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

Written by HealthyPlace.com Staff Writer

Normalized eating plan and the stop of binge eating. Helping patients combat food myths often requires specialized nutrition knowledge. The registered dietitian is uniquely qualified to provide scientific nutrition education (62). Given that there are so many fad diets and fallacies about nutrition, it is not uncommon for other members of the treatment team to be confused by the nutrition fallacies. Whenever possible, it is suggested that either formal or informal basic nutrition education inservices be provided for the treatment team.

Cognitive-behavioral therapy is now a well-established treatment modality for BN (15,63). A key component of the CBT process is nutrition education and dietary guidance. Meal planning, assistance with a regular pattern of eating, and rationale for and discouragement of dieting are all included in CBT. Nutrition education consists of teaching about body weight regulation, energy balance, effects of starvation, misconceptions about dieting and weight control and the physical consequences of purging behavior. Meal planning consists of three meals a day, with one to three snacks per day prescribed in a structured fashion to help break the chaotic eating pattern that continues the cycle of binging and purging. Caloric intake should initially be based on the maintenance of weight to help prevent hunger since hunger has been shown to substantially increase the susceptibility to binging. One of the hardest challenges of normalizing the eating pattern of the person with BN is to expand the diet to include the patient's self-imposed "forbidden" or "feared" foods. CBT provides a structure to plan for and expose patients to these foods from least feared to most feared, while in a safe, structured, supportive environment. This step is critical in breaking the all or none behavior that goes along with the deprive-binge cycle.

Discontinuing purging and normalizing eating patterns are a key focus of treatment. Once accomplished, the patient is faced with fluid retention and needs much education and understanding of this temporary, yet disturbing phenomenon. Education consists of information about the length of time to expect the fluid retention and information on calorie conversion to body mass to provide evidence that the weight gain is not causing body mass gain. In some cases, utilization of skinfold measurements to determine percent body fat may be helpful in determining body composition changes. The patient must also be taught that continual purging or other methods of dehydration such as restricting sodium, or using diuretics or laxatives will prolong the fluid retention.

If the patient is laxative dependent, it is important to understand the protocol for laxative withdrawal to prevent bowel obstruction. The registered dietitian plays a key role in helping the patient eat a high fiber diet with adequate fluids while the #physician monitors the slow withdrawal of laxatives and prescribes a stool softener.

A food record can be a useful tool in helping to normalize the patient's intake. Based on the patient's medical, psychological and cognitive status, food records can be individualized with columns looking at the patient's thoughts and reactions to eating/not eating to gather more information and to educate the patient on the antecedents of her/his behavior. The registered dietitian is the expert in explaining to a patient how to keep a food record, reviewing food records and understanding and explaining weight changes. Other members of the team may not be as sensitive to the fear of food recording or as familiar with strategies for reviewing the record as the registered dietitian. The registered dietitian can determine whether weight change is due to a fluid shift or a change in body mass.

Medication management is more effective in treating BN than in AN and especially with patients who present with comorbid conditions (11,62). Current evidence cites combined medication management and CBT as most effective in treating BN, (64) although research continues to look at the effectiveness of other methods and combinations of methods of treatment.

EATING DISORDERS NOT OTHERWISE SPECIFIED (EDNOS)

The large group of patients who present with EDNOS consists of subacute cases of AN or BN. The nature and intensity of the medical and nutritional problems and the most effective treatment modality will depend on the severity of impairment and the symptoms. These patients may have met all criteria for anorexia except that they have not missed three consecutive menstrual periods. Or, they may be of normal weight and purge without binging. Although the patient may not present with medical complications, they do often present with medical concerns.

EDNOS also includes Binge Eating Disorder (BED) which is listed separately in the appendix section of the DSM IV (See Figure) in which the patient has binging behavior without the compensatory purging seen in Bulimia Nervosa. It is estimated that prevalence of this disorder is 1 to 2% of the population. Binge episodes must occur at least twice a week and have occurred for at least 6 months. Most patients diagnosed with BED are overweight and suffer the same medical problems faced by the nonbinging obese population such as diabetes, high blood pressure, high blood cholesterol levels, gallbladder disease, heart disease and certain types of cancer.

The patient with binge eating disorder often presents with weight management concerns rather than eating disorder concerns. Although researchers are still trying to find the treatment that is the most helpful in controlling binge eating disorder, many treatment manuals exist utilizing the CBT model shown effective for Bulimia Nervosa. Whether weight loss should occur simultaneously with CBT or after a period of more stable, consistent eating is still being investigated (65,66,67)

In a primary care setting, it is the registered dietitian who often recognizes the underlying eating disorder before other members of the team who may resist a change of focus if the overall objective for the patient is weight loss. It is then the registered dietitian who must convince the primary care team and the patient to modify the treatment plan to include treatment of the eating disorder.

THE ADOLESCENT PATIENT

Eating disorders rank as the third most common chronic illness in adolescent females, with an incidence of up to 5%. The prevalence has increased dramatically over the past three decades (5,7). Large numbers of adolescents who have disordered eating do not meet the strict DSM-IV-TR criteria for either AN or BN but can be classified as EDNOS. In one study, (68) more than half of the adolescents evaluated for eating disorders had subclinical disease but suffered a similar degree of psychological distress as those who met strict diagnostic criteria. Diagnostic criteria for eating disorders such as DSMIV- TR may not be entirely applicable to adolescents. The wide variability in the rate, timing and magnitude of both height and weight gain during normal puberty, the absence of menstrual periods in early puberty along with the unpredictability of #menses soon after menarche, and the lack of abstract concepts, limit the application of diagnostic criteria to adolescents (5,69,70).

Because of the potentially irreversible effects of an eating disorder on physical and emotional growth and development in #adolescents, the onset and intensity of the intervention in adolescents should be lower than adults. Medical complications in adolescents that are potentially irreversible include: growth retardation if the disorder occurs before closure of the epiphyses, pubertal delay or arrest, and impaired acquisition of peak bone mass during the second decade of life, increasing the risk of osteoporosis in adulthood (7,69).