Nutrition Therapy for Clients with Disordered Eating

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Nutrition Therapy for Clients with Disordered
Eating

• By Megan Holt, MPH, RD

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REVIEW OF ED CRITERIA for AN (DSM-IV)

• Refusal to maintain body weight at or above a
  minimally normal weight for age and height (or
  failure to make expected weight gain during
  period of growth)
• Intense fear of gaining weight or becoming fat,
  even though underweight.
• Disturbance in the way in which one's body weight
  or shape is experienced, undue influence of body
  weight or shape on self-evaluation, or denial of
  the seriousness of the current low body weight.
• In postmenarchal females, amenorrhea ie, the
  absence of at least three consecutive cycles. (A
  woman is considered to have amenorrhea if her
  periods occur only following hormone
  administration.)
• Specify type
• Restricting Type During the current episode of
  AN, the person has not regularly engaged in
  binge-eating or purging behavior
• Binge-Eating/Purging Type During the current
  episode of AN, the person has regularly engaged
  in binge-eating or purging behavior

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REVIEW OF ED CRITERIA for BN (DSM-IV)

• Recurrent episodes of binge eating characterized
  by both of the following(1) Eating, in a
  discrete period of time (eg, within any 2-hour
  period), an amount of food that is larger than
  most would eat during a similar period of time
  and under similar circumstances.(2) A sense of
  lack of control over eating during the episode
• Recurrent inappropriate compensatory behavior in
  order to prevent weight gain, such as
  self-induced vomiting, misuse of laxatives,
  diuretics, enemas or other medications, fasting
  or excessive exercise.
• The binge eating and compensatory behaviors both
  occur, on average, at least twice/week for 3
  months.
• Self-evaluation is unduly influenced by body
  shape and weight.
• The disturbance does not occur exclusively during
  episodes of AN.
• Specify type
• Purging type During the current episode of BN,
  the person has regularly engaged in self-induced
  vomiting or the misuse of laxatives, diuretics or
  enemas.
• Nonpurging type During the current episode of
  BN, the person has used inappropriate
  compensatory behaviors, such as fasting or
  excessive exercise, but has not regularly engaged
  in self-induced vomiting or the misuse of
  laxatives, diuretics or enemas.

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REVIEW OF ED CRITERIA for ED-NOS (DSM-IV)

• For females, all AN criteria are met except that
  the individual has regular menses.
• All AN criteria are met except that, despite
  significant weight loss the current weight is in
  the normal range.
• All BN criteria are met except that the binge
  eating and inappropriate compensatory mechanisms
  occur at a frequency of less than twice a week or
  for duration of less than 3 months.
• The regular use of inappropriate compensatory
  behavior by an individual of normal body weight
  after eating small amounts of food (eg,
  self-induced vomiting after the consumption of
  two cookies).
• Repeatedly chewing and spitting out, but not
  swallowing, large amounts of food.
• Binge-eating disorder (falls under DSM-IV for
  now) recurrent episodes of binge eating in the
  absence of inappropriate compensatory behaviors
  characteristic of BN.

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AN Pathophysiology

• Depleted fat stores muscle wasting
• Amenorrhea
• Cheilosis
• Postural hypotension dehydration or edema
• Sleep disturbances
• Low body temperature/cold intolerance
• Lower metabolism low thyroid hormone

• Bone marrow hypoplasia (50 of AN patients)
• results in leukopenia, anemia, thrombocytopenia
  
• Iron deficiency anemia
• Increased infections
• Dry skin, hair and hair loss
• Yellow skin due to hypercarotenemia
• Lanugo fine body hairs

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AN Pathophysiology

• Osteopenia/Osteoporosis
• Reduced bone mineral density
• May result in vertebral compression, fractures
• Caused by estrogen deficiency, elevated
  glucocorticoid levels, malnutrition, reduced body
  mass
• Affects males and females

• T-Score

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AN Pathophysiology

• GI 
• Bloating, abnormal
• fullness
• after eating
• Constipation
• Diarrhea
• Digestive enzymes low (i.e. lactase)

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AN Pathophysiology

• Cardiovascular  
• Decreased heart rate lt60 bpm
• Fatigue, fainting
• Decreased blood pressure lt70 mm/Hg systolic
  orthostatic hypotension
• Reduction in heart mass
• Mitral valve prolapse related to hypovolemia or
  cardiomyopathy
• Death from CHF
• Electrolyte imbalance ? heart failure, death
• Low intake potassium
• Loss in vomiting, diuretics
• Refeeding syndrome electrolyte imbalances caused
  by rapid refeeding

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BN Pathophysiology

• Vomiting 
• Dehydration
• Alkalosis
• Hypokalemia (low potassium)
• Sore throat, esophagitis, mild hematemesis
• Abdominal pain
• Subconjunctival hemorrhage
• Esophageal tears/ruptures (rare)
• Acute gastric dilatation or rupture
• Salivary gland infections
• Cardiac arrhythmias related to electrolyte and
  acid-base imbalance caused by vomiting, laxative,
  and diuretic abuse
• Ipecac may cause irreversible myocardial damage
  and sudden death
• Menstrual irregularities

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BN Pathophysiology

• Laxative Abuse 
• Dehydration
• Elevation of serum aldosterone and vasopressin
  levels
• Rectal bleeding
• Intestinal atony
• Abdominal cramps
•  
• Diuretic Abuse 
• Dehydration
• Hypokalemia

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Role of the dietitian in a treatment team and
goals of nutrition therapy

• AN weight gain/prevention of further loss and
  correction of malnutrition induced disorders
  normalization of eating patterns and behaviors
• BN weight maintenance in the short term even if
  patient is overweight until eating habits are
  stabilized
• Increase food intake to raise the BMR (basal
  metabolic rate)
• Some weight restoration and treatment of
  malnutrition may make
• psychotherapy more effective due to improved
  cognition
• (Nutritional intervention must support
  psychological strategy)

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Role of the dietitian in a treatment team and
goals of nutrition therapy

• Often require hospitalization to begin refeeding
• Some require enteral feedings, but most can be
• rehabbed with oral feedings
• Goal is increase in energy intake with weight
  gain
• Energy intake must be increased gradually while
• minimizing caloric expenditure
• Hospitalized patients goal is 2-3 lb/week
• Outpatients 1 pound/week  
• (APA Practice Guidelines for the Treatment
• of Eating Disorders, January, 2006)

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Part I Nutrition Assessment

• Calories compared with DRI (dietary reference
  intake)
• Evaluate macronutrient mix (carbohydrate,
  protein, fat)
• Evaluate micronutrient intake compared with DRI
• Estimate fluids and compare with needs
• Evaluate alcohol, caffeine, drugs, dietary
  supplements
• (www.usda.gov) for DRIs

• (The Eating Disorders Clinical Pocket Guide by
  Jessica Setnick)

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Nutrition Assessment

• Pertinent medical history
• Ex diabetes, hypertension, high cholesterol,
  kidney disease, etc .
• Pertinent family history (parents, siblings)
• ED, heart disease, etc.
• Eating habits, weight and stature, relationship
  with food

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Nutrition Assessment

• Height
• (verify- particularly in adolescents)
• ED history
• bingeing, purging, relationship
• with food/shape/exercise
• Weight history
• lifetime highest,
• lowest during ED
• Conditions around extreme weights

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Nutrition Assessment

• Current ED behaviors
• How often does the client
• weight at home?
• Binge
• Purge (33-75 kcals still absorbed)
• Fluid intake
• (caffeinated and decaf)

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Food Rituals

• Eating foods in certain orders (ex veggies
  first)
• Excessive chewing (or counting chews)
• Rearranging food on a plate (ex 8 peas)
• Eating finger foods with fork and knife
• Wiping fork after each use
• Not allowing foods to touch
• One food per meal (ex blueberries)

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Nutrition Assessment

• Medical changes related to ED
• Constipation, diarrhea,
• lactose intolerance, dental problems, bone
  health?
• Last period and when
• stopped if amenorrhea
• Medications and
• supplements
• BCP, calcium, MVI, herbal supplements, miralax,
  etc.

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Nutrition Assessment

• Methods to suppress hunger
• Gum, diet soda/products,
• coffee, condiments
• Vegetarianism
• How long? Does this coincide with start of ED?
• Honoring vegetarianism and level of care (later)
• Food Allergies?
• Gluten
• Lactose
• Other?

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Nutrition Assessment

• Blood values and nutritional significance
• Albumin
• Total protein
• Blood Urea Nitrogen (BUN)
• Creatinine
• Mangnesium
• Phosphorus
• Sodium
• Potassium
• Hemoglobin/Hematocrit
• Estradiol
• Frequency of blood draws?

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Food Journal

• (see sample food journal)
• Keeps for three days prior to visit
• Continues until eating and B/P stable
• More useful with clients that are new
• to treatment/little knowledge of nutrition
• No judgment!!!!

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Plan of Care

• MVI/Supplement recommendations
• Calcium Needs 1200mg/day
• Supplementation 500-1000mg/day
• Calcium Carbonate most common
• MVI with Vitamin D

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Plan of Care

• MVI/Supplement recommendations
• Iron Needs 15-18mg/day
• Supplementation 50-60mg twice daily
• Frequent complaints constipation, nausea
• Vitamin C, meat protein (heme iron) increases
  absorption
• Caffeine and phytates inhibit absorption
• Other supplements per MD (ex B12)

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Whats wrong with this picture?

• Break up into groups
• Look at the 3 different sample menus
• How would you make this day more balanced?

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Mindful Eating!

• Synonymous words
• Intuitive eating
• Conscious eating
• Thoughtful eating
• Characteristics of
• Being connected and present
• Awareness
• Respecting body
• Being in-tune with physical hunger and fullness
  cues
• Being non-judgmental

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Mindful Eating Practice

• Take your time (slow down!)
• Use timer
• Put utensils down
• Push plate away
• Use your 4 senses
• Limit distractions
• Set environment to be calm
• Meditation or prayer

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Body Cues

• How to distinguish between emotional and physical
  hunger and fullness
• Use Hunger Scale (on food journal)
• Use inquiry
• When did I eat last?
• Did I have a balanced meal or snack?
• Was I fully satisfied when I finished?
• Are there any particular emotions present?

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Part IIMeal Planning

• Estimating needs for AN
• 30-40 kcals/kg body weight (1200-1600kcals daily
  to start)
• 200-300 kcal increases 2 times weekly
• 70-100 kcals/kg ultimately, with weight
  restoration goal of 1-2 lbs weekly (outpatient)
  or 2-3 lbs weekly (inpatient)
• Fluids 30-40ml/kg body weight or 64oz
• (APA Practice Guidelines for
• Treatment of EDs 2006)

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Determining Goal Weight

• CDC Growth Charts (adolescents)
• http//www.cdc.gov/GROWTHCHARTS/
• Hamwi Equation
• Hamwi Formula for Men106 lbs for first 5 feet
  6 lbs for each inch over 5 feet (med. frame)
• Small frame (- 10), Large frame ( 10)Hamwi
  Formula for Women100 lbs for first 5 feet 5
  lbs for each inch over 5 feet (med. frame)
• Small frame (- 10), Large frame ( 10)
• Past History/ menstruation
• Genetics parents build and eating habits

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Meal Planning-AN

• 3 meals and 3 snacks
• Liquids and use of supplements
• May need reglan due to delayed
• gastric emptying for comfort

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Meal Planning-BN

• Estimating needs for BN
• 25-35 kcals/kg body weight, depending
• on current intake and exercise
• Primary goal interuption of B/P
• Initial prescription typically around 1500 kcals
• Adjust for weight maintenance, and avoid weight
• reduction diet until eating is stable
• Expect impairment of hunger/satiety signals
• Ex 5 ft 4 in., 128 lbs (58kg)1450-2030 kcals
• (APA Practice Guidelines for Treatment of EDs
  2006)

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Meal Planning Macronutrients

• 50-55 carbohydrate (25-30g fiber)
• 15-20 protein (0.8-1.0g/kg body wt)
• 25-30 fat (less than 10 total kcals
• from saturated/trans fatty acids)
• www.mypyramid.gov
• www.eatright.org
• www.americanheart.org

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Exchange System

• Exchanges versus Calories
• More flexible than Calorie counting
• Emphasizes balance and moderation
• Incorporates evidence based suggestions
• for macronutrients from ADA and AHA
• www.diabetes.org

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Exchange System

• Grains/Starches 6-11
• Milk/Dairy 3-4
• Fruit 2-4
• Vegetables 3-5
• Protein/Meat 4-6
• Fats 4-6
• Above guidelines may
• not be adequate for weight
• restoration!!
• See sample exchange
• lists

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Exchange System

• Starches/Grains 15g Carb, 3g protein, 0-1g fat,
• 80 kcals
• Dairy/Milk 12g Carb, 8g protein, 0-3g fat, 100
  kcals
• Fruit 15g Carb, 0g fat/protein, 60 kcals
• Veggies 5g Carb, 0-2g protein, 0g fat, 25 kcals
• Meat/Protein (lean) 0 Carb, 7g protein, 0-3g
  fat, 45 kcals
• Fats 0g Carb, 0g protein,
• 5g fat, 45 kcals

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Measuring food

• Discouraged!!
• Exceptions
• First time with a new food and very distorted
  view of portions
• New to treatment/meal planning
• Assure client that exchanges consider balance and
  quality of diet
• GOAL NORMALIZE EATING

• NO!!!!

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Portion Distortion

• Woman's fist or baseball - a serving of
  vegetables or fruit
• A rounded handful - about one half cup cooked or
  raw veggies or cut fruit, a piece of fruit, or ½
  cup of cooked rice or pasta - this is a good
  measure for a snack serving, such as chips or
  pretzels
• Deck of cards - a serving of meat, fish or
  poultry or the palm of your hand (don't count
  your fingers!) ex one chicken breast, ¼ pound
  hamburger patty
• Golf ball or large egg - one quarter cup of dried
  fruit or nuts
• Tennis ball - about one half cup of ice cream
• Computer mouse - about the size of a small baked
  potato
• Compact disc - about the size of one serving of
  pancake or small waffle
• Thumb tip - about one teaspoon of peanut butter
• Six dice - a serving of cheese
• Check book - a serving of fish (approximately 3
  oz.)

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No Weighing!

• Ask client to refrain from
• weighing at home
• Weight 1-2/week with practitioner, less if stable
  
• (ex normal wt BN)
• Blind weight challenge client to focus on other
  measures of health and remind them of past
  experiences with weighing (i.e. triggers ED
  behaviors)

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Whats the point?
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Where does exercise fit in?

• Restrict with AN until eating improves and client
  reaches 90 ideal body weight
• With normal weight BN, wait for improvement in
  B/P
• Monitor client for compensatory exercise (trading
  vomiting for exercise)
• Explain rationale and caution against exercising
  on purging days due to electrolyte disturbance
• Start with mindful activity yoga
• Weight bearing exercise and osteoporosis

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Female Athlete Triad

• Characterized by disordered eating, amenorrhea,
  and osteoporosis.
• 50 of these athletes may have bone mineral
  densities that are 1 standard deviation below
  normal for age.
• Requires exercise restriction.
• Coaches must de-emphasize weight and are
  cautioned to stop weighing athletes
  continually/focus on strength and mental
  conditioning.
• Some highly motivated and competitive athletes
  may correct their eating disorder if they are
  told that malnutrition will affect their
  performance.

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Meal Planning Using Exchange System

• Case Study
• see assessment form,
• sample meal plan
• and sample menus

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Vegetarianism and Considerations

• Duration of vegetarianism
• and motivation
• Minor/Adult
• Lacto-ovo? Vegan?
• Level of care
• Able to meet needs
• through other foods?

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Food Allergies

• Often used in service of ED and learned in higher
  LOC
• Verify if feasible (parents, allergist) and if
  accommodating allergy will limit progress
• Ex gluten, nuts, mayo
• Offer alternatives
• Ex for lactose intolerance offer lactaid tablet,
  lactaid milk, soy milk/yogurt
• Play detective! If it sounds fishy, it probably
  is!
• Ex pt states gluten intolerant, but eats
  oatmeal/bran muffins
• GOAL help to normalize eating and making peace
  with fear foods!

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HAES Model Health at Every Size

• Health enhancementattention to emotional,
  physical and spiritual well-being without focus
  on weight loss or achieving a specific ideal
  weight
• Size and self-acceptancerespect and appreciation
  for the wonderful diversity of body shapes and
  sizes (including one's own!), rather than the
  pursuit of an idealized weight or shape
• The pleasure of eating welleating based on
  internal cues of hunger, satiety, and appetite,
  rather than on external food plans or diets
• The joy of movementencouraging all physical
  activities for the associated pleasure and health
  benefits, rather than following a specific
  routine of regimented exercise for the primary
  purpose of weight loss
• An end to weight biasrecognition that body
  shape, size and/or weight are not evidence of any
  particular way of eating, level of physical
  activity, personality, psychological issue or
  moral character
• Confirmation that there is beauty and worth in
  EVERYbody

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Nutrition Education Topics

• Calcium intake and Osteoporosis
• Set Point Theory (Keys Study)
• Danger of Fad Diets
• Function of Foods Carbohydrate, Fat, Protein
• Changes to Expect with Refeeding (constipation,
  bloating, fullness)
• Moderate vs. Compulsive/Compensatory Exercise
• HAES model (Health at Every Size)
• Laxative Abuse
• Consequences of Malnutrition
• (Client ready handouts can be found in Winning
  the War Within)

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Questions?

• Thank you!