Nutrition Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa, and Eating Disorder Not Otherwise Specified (EDNOS) - Nutrition Intervention for Treating Anorexia Nervosa

Written by HealthyPlace.com Staff Writer

Adolescents with eating disorders require evaluation and treatment focused on biological, psychological, family, and social features of these complex, chronic health conditions. The expertise and dedication of the members of a treatment team who work specifically with adolescents and their families are more important than the particular treatment setting. In fact, traditional settings such as a general psychiatric ward may be less appropriate than an adolescent medical unit. Smooth transition from inpatient to outpatient care can be facilitated by an interdisciplinary team that provides continuity of care in a comprehensive, coordinated, developmentally oriented manner. Adolescent health care specialists need to be familiar with working not only with the patient, but also with the family, school, coaches, and other agencies or individuals who are important influences on healthy adolescent development (1,7).

In addition to having skills and knowledge in the area of eating disorders, the registered dietitian working with adolescents needs skills and knowledge in the areas of adolescent growth and development, adolescent interviewing, special nutritional needs of adolescents, cognitive development in adolescents, and family dynamics (71). Since many patients with eating disorders have a fear of eating in front of others, it can be difficult for the patient to achieve adequate intake from meals at school. Since school is a major element in the life of adolescents, dietitians need to be able to help adolescents and their families work within the system to achieve a healthy and varied nutrition intake. The registered dietitian needs to be able to provide MNT to the adolescent as an individual but also work with the family while maintaining the confidentiality of the adolescent. In working with the family of an adolescent, it is important to remember that the adolescent is the patient and that all therapy should be planned on an individual basis. Parents can be included for general nutrition education with the adolescent present. It is often helpful to have the RD meet with adolescent patients and their parents to provide nutrition education and to clarify and answer questions. Parents are often frightened and want a quick fix. Educating the parents regarding the stages of the nutrition plan as well as explaining the hospitalization criteria may be helpful.

There is limited research in the long-term outcomes of adolescents with eating disorders. There appear to be limited prognostic indicators to predict outcome (3,5,72). Generally, poor prognosis has been reported when adolescent patients have been treated almost exclusively by mental health care professionals (3,5). Data from treatment programs based in adolescent medicine show more favorable outcomes. Reviews by Kriepe and colleagues (3, 5, 73) showed a 71 to 86% satisfactory outcome when treated in adolescent-based programs. Strober and colleagues (72) conducted a long-term prospective follow-up of severe AN patients admitted to the hospital. At follow-up, results showed that nearly 76% of the cohort meet criteria for full recovery. In this study, approximately 30% of patients had relapses following hospital discharge. The authors also noted that the time to recovery ranged from 57 to 79 months.

POPULATIONS AT HIGH RISK

Specific population groups who focus on food or thinness such as athletes, models, culinary professionals, and young people who may be required to limit their food intake because of a disease state, are at risk for developing an eating disorder (21). Additionally, risks for developing an eating disorder may stem from predisposing factors such as a family history of mood, anxiety or substance abuse disorders. A family history of an eating disorder or obesity, and precipitating factors such as the dynamic interactions among family members and societal pressures to be thin are additional risk factors (74,75).

The prevalence of formally diagnosable AN and BN in males is accepted to be from 5 to 10% of all patients with an eating disorder (76,77). Young men who develop AN are usually members of subgroups (eg, athletes, dancers, models/ performers) that emphasize weight loss. The male anorexic is more likely to have been obese before the onset of the symptoms. Dieting may have been in response to past teasing or criticisms about his weight. Additionally, the association between dieting and sports activity is stronger among males. Both a dietary and activity history should be taken with special emphasis on body image, performance, and sports participation on the part of the male patient. These same young men should be screened for androgenic steroid use. The DSM- IVTR diagnostic criterion for AN of <85th percentile of ideal body weight is less useful in males. A focus on the BMI, nonlean body mass (percent body fat), and the height-weight ratio are far more useful in the assessment of the male with an eating disorder. Adolescent males below the 25th percentile for BMI, upper arm circumference, and subscapular and triceps skinfold thicknesses, should be considered to be in an unhealthy, malnourished state (69).

HUNGER/SATIETY CUES IN MANAGING AN EATING DISORDER

With the emergence of the nondieting approach to the treatment of disordered eating and obesity, it would seem that the use of hunger/satiety cues in managing an eating disorder may assist in resuming normal eating patterns. At this point in time, research suggests that eating-disordered patients have predominantly "abnorma" patterns of hunger and fullness, indicating a confusion of these concepts. Whether or not normal patterns of hunger and satiety resume after the normalization of weight and eating behaviors has yet to be determined (79- 81).

CONCLUSION

Eating disorders are complex illnesses. To be effective in treating individuals who suffer from these illnesses, the expert interaction between professionals in many disciplines is required. The registered dietitian is an integral member of the treatment team and is uniquely qualified to provide the medical nutrition therapy for patients with eating disorders. The registered dietitian working with this population must understand the complexities and the long-term commitment involved. Entry-level dietetics provides the basics of assessment and nutrition counseling, but working with this population requires advanced level training, which may come from a combination of self-study, continuing education programs and supervision by another experienced registered dietitian and/or an eating disorder therapist. Knowledge and practice using motivational interviewing and cognitive-behavioral therapy will enhance the effectiveness of counseling this population. Practice groups of the American Dietetic Association such as Sports, Cardiovascular, and Sports Nutrition (SCAN) and the Pediatric Nutrition Practice Group (PNPG) as well as other eating disorders organizations such as the Academy of Eating Disorders and the International Association of Eating Disorder Professionals provide workshops, newsletters and conferences which are helpful for the registered dietitian.

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