EATING DISORDERS

BY
DR FRANK HAYFORD,
PhD(SA) RD(Gh)
 Objectives
• What are eating disorders?
• Types/categories of eating disorders
• Main causes of eating disorders
• Characteristics of the different types of eating
disorders
• Medical Nutrition Therapy and other lifestyle
Management of eating disorders
 INTRODUCTION
• Eating disorders are psychiatric conditions characterized by
severe disturbances in eating behavior, resulting in significant
physiological impairment and in some cases even death (Polivy
&Herman, 2002; Garner & Garfinkel, 1997)

• The American Psychiatric Association (APA) recognizes three

categories of eating disorders:
• Anorexia nervosa
• Bulimia nervosa, and
• Eating disorders not otherwise specified (EDNOS) e.g., binge-
eating disorder (BED)
Polivy, J., & Herman, C. P. (2002). Causes of eating disorders. Annual review of psychology, 53(1), 187-
213.
Garner, D. M., & Garfinkel, P. E. (Eds.). (1997). Handbook of treatment for eating disorders. Guilford
Press.
Cont’d.............
• Eating disorders can cause serious physical problems
and can even be life-threatening in most severe
cases.
• Most people with eating disorders are females, but
males can also have eating disorders.
• An exception is binge-eating disorder, which appears
to affect almost as many males as females.
• Treatments and management for eating disorders
usually involve psychotherapy, nutrition/dietary
therapy & education, family counselling, medications
and hospitalization (in severe cases) (Berkman et al,
2006).
Berkman, N. D., Bulik, C. M., Brownley, K. A., Lohr, K. N., Sedway, J. A., Rooks, A., & Gartlehner, G. (2006).
Management of eating disorders. Evidence report/technology assessment, (135), 1-166
 Main Causes
Biological Abnormalities
• *Defects in hypothalamus function
• Genetic mutations leading to food addiction
• **Low levels of brain chemicals e.g. Serotonin
*Read further on the mechanisms behind these
Social
• Pressure from peers and family to be thin
• Food as reward
• Sexually abused children
• Certain job requirements (preference)

Psychological
• Depression
• Low self esteem
• Body dissatisfaction (Schneider et al.,2009)
• Difficulty in managing and expressing feelings
• Stress
Anorexia Nervosa
 Introduction
• Anorexia nervosa (AN) is a psychiatric eating disorder in
which an individual severely rejects food, resulting in
extreme weight loss, low basal metabolic rate and
exhaustion.
• AN patients refuses to maintain body weight at or
above a minimally normal body weight for age and
height.
• Anorexia affects females far more often than males and
is most common in adolescent females, especially b/n
12-13 and 19-20 years of age.
• Many experts consider people for whom thinness is
especially desirable, or a professional requirement
(such as models, dancers, actors and some athletes), to
be at higher risk for anorexia nervosa.
Garner, D. M. (1993). Pathogenesis of anorexia nervosa. The Lancet. Vol. 41/26: 1631, 1634.
Steinhausen, H. C. (2002). The outcome of anorexia nervosa in the 20th century. American journal of Psychiatry,
159(8), 1284-1293.
 Subtypes of AN
• There are two mutually exclusive subtypes of
AN:
 Restricting
Those with the restricting subtype accomplish their
weight loss through ‘dieting’, fasting, or excessive
exercises.
 Binge eating/purging
Those with the binge eating/purging subtype engage
in regular binge eating and/or purging (Seidel et al.,
2021)

Seidel, M., Markmann Jensen, S., Healy, D., Dureja, A., Watson, H. J., Holst, B., ... & Sjögren, J. M.
(2021). A systematic review and meta-analysis finds increased blood levels of all forms of
ghrelin in both restricting and binge-eating/purging subtypes of anorexia nervosa. Nutrients,
X’tics of Restricting vs. Purging Type
 WHAT LEADS TO AN?
• Begins with normal dieting, as weight loss progresses
there is :
 intense fear of gaining weight
they ‘diet’ more strictly,
Then develop all the characteristics of AN.

• No definite cause of anorexia nervosa has been

determined, but experts say it may be due
to/combination of :
demands from society and families to be thin and
attractive.
Character trait and genetics
a poor self-image .
A famous model. A poor self-image.
 Signs and symptoms of AN
As weight loss progresses, there is :
•Refusal to eat and denial of hunger
•Intense fear of gaining weight
•Negative or distorted self-image
•Excessive exercise
•Flat mood or lack of emotion
•Fear of eating in public and social withdrawal
•Preoccupation with food
•Thin appearance
•Irritability and mood swings
•Menstrual irregularities or loss of menstruation
(amenorrhea)
•Low blood pressure
•Dehydration
 Nutritional Assessment (NA)
• Diet history

• Medical/Clinical history

• social history

• Nutrition related physical findings

• Anthropometry using the BMI

 Nut. asses diagnostic X’tics of AN
Skin & CARDIOVASCULAR GASTRO BONE SERUM VALUES
Extremities INTESTINAL

Cold hands & Bradycardia (slow Salivary Decreased *Elevated BUN &
feet heart rate) gland bone creatinine
(hypothermia) enlargement mineral
density
Dry skin Hypotension Delayed Hypokalemia (low
gastric potassium)
emptying
Alopecia Orthostatic Hypercholesterolemia
hypotension(LBP
when up from
lying or sitting)
Lanugo Electrocardiograph Hypoglycemia
ic (ECG)
Dependent abnormalities Hypophosphatemia
oedema
Nutritional diagnoses terminologies
associated with AN
• Inadequate nutrient intake (macronutrient and
micronutrient)
• Body weight less than 85% of that expected for
age and height.
• For patients 20 years or older, a
 BMI ≤18.5 kg/m2

• For patients < 20 years of age, we use the

growth charts. Underweight is defined as a BMI
for age and sex that is ≤5th percentile on the
growth charts.
Other Health Complications of AN
Cold intolerance,
Reduced gastric emptying,
Constipation
• Common physical findings of AN include:
Fine, downy-like hair on the skin
(lanugo)
Alopecia (hair loss)
Cont’d….: Health Complications of AN
• There are also complications as a result of
malnutrition due to the self-imposed state of
starvation.
• But then all these reverses as healthy eating
habits are restored. Body weight can return to
normal.
NB: Nutritional status can improve, especially if AN
is diagnosed early in the course of the illness and
is treated by a skilled interdisciplinary team. Bone
mineral density may however be the exception in
severe cases. It may not be reversible.
 Nutrition Intervention
• Treatment may be out- patient or in- patient
• But the decision as to where and how to treat
the patient with AN is determined by the ff;
 subject’s current weight.
rapidity of recent weight loss.
severity of medical and psychological complications.
necessity of removing the patient from an
unhealthy environment.
What are the Nutrition Intervention
goals?
• The primary goal in AN is restoring the
patient’s weight to at least 90% of the
expected weight .
• Cessation of weight loss behaviors
• Improve eating behaviors,
• Improve emotional and psychological health.
• Preventing “refeeding syndrome”(metabolic disturbance
that occurs as a result of reinstitution of nutrition in people and animals who are
starved, severely malnourished, or metabolically stressed because of severe
illness) in severely malnourished patients.
 In-patients treatment
• Medical conditions warranting in-
patient treatment include;
Severe electrolyte imbalances
Body weight <75% of expected,
regardless of the patient’s
electrolytes or other laboratory
values.
 Nutrition Intervention Strategy
•
1
The recommended weight gain is 2 to 3 lb (0.91-
1.36kg)/week for in- patient treatment and 0.5 to 1 lb
(0.25-0.45kg) per week for out-patient treatment.
• Initial energy intake should be 30 to 40 kcal/kg of
body weight per day, which can then be advanced as
tolerated by the patient.
• But then during the phase of active weight gain, the
energy intake may need to be as high as 70 to 100
kcal/kg of body weight
• An intake of 40 to 60 kcal/kg of body weight is
sufficient for weight maintenance and to support
adequate growth and development.

Marzola, E., Nasser, J. A., Hashim, S. A., Shih, P. A. B., & Kaye, W. H. (2013). Nutritional rehabilitation in
anorexia nervosa: review of the literature and implications for treatment. BMC psychiatry, 13(1), 1-
 Nutrition Intervention Strategy 2
• Ensure adequate intake of vitamin D (400 IU/d)
and calcium (1500mg/d) to minimize bone losses.
• Supervise meal and stress the importance of
adequate food consumption
• Provide encouragement and reassurance about
eventual recovery.
• In most cases, this degree of nutritional repletion
can be accomplished by normal oral feedings.
• But enteral feedings are generally used as a last
resort when oral feeding is not feasible
 Evaluation and Monitoring 1
• The patient’s response to nutrition therapy can
be assessed by monitoring the patient’s;
 vital signs, food intake, fluid intake and output
 changes in BMI (mainly weight) and body
composition
 laboratory test values.
NB: Unexpected increase in body weight may
indicate fluid retention during refeeding or
excessive water or fluid intake by the patient to
artificially increase body weight.
 Evaluation and Monitoring 2
• The key to the successful treatment is to allow
sufficient duration for adequate weight gain and
weight stabilization and to provide adequate therapy
necessary to allow the patient to adjust emotionally
to the healthier weight.
• As with many other addictions, it takes a day-to-day
effort to control the urge to relapse. Many individuals
will require ongoing treatment for anorexia over
several years, and some may require treatment over
their entire life time.
 Effective Nutrition Care Yields Results

The anorexic girl, aged 19, was admitted to hospital & placed under treatment. six months later, she
had returned to her normal body weight & had established good eating habits
 Conclusion
• Since AN is a psychiatric illness with major
medical complications. its treatment requires an
interdisciplinary team of health care
professionals to provide psychiatric care and
considerable emotional support to overcome the
strenuous resistance to gaining weight.
• AN patients also require extensive counseling ( to
help them find healthier ways of developing self-
esteem, instead of the inappropriate low body
weight) as well as nutrition therapy to restore
their nutrition status.
BULIMIA NERVOSA
 BULIMIA NERVOSA (BN)
• BN is a disorder characterized by recurrent episodes of binge
eating followed by one or more inappropriate compensatory
behaviors to prevent weight gain (Keel& Mitchell, 1997).

• These behaviours include; self-induced vomiting, fasting,

excessive exercise, and misuse of laxatives and diuretics.

• Unlike Anorexia nervosa (AN), BN patients generally

maintain a body weight within normal limits.

• However, just like their AN counterparts, these individuals

place considerable importance on body shape and size, and
they are often frustrated by their inability to attain their
preferred weight status (Fairburn& Beglin, 1990).

Keel, P. K., & Mitchell, J. E. (1997). Outcome in bulimia nervosa. The American Journal of Psychiatry.
Fairburn, C. G., & Beglin, S. J. (1990). Studies of the epidemiology of bulimia nervosa.
The American journal of psychiatry.
 Subtypes of Bulimia Nervosa
• Purging Type
During the episode of bulimia nervosa, the person
regularly engages in self-induced vomiting or the
misuse of laxatives, diuretics, or enemas
• Non purging Type
During the episode of bulimia nervosa, the person
uses other inappropriate compensatory behaviors,
such as fasting or excessive exercise, but do not
regularly engage in self-induced vomiting or the
misuse of laxatives, diuretics, or enemas
FEATURES OF BULIMIA NERVOSA
• Overriding importance is placed on body image as an
attempt to improve self-esteem.

• Restrictive eating practices are adopted in an

attempt to control weight.

• Extreme dietary restriction causes increased

thoughts about food, which leads to binge eating.

• Purging behavior
 DIAGNOSTIC CRITERIA FOR BULIMIA
 The standard for diagnosing BN is by American Psychiatric
Association (APA’s) Diagnostic and statistical manual of
mental disorders iv (DSM-IV) original published in 1952

A. Recurrent episodes of binge eating.

An episode of binge eating is characterized by both of the

following;

1. Eating, in a discrete period of time (e.g., within any two-

hour period), an amount of food that is definitely larger
than most people would eat during a similar period of time
and under similar circumstances

2. A sense of lack of control over eating during the episode

(e.g. a feeling that one cannot stop eating or control what
or how much one is eating)
 DIAGNOSTIC CRITERIA FOR BULIMIA
B. 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.

C. The binge eating and inappropriate

compensatory behaviors both occur, on
average, at least twice a week for three
months.
NUTRITION RELATED PHYSICAL FINDINGS
IN BN
• Callus on back of hand from stimulating gag
reflex to induce vomiting (Russell sign).
• Loss of dental enamel
• Dental caries
• Salivary gland enlargement
• Esophagitis
• Oesophageal tearing
• Laxative dependence
• Dehydration
NB: manage individual problem as it occurs
BINGE EATING DISORDERS
 BINGE EATING DISORDER (BED)
• BED is characterized by compulsive overeating in which a person
consumes huge amounts of food while feeling out of control and
powerless to stop.

• Binge eating may occur for at least twice a week for six or more
months.

• They often eat when they are not hungry and continue to eat
long after they are full.

• Feeling extremely distressed/ upset during or after bingeing.

• Unlike BN, there are no regular attempts to make up for the

binges through vomiting, fasting or over-exercise.
 The Binge Eating Cycle

Food for relief Eating to feel better

Feeling even worse

 DIAGNOSTIC CRITERIA FOR BINGE
EATING
A. Recurrent episodes of binge eating
in the absence of the regular use of
inappropriate compensatory
behaviors characteristic of BN.

B. Binge episodes occurring at least 2

days per week for a period of 6
months.
 MEDICAL NUTRITION MANAGEMENT
FOR
BN & BED
• Management requires an interdisciplinary
approach because the eating disorders are
psychiatric illnesses with major medical
complication.

• The leading treatment for both BN and BED is

*Cognitive Behavioural Therapy (Read on that)
 MNT
NUTRITION ASSESSMENT
• Assess readiness to change using the Stages of
Change model
• Diet history: 24-hour recall
• Biochemical indices : FBS, Lipid profile
• Metabolic index: energy expenditure
• Anthropometry: weight, height, skin fold, waist
–to- hip
NUTRITION DIAGNOSIS -- BN
• PES-Disordered eating pattern related
to binging and purging as evidenced
by self-induced vomiting following
binge episodes accompanied by guilt
and restricted eating
 NUTRITION INTERVENTION
Nutrition counseling is mostly on an outpatient
basis.
Calories for weight maintenance
• Provide 1500 to 1600 kcal/day diet if patient has
a hypo-metabolic rate.
• If metabolic rate appears to be normal, provide
DRl for energy.
• Monitor body weight and adjust calories for
weight maintenance.
• Avoid weight reduction diets until eating
patterns and body weight are stabilized.
 Cont’d: Macronutrients
 Protein
• Minimum intake is (0.8-1) g/kg of ideal body weight.
• Provide 15% to 20% kcal of high biologic-value sources.

 Carbohydrate
• Provide 50% to 55% kcal, most of which should be from insoluble
fiber.

 Fat
• Provide approximately 30% kcal, mainly from the essential fatty
acids.

 Micronutrients
• Provide 100% RDA multivitamin with minerals supplement.
 Monitoring and Evaluation
• Monitor weight by recording weekly

• Monitor behaviour

• Review meal plan and remove dieting

behaviours if there are any after initial
counselling

• Finally, use recording sheets or food diary to

monitor dietary behaviour
 END OF LECTURE
BOOKS FOR FURTHER READING:
• Thomas B, Bishop J., Manual for Dietetics Practice, 4th ed, Blackwell publishing
Ltd, UK. Publishers: Blackwell Publishing Ltd, Oxford

• Kathleen Mahan L, Escott-Stump S., Krause’s Food and Nutrition Therapy, 12th
ed, Saunders Elsevier, 11830 west line industrial drive, St Louis Missouri 63146,
USA. Publishers: WB Saunders Company, Philadelphia, London

• Modern Nutrition in Health and Disease, latest edition . Shils, ME, Young, VR .
Publishers: Lea and Febiger

• Sylvia Escott-Stump.,Nutrition and Diagnosis-Related Care,7th ed,Lippincott william

& wilkins,a wolter kluwer business,351 west camden street,Baltimore,MD 21201

• Schneider, N., Frieler, K., Pfeiffer, E., Lehmkuhl, U., & Salbach ‐Andrae, H. (2009).
Comparison of body size estimation in adolescents with different types of eating
disorders. European Eating Disorders Review: The Professional Journal of the
Eating Disorders Association, 17(6), 468-475.