Nutritional management of eating disorders

Catheter-related bloodstream infection in patients With severe anorexia nervosa

PURPOSE

Anorexia nervosa (AN) may be treated with intravenous hyperalimentation (IVH) that may be associated with catheter-related bloodstream infection (CRBSI).

DESIGN AND METHODS

Retrospective chart review was conducted to compare those who developed CRBSI were compared with those who did not.

FINDINGS

Of 34 patients, 17 episodes of AN treated with IVH were identified, of which five resulted in CRBSI. The average body mass index at admission was low at 12.2. Patients who needed physical restraint during IVH had a higher (albeit statistically nonsignificant) risk. Also, those with purging had numerically lower risk.

PRACTICE IMPLICATIONS

CRBSI complicated IVH in 29.4% instances of severe life-threatening AN in our sample. Whether physical restraints and no purging constitute a risk factor of CRBSI needs to be further investigated.

A review of treatment manuals for adults with an eating disorder: nutrition content and consistency with current dietetic evidence

PURPOSE

This study aimed to summarise the nutrition and food-related content of treatment manuals for adults with eating disorders (EDs) and assess the degree to which this information conforms with current guidelines and literature.

METHODS

Treatment manuals for adults with an ED were identified by conducting an online search of Internet book dealer Amazon and University of Sydney library catalogue as per methods used in previous reviews of self-help patient resources. The nutrition and food-related content of these manuals was extracted and reviewed independently by two reviewers using a criteria based on current best evidence to date regarding dietetic treatment for EDs.

RESULTS

Twenty-two manuals met inclusion criteria, 20 (91%) of which contained some degree of nutrition and food-related content. Two manuals (9%) included content written by a dietitian, six (27%) included citation of dietetic literature to support the recommendations made and eight (36%) recommended a dietitian be consulted as part of a multidisciplinary approach to treatment. Thirteen manuals (60%) contained nutrition and food-related information not substantiated by current evidence.

CONCLUSION

It is common for treatment manuals for EDs to contain nutrition and food-related content. However, most of the authors of the 22 manuals identified did not appear to collaborate with a dietitian in writing this content or cite peer-reviewed literature to substantiate dietary advice given. Consistent with current clinical practice guidelines, greater collaboration between dietitians and clinicians is required to develop, evaluate and disseminate evidence-based approaches to dietetic management.

LEVEL OF EVIDENCE

Level V, narrative review.

Development of the "Recovery from Eating Disorders for Life" Food Guide (REAL Food Guide) - a food pyramid for adults with an eating disorder

BACKGROUND

There is limited evidence to inform nutrition and dietetic interventions for individuals with eating disorders even though it is recommended as an essential part of multidisciplinary management. There is minimal guidance, an absence of standardised nutrition educational material, and no research on how best to educate patients on healthy eating and how to achieve nutrition adequacy. Therefore the REAL Food Guide was developed.

METHODS

The REAL Food Guide is a pyramid with four layers and key nutrition messages beside each layer that was conceived to address gaps in nutrition education and intervention for individuals with eating disorders. Written and verbal consumer feedback was obtained from consumers receiving treatment regarding the acceptability and usefulness of the REAL Food Guide. A unique database was developed to reflect the types of foods and realistic portion sizes that patients are likely to select. This database was used for nutrition modelling to assess the nutrition adequacy of three meal patterns (meat containing, vegetarian and semi-vegan) for both weight maintenance and weight regain. Each meal pattern was compared to the Nutrient Reference Values for Australia and New Zealand.

RESULTS

Nutritional analysis demonstrated nutritional adequacy of meal patterns for energy, macronutrients and most micronutrients when the recommended number of serves from the REAL Food Guide were assessed. All meal patterns were adequate in micronutrients except for the semi-vegan meal pattern that was inadequate in vitamin D. Feedback from individuals with eating disorders demonstrates the nutrition education tool was acceptable to them as they felt it was more helpful for their recovery than general nutrition guidelines.

CONCLUSION

The REAL Food Guide is a comprehensive and user-friendly guide that clinicians can use to educate patients about components of a balanced and healthy diet. The guide can educate all eating disorder clinicians, including those who are new to the field, about the basics of nutrition. Clinicians using the guide can be confident that, if followed, patient's energy and nutritional requirements will be met and important nutrition education messages are reinforced, that are tailored to the beliefs and concerns of individuals with eating disorders.

Feelings and perceptions of women recovering from anorexia nervosa regarding their eating behavior

Abstract: According to the phenomenological approach, observing a phenomenon through the perspective of those who lived it may be necessary to acquire fully comprehension of it. Therefore, to fully understand the eating behavior during anorexia nervosa and during its recovery, this study investigated individual perceptions and feelings of three women recovering from anorexia nervosa. This study is characterized as a qualitative research with phenomenological approach. The data were collected through interviews and analyzed following steps proposed by phenomenology researchers. During the anorexia nervosa experience, food restriction and irregular meal patterns were observed. Controlling food intake was associated with happiness. Guilt, anguish, sadness, fear and anger were associated with eating, and food was considered a villain. An obsessive thinking about food and a paradox between liking to eat and not wanting to eat were also observed. During recovery, it is important to have a more flexible eating behavior without negative feelings regarding food; however, feelings of guilty and fear were still detected. Perceptions about contact with nutritionists revealed the use of ineffective strategies. Although similarities were found in all reports, every woman had their own particular and singular experience. Rescuing their memories and experiences through their speech was important to fully understand and comprehend these personal experiences, and this complete understanding may enable health professionals to act more efficiently in the treatment of this complex phenomenon.

An assessment of basic nutrition knowledge of adolescents with eating disorders and their parents

Objective: This study aims to determine and compare the level of basic nutrition knowledge of adolescents with eating disorders and their parents to adolescents without eating disorders and their parents.

MATERIALS AND METHODS

This six-month convenience based survey recruited a total of 182 adolescents with and without an eating disorder and their parents. The surveys were conducted in a suburban adolescent medicine office. Main outcome measures were based on the 18 basic nutrition questions, while means, standard deviations, Wilcoxon Rank Sum Test, and χ2 were all employed for the analysis.

RESULTS

None of the groups correctly answered more than half of the questions. In terms of the percentage of correct responses, there was a statistically significant difference between adolescents with eating disorders and their parents compared with adolescents without an eating disorder and their parents. Fewer than 16% of respondents in each group correctly answered the recommended daily caloric balance of fats, carbohydrates, and proteins.

CONCLUSIONS

There is a deficiency in basic nutrition knowledge among adolescents with and without eating disorders and their parents. A significant increase in basic nutrition education needs to occur in order to increase the understanding of what is a "healthy" diet.

Treatment of Adolescents with Anorexia Nervosa

Research on the treatment of adolescents with anorexia nervosa is limited but shows that effective strategies employ a multidisciplinary team approach. Most patients receive medical attention when there is an acute medical or psychiatric emergency after losing a significant amount of weight and there is a need for nutritional and metabolic stabilization. Medical and nutritional stabilization are the first courses of treatment, followed by psychological stabilization. Initial treatment settings are dependent on the severity of symptoms and can range from inpatient to partial hospitalization or from day treatment to outpatient clinics. Physical activity and weight gain must be gradually accomplished. Effective treatment includes a variety of psychotherapeutic approaches (individuals and family therapy). Psychopharmacotherapy is generally unreliable in the treatment of anorexia nervosa and should be targeted to specific symptoms or complications. Prevention programs have been shown to have limited success.

Nutritional rehabilitation in anorexia nervosa: review of the literature and implications for treatment

Restoration of weight and nutritional status are key elements in the treatment of anorexia nervosa (AN). This review aims to describe issues related to the caloric requirements needed to gain and maintain weight for short and long-term recovery for AN inpatients and outpatients.We reviewed the literature in PubMed pertaining to nutritional restoration in AN between 1960-2012. Based on this search, several themes emerged: 1. AN eating behavior; 2. Weight restoration in AN; 3. Role of exercise and metabolism in resistance to weight gain; 3. Medical consequences of weight restoration; 4. Rate of weight gain; 5. Weight maintenance; and 6. Nutrient intake.A fair amount is known about overall caloric requirements for weight restoration and maintenance for AN. For example, starting at 30-40 kilocalories per kilogram per day (kcal/kg/day) with increases up to 70-100 kcal/kg/day can achieve a weight gain of 1-1.5 kg/week for inpatients. However, little is known about the effects of nutritional deficits on weight gain, or how to meet nutrient requirements for restoration of nutritional status.This review seeks to draw attention to the need for the development of a foundation of basic nutritional knowledge about AN so that future treatment can be evidenced-based.

Evaluation of a nutrition rehabilitation protocol in hospitalized adolescents with restrictive eating disorders

PURPOSE

Nutritional rehabilitation is an essential part of inpatient treatment for adolescents with restrictive eating disorders (ED). The purpose of this study was to examine weight gain, prevalence of refeeding syndrome, and nutritional composition of the diet in hospitalized adolescents with anorexia nervosa (AN) and eating disorder not otherwise specified (EDNOS), restrictive type, on a structured nutrition rehabilitation protocol (NRP).

METHODS

An evidence-based NRP was implemented on the inpatient eating disorders unit at the Hospital for Sick Children in June 2011. Adolescents 12-18 years of age with AN or EDNOS, an ideal body weight (IBW) of 70% or greater, no clinical or metabolic signs of refeeding syndrome, and on their first admission were assigned to the NRP. A retrospective chart review between June 2011 and June 2012 was completed. A repeated measures analysis was used to determine the mean rate of weight gain. Mean cumulative % change in body mass index (BMI) was plotted against days to assess daily weight trajectory.

RESULTS

Twenty-nine patients, mean age of 14.7 (SD ± 1.5) years, were included in the study. A total of 3.5% developed hypophosphatemia on day 1. Mean weight gain was .24 kg/day (p < .0001) and 1.7 kg/week. An increase in mean cumulative % change in BMI was observed from days 2-14. Actual caloric intake was 98%-113% of the prescribed intake. Macronutrient distribution was within acceptable limits based on dietary reference intakes.

CONCLUSIONS

The NRP is considered effective, efficient, and safe. Further research is needed to explore the effectiveness and safety of NRPs in other populations.

A review of feeding methods used in the treatment of anorexia nervosa

BACKGROUND

Clear evidence based guidelines on the best and safest method of achieving and maintaining normal body weight during inpatient treatment of Anorexia Nervosa (AN) are currently not available. Oral feeding with food alone, high-energy liquid supplements, nasogastric feeding and parenteral nutrition all have the potential to achieve weight gain in the treatment of AN but the advantages and disadvantages of each method have not been comprehensively evaluated. A literature search was undertaken to identify papers describing feeding methods used during inpatient treatment of AN. The selection criteria searched for papers that described the feeding method; and reported weight change variables such as admission and discharge weight in kilograms, or Body Mass Index; or weight change over the course of inpatient treatment.

RESULTS

Twenty-six papers were identified, describing a total of 37 samples with a mean sample size of 58.9 participants, and a range from 6 to 318. The majority (84.6%) of papers were observational cohorts and retrospective chart reviews. The most common feeding method described was nasogastric feeding and food, then high-energy liquid supplements and food.

CONCLUSIONS

There is limited evidence on the efficacy of feeding methods used in the refeeding and nutritional rehabilitation of AN, therefore no conclusion can be made about the most effective method of achieving weight gain during inpatient treatment. While there are a number of papers exploring this issue there is no consistency in the way the information is reported to enable comparisons between the different methods. There is an urgent need for research in this area to guide decision-making in the inpatient management, refeeding and nutritional rehabilitation of AN.

How do eating disorder patients eat after treatment? Dietary habits and eating behaviour three years after entering treatment

OBJECTIVE

Improvements in psychological symptoms and weight have often been demonstrated following eating disorder (ED) treatment, but it is not clear to what extent eating behaviour itself is normalised. This cross-sectional study aimed to investigate dietary habits and eating behaviour in ED patients three years after entering treatment.

METHOD

ED patients (N=70) were divided into those who had recovered (N=36), and those who still suffered from bulimic (N=18) or anorexic (N=16) psychopathology. Patients were compared to a female normal control group of similar age (N=61), and assessments were made on a dietary questionnaire, as well as the BDI, EDI-2, SASB and SCL-90.

RESULTS

With some notable exceptions eating patterns in recovered patients resembled those of controls. Dieting was most evident in recovered and current bulimic patients, while restrictive eating and vegetarianism was found in recovered or current anorexic patients. A majority of the patients with ongoing EDs avoided fatty foods.

DISCUSSION

Risk behaviours such as restrictive eating, dieting and food avoidance, may have an important impact on relapse rates, and it may therefore be imperative to continue to monitor eating behaviour in ED patients following treatment termination to ensure better long-term outcome.

Identification and management of eating disorders in children and adolescents

The incidence and prevalence of eating disorders in children and adolescents has increased significantly in recent decades, making it essential for pediatricians to consider these disorders in appropriate clinical settings, to evaluate patients suspected of having these disorders, and to manage (or refer) patients in whom eating disorders are diagnosed. This clinical report includes a discussion of diagnostic criteria and outlines the initial evaluation of the patient with disordered eating. Medical complications of eating disorders may affect any organ system, and careful monitoring for these complications is required. The range of treatment options, including pharmacotherapy, is described in this report. Pediatricians are encouraged to advocate for legislation and policies that ensure appropriate services for patients with eating disorders, including medical care, nutritional intervention, mental health treatment, and care coordination.

Tratamento nutricional da bulimia nervosa

A bulimia nervosa é um transtorno alimentar caracterizado por compulsões alimentares e métodos compen-satórios recorrentes. Os pacientes apresentam ingestão alimentar inadequada e comportamentos alimentares disfuncionais. O adequado tratamento do transtorno requer uma equipe multiprofissional e terapia nutricional especializada. Compreender as características desse transtorno, os padrões de consumo e o comportamento alimentar, bem como atentar para as atitudes alimentares dos pacientes, é fundamental para o planejamento e para a adequada condução da abordagem nutricional. A terapia nutricional para esse transtorno é diferenciada, exigindo do nutricionista maiores habilidades de aconselhamento nutricional. Educação nutricional e acon-selhamento nutricional, com ênfase na abordagem de atitudes alimentares e insatisfação corporal, são o foco da terapia nutricional. Para o atendimento eficaz desses pacientes e o sucesso no tratamento nutricional, é importante que o profissional se mantenha atualizado sobre nutrição e transtornos alimentares e procure especialização e experiência nessa área do conhecimento.

Zinc-specific Food Frequency Questionnaire To Assess College Women’s Eating Habits

Zinc deficiency has been reported in individuals with eating disorders, the risks of which increase during the adolescent and early adult years. A food frequency questionnaire (FFQ) specific for zinc-rich foods was tested for its usefulness in identifying problematic eating behaviour tendencies in college-age women. Ninety-two female students enrolled in a university introductory psychology course volunteered to complete demographic information, the Eating Attitudes Test (EAT-26), and a zinc-specific FFQ (ZnFFQ). Relationships among estimated zinc intakes, food/lifestyle habits, and eating attitude variables were examined. Twenty-five women had estimated intakes below the Recommended Dietary Allowance (RDA) for zinc. Individuals in the highest zinc intake group (over twice the RDA) had a tendency to score higher on the EAT-26 and the bulimia subscale. Vegetarians also scored high on the EAT-26. Although our data are limited, the ZnFFQ should be studied further to determine whether it could play a useful role in identifying individuals at risk for bulimia. The ZnFFQ is a simple, non-confrontational assessment tool and may be a helpful starting point for identifying women with unhealthy eating habits.

Nutrition expertise in eating disorders

Anorexia nervosa (AN) and bulimia nervosa (BN) dominate published reports on disordered eating, although they actually account for a small number of cases. Binge eating disorder (BED) and subclinical syndromes of disturbed eating and distress are far more prevalent. Medical nutrition therapy including education is a cornerstone of therapy, however there has been no evaluation of baseline knowledge of nutrition and diet composition in this population relative to individuals who do not exhibit pathological eating behavior. In addition, previous reports suggest that individuals with clinical eating disorders have above-average knowledge of nutrition. In the present investigation, individuals with subclinical eating disorders did not differ from control participants. Poor scores overall indicate that nutritional counseling may be a useful component of treatment. These results further suggest that nutrition expertise is not an early feature of the disorder and, therefore, does not likely contribute to its development.

Identifying and treating eating disorders

Pediatricians are called on to become involved in the identification and management of eating disorders in several settings and at several critical points in the illness. In the primary care pediatrician's practice, early detection, initial evaluation, and ongoing management can play a significant role in preventing the illness from progressing to a more severe or chronic state. In the subspecialty setting, management of medical complications, provision of nutritional rehabilitation, and coordination with the psychosocial and psychiatric aspects of care are often handled by pediatricians, especially those who have experience or expertise in the care of adolescents with eating disorders. In hospital and day program settings, pediatricians are involved in program development, determining appropriate admission and discharge criteria, and provision and coordination of care. Lastly, primary care pediatricians need to be involved at local, state, and national levels in preventive efforts and in providing advocacy for patients and families. The roles of pediatricians in the management of eating disorders in the pediatric practice, subspecialty, hospital, day program, and community settings are reviewed in this statement.

Terapia nutricional na anorexia e bulimia nervosas

A alimentação e a dieta têm um importante papel no desenvolvimento e manutenção dos transtornos alimentares. Portanto, devem ser levados em consideração nos programas de tratamento dessas condições clínicas. Pacientes com transtornos alimentares apresentam importantes restrições dietéticas, padrões alimentares inadequados e hábitos errôneos devido a uma série de falsos mitos e crenças e a uma sensação de incompetência para lidar com o alimento. Tais alterações podem levar a mudanças em seu estado nutricional, que necessita de cuidados dietéticos específicos, como reabilitação nutricional e orientação sobre dieta adequada. Além disto, o aconselhamento nutricional é necessário para esclarecer e desmistificar crenças inadequadas e para estabelecer uma adequada relação com o alimento.

Nutritional interventions for individuals with bulimia nervosa

Many physical and psychological effects of bulimia nervosa are caused by the patient's partial starvation and chaotic nutritional cycle. Attention should thus be initially directed to correcting nutritional deficiencies and abnormal eating patterns, and providing dietary counselling. Nevertheless, very little has been written about the nutritional management of this eating disorder. Nutritional counselling for bulimia patients is reviewed in this paper. Current knowledge about nutritional therapy and its efficacy, goals and objectives is presented, along with recommendations used in treatment programmes. Lastly, the key steps of nutritional management are summarised.

Macronutrient intake in anorexia nervosa: The National Heart, Lung, and Blood Institute Growth and Health Study

OBJECTIVE

To compare the macronutrient intake of females with or without a history of anorexia nervosa (AN) at three times: two years and one year before the onset of AN, and during the first year of the illness.

STUDY DESIGN

Prospective cohort study with 3-day food intake records collected over 10 years. Subjects were 154 white females (aged 9 or 10 years at study entry), of whom 14 had AN and 140 were healthy females matched for age at study entry and parental education.

RESULTS

Compared with the healthy girls, girls with AN reported significantly lower total energy intake and fat intake during the first year of the illness; the lower total energy intake was evident already at the 1-year (but not the 2-year) pre-onset assessment.

CONCLUSIONS

To identify AN early on, health practitioners caring for adolescent girls should inquire about food intake and reluctance to eat certain foods, especially those containing fat.

Inpatient and partial hospital treatment for adolescent eating disorders

The eating disorders are complex illnesses that tend to have a chronic relapsing course with severe morbidity and high mortality rates. Outcome seems to be best when the disorders are recognized early, brought to treatment quickly, the family is involved, and the first episode of care results in full return and maintenance of weight and menstruation. Adolescents who reach the point of needing hospitalization should be treated aggressively. In this article the authors have tried to outline some key treatment principles not just for the hospital stay, but elements that should be carried throughout the entire program of recovery for adolescents with eating disorders: from medical evaluation, through inpatient stay, partial hospitalization, intensive outpatient program, and follow-up outpatient therapy. Recent reductions in insurance authorizations and decreased lengths of stay in the psychiatric hospital make the already difficult challenge of recovery from AN and BN even more daunting. Despite these difficulties, we are still able to get a high proportion of youths better and eventually fully recovered.

Anorexia nervosa: manifestations and management for the gastroenterologist

Anorexia nervosa is a complex psychiatric disorder with significant morbidity and mortality. It is important for gastroenterologists to be aware of the physiological effects and potential complications of anorexia nervosa, as they are frequently involved in treating patients with this disorder. We review the classic, GI, and neuroendocrinological features of anorexia nervosa. We also discuss gender differences and treatment options in anorexia nervosa. Further studies of GI physiology and pharmacology are needed to determine whether any disturbances may be amenable to therapeutic intervention. Future treatments directed at improving GI sensorimotor function and neurohormonal abnormalities in patients with anorexia nervosa may impact their nutritional rehabilitation and may have important health economic implications as patients avoid hospitalization and are restored to full activities in society. The current team approach, which incorporates psychiatrists, psychologists, nutritionists, pediatricians, internists, and gastroenterologists in the treatment of patients with anorexia nervosa, will continue to be essential.

Dysfunctional eating in the eating disorders

Aberrant eating patterns in the eating disorders have been observed across various laboratory-based and clinical studies. It is now clear that problems in experiencing and expressing hunger, appetite, and satiety in anorexia and bulimia nervosa are likely to perpetuate the disorders once established. Whether problems in appetite regulation are primary or secondary to the development of the disorders is unknown. In studies examining indices of appetite regulation after treatment, there still remain significant levels of eating abnormality. This suggests that the main goals of treatment, including restoration of body weight in anorexia nervosa, abstaining from dieting in anorexia or bulimia nervosa, and reducing or abstaining from binge eating, do not correct some features of abnormal eating. The efficacy of nutritional counseling and specific nutritional management programs have been tested, and these seem to produce positive outcomes in improving eating behavior. Direct behavioral interventions to change eating patterns also have been examined, and these too seem to produce benefits that may be incorporated into CBT. Greater collaboration and cooperation between researchers and clinicians in addressing dysfunctional eating in the eating disorders will highlight improvements in treatment for identifiable eating abnormalities and will further the understanding of the human appetite system.

Cognitive-behavioral therapy and nutritional counseling in the treatment of bulimia nervosa and binge eating

The goals of manual-based cognitive-behavioral therapy (CBT) and nutritional counseling for eating disorders are similar, namely, eliminating dysfunctional patterns of eating. Modifying these behaviors requires specific therapeutic expertise in the principles and procedures of behavior change that is not typically part of the training of nutritionists and dieticians or mental health professionals without specific expertise. We discuss ways in which principles of behavior change can be applied to eating disorders by non-CBT experts. Specific nutritional rehabilitation programs have the potential to augment CBT in addressing the array of appetitive abnormalities present in eating disorder patients. The dysfunctional appetitive, hedonic, and metabolic characteristics of patients with bulimia nervosa (BN) and binge eating disorder are reviewed. These abnormalities constitute potential target areas that might be more fully addressed by nutritional interventions designed to restore normal appetitive function.