely helpful in providing a strucrured meal plan and
guidance in the selection of nutritionally adequatemeals of
adequatevariety and caloric density.
In an outpatient setting the trearrnenr team obviously has
less control over rhe AN patient's food choices, energy in-
take, and energy distribution. Under these circumsrances
the RD must use counseling skills to begin the process of
developing a plan for nutritional rehabilitation. AN patients
are t'?ically precontemplative and, at best, ambivalent
about making changes in eating behavioq diet, and body
weight; some are defiant and hostile on initial presentation.
At this point the nutrition counselor, using motivational
interviewing techniques can help the AN patienr resolve
ambivalence toward the idea of change and move bevond
the precontemplative stage (Box 22-51.
Weight restoration is critical to recovery in AN. Effective
nutritional rehabilitation and counseling must ultimately
result in weight gain and improved eatin[ attitudes and be-
haviors. A comprehensive review of nutrition counselinq
techniquescan be found in Chapter 18 and in Herrin (2003)
and Stellefson-Meyer (1999) (see Clinical Insight: DoesEat-
ing Behavior Normalize After Weight Restoration?).
The treatment plan of an AN patienr should include an
expected rate of weight gain. Gains of 2 to 3 lb/week for
the hospitalizedpatient and 0.5 to I lb/week for the out-
patient are reasonableand attainable goals. Calorie ore-
scriptions in the range of I 000 to 1600 kcal/day (30 to 40
kcal/kg of body weight per day) are sufficient to initiate
weight gain (APA, 2006).
To promote controlled weight gain, the caloric prescrip-
tion must be progressivelyincreased.Increasing the energy
intake by 100 to 200 calories every 2 to 3 days is generally
well tolerated (APA, 2006); however, some inpatient ffear-
Principlesof Motivational Interviewing
l. Expressempathy:
Acceptancefacilitates change.
Skillful reflective listening is fundamental.
Ambivalence on the part of the client is normal.
2. Develop discrepanry:
Client, not the counselor,should present the arguments
for change.
Change is motivated by a perceiveddiscrepanry
between present behavior and important personal
goals or value.
3. Roll with resistance:
Avoid arguing for change.
Resistanceis not direcdy opposed.
New perspectivesare invited but not imposed.
Client is a primary resourcein finding answersand
solutions.
Resistanceis a signal (to the counselor) to respond
differendy.
4. Supportself-efficary:
A person'sbelief in the possibility of changeis an
important motivator.
Client, not the counselor,is responsiblefor choosing
and carrying out change.
The counselor'sown belief in the person'sability to
changebecomesa self-fulfilling prophecy.
From Miller WR, Rollnick S: Motiaatiunal interuiewing preparing peaplefm
change,ed 2, New York, The Guildford Press,2002, pp.33-42.
ment programs increase the caloric prescription in 500-
calorie increments (Yaget and Andersen, 2005).
Aggressive refeeding of severely malnourished AN pa-
tients (i.e., those weighing less than 70o/" standard body
weight) may precipitate life-threatening complications of
the refeeding syndrome during the first week of oral, naso-
gastric, or intravenousrefeeding (Ornstein et al., 2003) (see
Chapter 3). Manifestations of the slmdrome are fluid and
electrolyte imbalance; cardiac,neurologic, and hematologic
complications;and sudden death. High-risk patients need to
be carefully monitored with daily measurements of serum
phosphorus, magnesium, potassium, and calcium for the
first 5 days of refeeding and every other day for several
weeks thereafter. Supplemental phosphorus, magnesium,
and potassium may be given orally or intravenously.
Continued weight gain requires progressive increases in
caloric intake, and consumption of 70 to 100 kcal/kg of
body weight daily may be needed in some AN patients
(APA, 2006). Changes in REE, DI! and the qpe of tissue
gained are all factors. In addition, the energy cost ofphysi-
cal activity must be considered becausemany AN patients
expend significant amounts of energy in physical acriviry
and or fidgeting behavior (de Zwann et a1.,2002).
In general, caloric prescriptions in the range of 3000 to
4000 kcaVday may be needed later in the course of weight
 22 : Nutritionin EatingDisorders579
CHAPTER

Guidelinesfor Medical Nutrition

Does Eating Behavior Normalize Therapy of AnorexiaNervosa
After Weight Restoration?
1. Caloric prescription:
A. Initial weight gain
l-\isturbances in eating behavior and weight loss are charac-
lJ teristic features of AN. Successfultreaffnent of the AN (1) Start at 30 to 40 kcakg/day (approximately
patient resuls in weight gain, but do disturbed eating behav- 1000 to 1600 kcal/day)
iors also normalize during the processof weight restoration? (2) Assessrisk for refeeding syndrome
Sysko and colleagues (2005) studied twelve hospitalized B. Controlled weight gain phase
AN patiens and compared them with normal healthy con- (l) Increaseprescription in small, progressive
trols. All twelve AN patients were tested shordy after admis- increments to promote expectedrate of
sion to an inpatient treatment program, and eleven were re- conrolled weight gain (e.9.,2-3lb/wkfor
tested after weight restoration (greater than or equal to 90% inpatients, 0.5 to I lb/wk for ourpatiena)
of IBW). To test the eating behavior of patients and controls, (2) Late treatrnent: 70 to 100 kcaUkg/day
subjectswere given a large, sealed,83 fl oz opaque container Females:3000 to 4000 kcaVday
of strawberry yogurt shake, which provided approximately Males: 4000 to 4500 kcaUday
I calorie per gram. Subjectscould not see how much shake (3) Ifpatient requires a higher kcal prescription,
was in the container, and they were not informed of the quan- evaluatefor vomiting, discarding food, increased
tity or the caloric content. Instructions specifiedthat partici- exercise,increasedmotor activity, increased
pants could drink as much shake as they liked and that the REE/DIT
shakewould replacetheir lunch meal for that day.In AN pa- C. Weight maintenancephase
tients mean shakeconsumption was l0+ -r 102 g when they (l) Adults: 40 to 60 kcal/kg/day
were at their low weight and 178 -+ 203 g after weight restora- (2) Ongoing grovth and developmentin children
tion; these amounts were not significandy different. Normal and adolescents:40-60 kcalkg/day
control subjects consumed significandy more than did AN 2. Macronutrients
patientsat both time points, and the averagemeal sizewas490 A. Protein
-r 188 g. Despite weight restoration and significant improve- (1) Minimum intake : RDA in g/kg ideal body
ment in psychological syrnptoms, AN patients exhibited a weight
persistent disturbance in eating behavior. The authors con- (2) ls%" to 20"/" kcal
cluded that nutritional rehabilitation and weight restoration (3) High biologic value sources
may not resolve the core eating difficulties in AN. This may B. Carbohydrate
contribute to the high relapserate seenin this population. (l) 50Y"to 55% kcal
(2) Encourage insoluble fiber for treatment
of constipation
C. Fat
(l) 25"/"to 30% kcal
restoration, and male AN patients may require even more-
(2) Encourage small increasesin fat intake until
4000 to 4500 kcaVday (APA, 2006). Patients who require ex-
goal can be attained
traordinarily high energy intakes should be questioned or
(3) Provide source ofessential fatry acid
observed for discarding of food, vomiting, exercising, and
3. Micronutrients
excessivephysical activitlz,including fidgeting. After the goal
A. 100% RDA multivitamin with minerals supplement
weight is attained, the caloric prescription may be slowly de-
B. Note that iron-containing preparationsmay
creased to promote weight maintenance. However, caloric
aggravateconstipation
prescriptions may remain at higher levels in adolescentswith
From Luder E, SchebendachJ:Nutrition managementofeating disorders,
the potential for continued growth and development.
TbpClin Nutr 8:48, 1993.
AN patients receiving care in less structured treatment
D1f, Diet-induced thermogenesis;RDl, recommendeddietary allowance;
settings such as outpatient treatment programs may be par- REd resting energy expenditure.
ticularly resistant to formalized meal plans. A practical ap-
proach may be the addition of 200 to 300 caloriesper day to
the patient's gpical (baseline) energy intake. Howeveq the
nutritionist must carefully query and assessintake since treme avoidance of dietary fat is common, but continued
these patients typically overestimate their food and energy omission will make it difficult to provide concentrated
consumption (Hadigan et al., 2000). sourcesof energy needed for weight restoration. A dietary
Once the caloric prescription is calculated, a reasonable fat intake in the range of 25"/o to 30"/" of calories is recom-
distribution of macronutrients must be determined (Box mended. This can be accomplished easily when AN patients
22-6). Patients may express multiple food aversions. Ex- are treated on inpatient units or in day hospital programs.
580 PART4 i Nutrition for Healthand Fitness
However, on an outpatient basis small progressive increases
in dietary fat intake rather than a set optimal amount right
away may be met with less resistance.
Although some patients will accept small amounts of
added fat (such as salad dressing, mayo, or butter), many do
better when the fat conrent is less obvious (as in cheese,
peanut butter, granola, and snack foods). Encouraging the
gradual change from fat-free products (fat-free milk) to low-
fat products (l% or 2% mrlk) and finally to full-fat items
(whole milk) is also acceptable to some patients. Focusing
on good fat rather tlan saturated fat is another useful tip.
A protein intake in the range of 15"/o to 20"/o of total
calories is recommended. To ensure adequacy the minimum
protein prescription should equal the recommended dietary
allowance (RDA) for age and sex in grams per kilogram of
ideal body weight (see inside front cover). Vegetarian diets
are often requested but should be discouraged during nutri-
tional rehabilitation.
Carbohydrate intake in the range of 50o/"to 557" of calo-
ries is well tolerated. Sources of insoluble fiber should be
included for optimal health, but also to relieve the constipa-
tion frequendy seen in this popularion.
Although vitamin and mineral supplements are not univer-
sally prescribed, the potential for increased needs during the
anabolic phase must be considered. A vitamin and mineral
supplement providing 100% of the RDA is recommended,
but iron-containing preparations may aggravateconstipation
in some patients. Care must be taken throughout the refeed-
ing processto ensure a reasonablevariety ofintake. Particular
attention to the inclusion of calcium-rich foods along with
extra vitamin D is recommended becauseof the increasedrisk
ofosteopenia and osteoporosis(seeChapter 24).
Delayed gastric emptying with complaints of abdominal
distention and discomfort after eating are common in AN.
In early treatment intake is generally-low and can be toler-
ated in three meals per day. However, as the caloric pre-
scription increases,between-meal feedings become essen-
tial. The addition of an afternoon or evening snack may
relieve the physical discomfort associatedwith larger meals,
but some patients express feelings of guilt for "indulging"
between meals. Commerciallv available. defined-formula
liquid supplements containing 30 to 45 calories per fluid
ounce are often prescribed once or twice daily (see Appen-
dix 32). Patients are fearful that they will become accus-
tomed to the large amount of food required to meet in-
creasedcaloric requirements;thus use of a liquid supplement
is appealing becauseit can easily be discontinued when the
goal weight is attained.
B u l i m i aN e r v o s a
Bulimia nervosa is described as a state of dietarv chaos.
characterized by periods of uncontrolled, poorly struc-
tured eating, which are often followed by a periods of re-
strained food intake. The nutritionist's role is to help de-
velop a reasonableplan of controlled eating while assessing
the patient's tolerance for structure. Since BN patients are
hospitalized infrequently, nutrition counseling will most
likely begin in an outpatient treatment setting.
In BN much of the patient's eating and purging behav-
ior is aimed at weight loss. Although weight reduction
may be a reasonable long-term goal, immediate goals
must be interruption of the binge-and-purge cycle, resto-
ration of normal eating behavio5 and stabilization of body
weight. Attempts at dietary restraint for the purpose of
weight loss typically exacerbate binge/purge behavior in
BN patients.
Patients with BN have varying degrees of metabolic ef-
ficiency which must be taken into accountwhen prescribing
the baseline diet. Assessment of REE along with clinical
signs of a hypometabolic state such as a low T3 level and
cold intolerance are useful in determining the caloric pre-
scription. If a low metabolism is suspected, a caloric pre-
scription of 1500 to 1600 calories daily is a reasonableplace
to start. Another technique that is helpful in establishing an
initial caloric prescription is to base it on the patient's pres-
ent intake by using the following method:
1. For a typical week ask the patient to estimate the
number of binge/purge days, binge/nonpurge days,
moderate-intake days, and restrained-intake days.
2. Have the patient describe a typical food intake on a
binge/purge day, a binge/nonpurge day, a moderate-
intake day, and a restrained-intake day.
3. Estimate 50% of the caloric intake on the binge/
purge days and 100% of caloric intake on the binge/
nonpurge days, moderate-intake days, and resuained-
intake days.
4. Calculate the total caloric intake over the 7 -day
period.
5. Calculate an average daily intake. The RD can then
formulate an initial eating and meal plan based on
this estimated average daily intake.
Body weight should be monitored with a goal of stabili-
zatton. If the patient's weight is stabilized on a lower-than-
average caloric intake, small but consistent increasesin the
caloric intake should be prescribed every 1 to 2 weefts.This
will induce incremental increases in the metabolic rate
(Schebendach,2003).
BN patients need a great deal of encouragement ro fol-
low weight-maintenance versus weightJoss diets. They
must be reminded that attempts to restrict caloric intake
may only increase the risk of binge eating and that their pat-
tern of restrained intake followed by binge eating has not
facilitated weight loss in the past.
A balanced macronutrient intake is essential for the pro-
vision of a regular meal pattern. This should include suffi-
cient carbohydrates to prevent craving and adequate protein
and fat to promote satiety. In general, a balanced diet pro-
viding 507" to 55% ofthe calories from carbohydrate, l57o
to 20"/" from protein, and,25"/" to 10"/o from fat is reason-
able. Small amounts of dietary fat should be encouraged at
each meal. fu is the casewith AN, this may be better toler-
ated when provided in a less obvious mannet such as in
peanut butter, cheese,or whole milk.
Adequacy of micronutrient intake relative to the caloric
prescription and variety of intake should be assessed.A
 22 i Nutrition
CHAPTER in Eating
Disorders
5 81

multivitamin-mineral preparation may be prescribed to

ensure adequacy,particularly in the initial phase of treat-
ment (Box 22-7). Guidelines for Medical Nutrition
Bingeing, purging, and restrained intake often impair
recognition of hunger and satiety cues. The cessation of
Therapy of Bulimia Nervosa
purging behavior coupled with a reasonable daily distribu-
1. Caloric prescription for weight maintenance
tion of calories at three meals and prescribed snackscan be
A. Provide 1500 to 1600 kcaVdaydiet if patient
instrumental in strengthening these biologic cues. Many
is hypometabolic
patients with BN are afraid to eat earlier in the day, fearful
B. Provide DRI for energyif meubolic rate
that these calories will contribute to caloric excessif they
is normal
binge later. They may also digress from their meal plans
C. Monitor body weight and adjust caloric
after a binge, attempting to restrict intake to balance out the
prescription for weight maintenance
binge calories. Patience and support are essential in this
D. Avoid weight reduction diets until eating
processof making positive changesin their eating habits.
pafterns and body weight are stabilized
Cognitive behavioraltherapy (CBT), a highly structured
2. Macronutrients
psychotherapeutic method used to alter attitudes and prob-
A. Protein
lem behaviors by identi4'ing and replacing negative, inac-
(l) Minimum inake : RDAin glkgideal
curate thoughts and changing the rewards of the behavior,
body weight
is the treatment of choice in BN (APA, 2006). When applied
(2) lsV" to 20"/" kcal
to an eating disorder, CBT is typically a 20-week interven-
(3) High biologic value sources
tion that consists of three distinct and systematic phases of
B. Carbohydrate
trealrnent: (1) establishing a regular eating pattern; (2)
(1) 50% to 55% kcal
evaluating and changing beliefs about shape and weight; and
(2) Encourage insoluble fiber for treatment
(3) preventing relapse.
of constipation
When the BN patient is receiving CBI the RD can be
C. Fat
instrumental in helping the patient to establish a regular
(l) 25Y"to 30% kcal
meal pattern (phase 1). However, the RD and the psycho-
(2) Provide source ofessential fatty acids
therapist must maintain active communication to avoid
overlap in the counseling sessions.If the BN patient is en- 3. Micronutrients
gaged in a type of psychotherapy other than CBI the RD A. 100% RDAmultivitamin with minerals
supplement
should incorporate more CBT skills into the nutrition
B. Note that iron-containing preparation may
counseling sessions(Herrin, 2003).
Patients with BN are q?ically more receptive and less aggruvateconstipation
From LuderE, SchebendachJ: Nutrition managementofeatingdisorders;.
resistant to nutrition counseling than the AN patient and
TopClin Nutr 8:48,1993.
less likely to present in the precontemplation stage of . '
RDl, Recommended dietaryallowance;RDd referencedaily intake.
change. Suggested strategies for nutrition counseling at the
precontemplation, contemplation, preparation, action, and
maintenancestagesare given in Table 22-3.

Counseling
Strategies
Usingthe Stagesof Change
Modelin EatingDisorders
Stage of Change GounselingStrategies
Precontemplation . Establish rapport
. Assessnutrition knowledge, beliefs, attitudes
' Conduct thorough review offood likes/dislikes,safe/riskyfoods, forbidden foods (assessreason),
binge/purge foods
. Assessphysical,anthropometric, metabolic status
o Assesslevel of motivation
. IJse motivational interviewing techniques
o Decisional balance:weigh costsand benefits of maintaining current statusvs. costsand benefis
of change
Modified from Stellefson-MyersE: Winning the war within: nutrition theraplfor clienx with anorexiaor bulimia nmosa, Dallas, Tex, 1999,Helm Publishing.

Continued
582 PART4 1 Nutritionfor HealthandFitness

Counseling
Strategies
Usingthe Stagesof Change
Modelin EatingDisorders-cont'd
Stage of Change CounselingStrategies
Contemplation a Identifr behaviors to change;prioritize
a Identi{' barriers to change
a Identifo coping mechanisms

a Identi{' support systems

a Discussself-monitoring
tools: food and eating behavior records
a Continue motivational
interviewing technique
Preparation . Implement: nutrition-focused cognitive behavioral therapy (CBT)
a Implement self-monitoring
tools: food and eating behavior records
a Determine list of alternative
behaviorsto bingeing and purging
Action a Develop a
plan of healthy eating
a Reinforce positive
decision making, self-confidence,and self-effrcary
a Promote
positive self-rewarding behaviors
a Develop strategiesfor handling
impulsive behaviors,high-risk situations, and "slips"
a Continue CBT

a Continue self-monitoring

Maintenance/relapse . Idend$/strategies; managementof high-risk srtuatrons

a Continue positive
self-rewarding behaviors
Reinforce coping skills and impulse control techniques
Reinforce relapseprevention strategies
Determine/schedulefollow-up sessionsneededfor maintenance/reinforcementof positive
changesin eating behavior and nutrition status

Patient Monitoring
1. Body weight (3) Outpatient
A Establish goal weight a. Once every l-2 wk in early treatment, less
B. Determine frequendy in mid- to late treatrnenr
(1) Acceptablerate of weight gain in AN b. Gowned
(2) Maintenance weight range in BN c. Poswoid
C. Monitor weight d. Sametime of day
(l) Inpatient e. Samescale
a . Daily, or every other day f. Obtain urine specific gravity
b. Gowned 2 . Height
c. Preprandial A. Obain baselineO{CHS percentile for children and
d . Poswoid adolescents)
e. Obtain urine specific gravity B. Monitor: every l-2 mo in patients with growth
f. Obtain addidonal, random, afternoon, or potential
evening weight if fluid loading is suspected J. Anthropometric measurements(optional)
(2) Day treatrnent A. Obtain baseline
t May vary, depending on diagnosis,age of (1) Skinfolds; triceps, biceps,subscapula,suprailiac
patient, and treatrnent setting (i.e., daily, (2) Midarm circumference
severaltimes per week, once per week) (3) Midarm muscle circumference
b. Gowned B. Monitor
c. Poswoid (l) Inpatient: as medically indicated
d. Sametime of day (2) Outpatient: as medically indicated
e, Samescale
f. Obtain urine specific gravity

Patient Monitoring-cont'd
A
a- Resting and postprandial energy expenditure (optional)
Obtain baseline
Monitor
(1) Inpatient: as medicallyindicated
(2) Outpatient: as medicallyindicated
5 . Outpatient diet monitoring
A. Anorexia nervosa
Daily food record to include:
(1) Food
(2) Fluid: caloric and noncaloric, alcohol
(3) Artificial sweeteners
(4) Eating behavior: time, place, how eaten,with
whom
(5) Exercise
Binge-Eatin
Dgi s o r d e r
Strategiesfor treatment of BED include nutrition counsel-
ing and dietary management,individual and group psycho-
therapy, and medication. Some trearment programs focus
primarily on nutrition counseling and weight loss.Nthough
successfulweight loss and decreasedfrequenry of binge eat-
ing episodesmay result, relapse occurs often. Other treat-
ment programs focus primarily on reduction of binge epi-
sodes rather than weight loss. Self-acceptance,improved
body image, increased physical activiry, and better overall
nutrition are also goals of treatment in BED.
M o n i t o r i nN
g u t r i t i o n aRl e h a b i l i t a t i o n
Guidelines for monitoring the nutritional management of
patients with AN are indicated in Box 22-8. The health pro-
fessional,patient, and family must be realistic about treatrnent,
which is often a long-term process.Although outcomes may
be favorable, the course of treatrnent is rarelv smooth. and
cliniciansmust be preparedro monitor progr.i, carefully.
Patients with eating disordersmay appearquite knowledge-
able about food and nutrition. Despite this, nutrition educa-
tion is an essentialcomponent of their treatment plan. In-
deed, some patients spend significant amounts of time
reading nutrition-related information, but their sources
may be unreliable, and their interpretation potentially dis-
torted by their illness.Malnutrition may impair the patient's
ability to assimilate and process new information. Early-
and mid-adolescent development is characterized by the
transition from concrete to abstract operations in problem
solving and directed thinking, and normal developmental
22 I Nutritionin EatingDisorders583
CHAPTER
B. Bulimia nervosa
Daily food record to include:
(1) Food
(2) Fluid: caloric and non-caloric, alcohol
(3) Artificial sweeteners
(4) Eating behavior: time, place, how eaten,with
whom
(5) Emotions/feelings when eating
(6) Foods eaten at a binge
(7) Time and method of purge
(8) Exercise
From: Luder E, SchebendachJ:Nutrition managementof eating
disorders, TopClin Nutr 8:48, 1993.
lN, Anorexia nervosa;BN, bulimia nervosa;NCIIS, National Center for
Health Statistics.
issues must be considered when teaching adolescents with
eating disorders (seeChapter 8).
Nutrition education materials must be thoroughly as-
sessedto determine if language and subject matter are bias
free and appropriate for AN and BN patients. For example,
literature provided by many health organizations promotes
a low-fat diet and low-calorie lifestyle for the prevention
and treatment of chronic disease.This material would be in
direct conflict with a treatment plan that encourages in-
creased caloric and fat intake for the purpose ofnutritional
rehabilitation and weight restoration.
Although the interactive process of a group setting may
have advantages,these topics can also be effectively incor-
porated into individual counseling sessions.Topics for nu-
trition education are suggestedinBox22-9.
PnocNosrs
Relapse rates after weight restoration in AN are high, with
as many as 507" of patients requiring rehospitalization
within I year of inpatient treatment flValsh et aI., 2006).
Follow-up studies suggest that two thirds of AN patients
will have enduring morbid food and weight preoccupation
(APA, 2006). In general, adolescentshave better outcomes
than adults, and younger adolescents have better outcomes
than older adolescents.
Mortality rates in AN are among the highest in psychiat-
ric illnesses, and women with AN are reportedly 12 times
more likely to die than women of similar agesin the general
population (APA, 2006). Outcomes studies in treated BN
patients suggesta short-term successrate of 50o/"to 70Y";
however, relapse rates in the range of 30"/" to 85 % have also
been reported (APA, 2006).
584 PART4 : Nutritionfor HealthandFitness
Topicsfor Nutrition Education
l. Impact of malnutrition on growth and development
2. Impact of malnutrition on behavior
3. Set-pointtheory
4. Metabolic adaptation to dieting
5. Restrainedeating and disinhibition
6. Causesof bingeing and purging
7. What does "weight gain" mean?
A. Glycogen storage
B. Fluid balance
C. Lean body mass
D. Adiposetissue
8. Impact of exerciseon caloric expenditure
9. Ineffectivenessof vomiting, laxatives,and diuretics in
long-term weight control
Anorexia nervosa and bulimia nervosa must be
understood and appreciated as potentially chronic
disorders characterized by periods of relapse.
Refeeding in eating disorders requires the
collaborative effort of medical and mental heath
professionals, with the support of friends and family.
arais a 13-year-oldgirl. Her height is 61 in, and her weight
is 72 lb. Sara began menstruating * age 12 but has not
menstruatedfor the past5 months.Laboratory data:glucose,62
mg/dl; albumin, 4.6 g/dl; cholesterol,240 mg/dl; phosphorus,
2.3 mg/dl; T3-radioimmunoassay(RIA), 78 ng/dl; ESR, 2 mrr/
hr. Anthropometric status: Skin folds: triceps, 4 mm; biceps,
2 mm; subscapulaa5 mm; suprailiac,4mml midarm circumfer-
ence, 18 cm; midarm musclecircumference,16.7 cm.
Sara'smaximum weight was 103 lb 8 months ago. She was
concerned that her hips and thighs were fat and sarted to
eliminate snacksand dessertsfrom her diet. Sarawas pleased
with her "willpower." Shethen decidedto eat heaft healthy and
excluded all sources of dietary fat. About 5 months ago Sara
eliminated red mear, poultry, and seafood,claiming that a veg-
etarian diet was a healthier option. fu she lost weight, Sarabe-
came increasinglymore concernedabout her body shapeand
size.Her diet becamemore resrrictedin the amount and variety
of intake, providing about 650 kcal per day. Sara'sfamily ex-
pressedconcem about her eating behaviors.Shewould ritualis-
tically cut small portions of food into many piecesand spendup
to an hour consuming one small meal. After eating Sara ex-
pressedconsiderableguilt about overeating and often cried.
10. Portion control
11. Food exchangesystem
12. Socialdining and holiday dining
13. MyPyramid food guidancesystem
14. Hunger and satiety cues
15. Interpreting food labels
| 6. Nutrition misinformation
From SchebendachJ, NussbaumMP: Nuuition managementin adolescents
with eating disorders,Ad,olesc
Med StateAn Reo 3(3):545,1992.
Nutritional rehabilitationcan correct some(i.e.,
hypometabolicstate,vital sign instability)but not
all (organmass,bone mass,and growth) of the
pathophysiologicconsequences of malnutrition in
eating disorders.
Successfullong-term treatrnentcan takeyears,and
the expectationofa quick cure shouldbe dispelled.
Some days she barely ate at all, consuming only large amounts
of water and diet soda.Despiteher limited caloric intake, Sara's
parentswere amazedat her energylevel. She continued to play
soccer(1 to 2 hours daily, 5 daysa week), did regular calisthenics
Qeglifu and sit-ups, 30 minutes daily), and went running each
morning (5 to 7 miles).
Nutrition Diagnosis: Disorderedeatingpattern
related to restricting foods as evidencedby rituals
surrounding mealsand foods and low weight for height
l. What are some possiblemedical complications that
Saramay develop secondaryto self-starvation?
2. Discusslaboratory valuesand what you might expect
to happen to theseindices during refeeding.
3. Determine Sara'sdesirablebodyweight, goal weight
for treatrnent, and recommendedrate of weight gain.
4. Calculate Sara'sinitial caloric prescription and discuss
how you arrived at this. How might this changeover
time and why?
5. Plan a samplemenu.
 22 i Nutritionin EatingDisorders585
CHAPTER

! ennifer is a l9-year-old woman. Her height is 65 in. and Nutrition Diagnosis: Disorderedeatingpattern
c",$her weight is 138 lb. Laboratory data:glucose,S2 mg/dl; related to binging and purging as evidencedby self-
albumin, 4.2 g/dl; cholesterol, 180 mg/dl; potassium,2.7
induced vomiting following binge episodesaccompanied
mmol./L; serum CO2, 31 mmol/L. Anthropometric status:
by guilt and restricted eating
Skin folds:triceps,20mm; biceps,7 mm; subscapular, l0 mm;
suprailiac,13 mm; midarm circumference,26.Tcm; midarm
l. What are some possiblemedical complications that
muscle circumference,20.4 cm.
Jennifer may develop secondaryto binge eating and
Jennifer has always been unhappy with her weight. She her compensatorybehaviors?
went on every fad diet throughout high school and lost some
2. Discussher laboratory valuesand what you might
weight but always regained it. About I year ago, Jennifer
expectto happen to theseindices during rehabilitation.
began binge eating. Binge episodesnow occur three to four
3. Determine Jennifer'sideal body weight and goal
times per week. During these binges Jennifer consumes
weight for short-term and long-term treatment.
about 1500 to 2000 kcal in a 2-hour period. Binge foods
4. CalculateJennifer'sinitial caloric prescription and
include ice cream, cookies, potato chips, and other foods.
discusshow you arrived at this.
Jennifer describesthem as "fattening and unhealthy." A.fter 5. Plan a samplemenu.
binge eating Jennifer feels extremely guilty, and vomiting is
6. Discusshow you would handle foods thatJennifer
immediately self-induced.Jennifer alwaystries to eat aslittle
considersbinge "trigger" foods.
as possiblethe next day, sometimesconsuming only 700 or
7. What would you suggestforJennifer to help conrol
800 kcal. Three months ago Jennifer started to overdose on
her episodesof vomiting, laxativeuse, and diet pill use?
laxatives about three times a week. She occasionally uses
over-the-counterdiet pills, but they never really help. Jen-
nifer feels fat in her abdomen, buttocks, and thighs. Her
physical activity includes 100 sit-ups and 100 leg lifts three
or four times per week.

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