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

Written by HealthyPlace.com Staff Writer

The registered dietitian will need to recommend dietary supplements as needed to meet nutritional needs. In many cases, the registered dietitian will be the team member to recommend physical activity levels based on medical status, psychological status, and nutritional intake. Physical activity may need to be limited or initially eliminated with the compulsive exerciser who has AN so that weight restoration can be achieved. The counseling effort needs to focus on the message that exercise is an activity undertaken for enjoyment and fitness rather than a way to expend energy and promote weight loss. Supervised, low weight strength training is less likely to impede weight gain than other forms of activity and may be psychologically helpful for patients (7). Nutrition therapy must be ongoing to allow the patient to understand his/her nutritional needs as well as to adjust and adapt the nutrition plan to meet the patient's medical and nutritional requirements.

During the refeeding phase (especially in the early refeeding process), the patient needs to be monitored closely for signs of refeeding syndrome (51). Refeeding syndrome is characterized by sudden and sometimes severe hypophosphatemia, sudden drops in potassium and magnesium, glucose intolerance, hypokalemia, gastrointestinal dysfunction, and cardiac arrhythmias (a prolonged QT interval is a contributing cause of the rhythm disturbances) (27,52,53). Water retention during refeeding should be anticipated and discussed with the patient. Guidance with food choices to promote normal bowel function should be provided as well (2,45). A weight gain goal of 1 to 2 pounds per week for outpatient and 2 to 3 pounds for inpatients is recommended. In the beginning of therapy the registered dietitian will need to see the patient on a frequent basis. If the patient responds to medical, nutritional, and psychiatric therapy, nutrition visits may be less frequent. Refeeding syndrome can be seen in both the outpatient and inpatient settings and the patient should be monitored closely during the early refeeding process. Because more aggressive and rapid refeeding is initiated on the inpatient units, refeeding syndrome is more commonly seen in these units. (2,45).

Inpatient

Although many patients may respond to outpatient therapy, others do not. Low weight is only one index of malnutrition; weight should never be used as the only criterion for hospital admission. Most patients with AN are knowledgeable enough to falsify weights through such strategies as excessive water/fluid intake. If body weight alone is used for hospital admission criteria, behaviors may result in acute hyponatremia or dangerous degrees of unrecognized weight loss (5). All criteria for admission should be considered. The criteria for inpatient admission include (5,7,53):

Severe malnutrition (weight <75% expected weight/height) Dehydration Electrolyte disturbances Cardiac dysrhythmia (including prolonged QT) Physiological instability

severe bradycardia (45/min) hypotension hypothermia (36° C) orthostatic changes (pulse and blood pressure)

Arrested growth and development Failure of outpatient treatment Acute food refusal Uncontrollable binge eating and purging Acute medical complication of malnutrition (e.g., syncope, seizures, cardiac failure, pancreatitis, etc.) Acute psychiatric emergencies (e.g., suicidal ideation, acute psychoses) Comorbid diagnosis that interferes with the treatment of the eating disorder (e.g., severe depression, obsessive compulsive disorder, severe family dysfunction).

The goals of inpatient therapy are the same as outpatient management; only the intensity increases. If admitted for medical instability, medical and nutrition stabilization is the first and most important goal of inpatient treatment. This is often necessary before psychological therapy can be optimally effective. Often, the first phase of inpatient treatment is on a medical unit to medically stabilize the patient. After medical stabilization the patient can be moved to an inpatient psychiatric floor or discharged home to allow the patient to try outpatient treatment. If a patient is admitted for psychiatric instability but is medically stable, the patient should be admitted directly to a psychiatric floor or facility (7,54,55).

The registered dietitian should guide the nutrition plan. The nutrition plan should help the patient, as quickly as possible, to consume a diet that is adequate in energy intake and nutritionally well balanced. The registered dietitian should monitor the energy intake as well as body composition to ensure that appropriate weight gain is achieved. As with outpatient therapy, MNT should be targeted at helping the patient understand nutritional needs as well as help the patient to begin to make wise food choices by increasing variety in diet and by practicing appropriate food behaviors (2). In very rare instances, enteral or parenteral feeding may be necessary. However, risks associated with aggressive nutrition support in these patients are substantial, including hypophosphatemia, edema, cardiac failure, seizures, aspiration of enteral formula and death (2,55). Reliance on foods (rather than enteral or parenteral nutrition support) as the primary method of weight restoration contrib#utes significantly to successful long-term recovery. The overall goal is to help the patient normalize eating patterns and learn that behavior change must involve planning and practicing with real food.

Partial Hospitalizations

Partial hospitalizations (day treatment) are increasingly utilized in an attempt to decrease the length of some inpatient hospitalizations and also for milder AN cases, in place of a hospitalization. Patients usually attend for 7 to 10 hours per day, and are served two meals and 1 to 2 snacks. During the day, they participate in medical and nutritional monitoring, nutrition counseling, and psychotherapy, #both group and individual. The patient is responsible for one meal and any recommended snacks at home. The individual who participates in partial hospitalization must be motivated to participate and be able to consume an adequate nutritional intake at home as well as follow recommendations regarding physical activity (11).

Recovery

Recovery from AN takes time. Even after the patient has recovered medically they may need ongoing psychological support to sustain the change. For patients with AN, one of their greatest fears is reaching a low healthy weight and not being able to stop gaining weight. In long-term follow-up the registered dietitian's role is to assist the patient in reaching an acceptable healthy weight and to help the patient maintain this weight over time. The registered dietitian's counseling should focus on helping the patient to consume an appropriate, varied diet to maintain weight and appropriate body composition