Nutrition therapy for eating disorder

Nutrition therapy for eating disorder
http://ncp.sagepub.com/ Nutrition in Clinical Practice http://ncp.sagepub.com/content/25/2/122 The online version of this article can be found at: DOI: 10.1177/0884533610361606 2010 25: 122Nutr Clin Pract Christina Scribner Reiter and Leah Graves Nutrition Therapy for Eating Disorders Published by: http://www.sagepublications.com On behalf of: The American Society for Parenteral & Enteral Nutrition can be found at:Nutrition in Clinical PracticeAdditional services and information for http://ncp.sagepub.com/cgi/alertsEmail Alerts: http://ncp.sagepub.com/subscriptionsSubscriptions: http://www.sagepub.com/journalsReprints.navReprints: http://www.sagepub.com/journalsPermissions.navPermissions: What is This? - Apr 22, 2010Version of Record>> at Aston University - FAST on August 22, 2014ncp.sagepub.comDownloaded from at Aston University - FAST on August 22, 2014ncp.sagepub.comDownloaded from at Aston University - FAST on August 22, 2014ncp.sagepub.comDownloaded from
122 Nutrition in Clinical Practice Volume 25 Number 2 April 2010 122-136 © 2010 American Society for Parenteral and Enteral Nutrition 10.1177/0884533610361606 http://ncp.sagepub.com hosted at http://online.sagepub.com Background Eating fulfills basic biological needs and supports life. Unfortunately, fear and distrust about eating contribute to eating disorders, disordered eating, or concerns about possible food addiction.1 The actual prevalence of eating disorders is likely far underestimated2 as many people are reluctant to disclose information about their eating behaviors3 or do not meet the strict diagnostic criteria for an eating disorder.2 Furthermore, prevalence and incidence data for eating disorders are confounded by diffi- culty in recognizing early signs of eating disorders, variability in screening and referral practices, choice to not seek medical treatment if afflicted with an eating disorder, and variance in interpretation of diagnostic criteria.4 As a result, up to 90% of those with an eating disorder may go untreated.3 Disordered eating and eating disorders that are char- acterized by serious dysfunctional response to hunger and satiety signals5 are considered commonplace,6 particularly among adolescent girls and young adult women. Eating disorders result in impaired function and morbidity with mortality rates that rank among the highest of all From 1 Metropolitan State College of Denver, Denver, Colorado; 2 Laureate Eating Disorders Program, Tulsa, Oklahoma Christina Scribner Reiter, MS, RD, CSSD, Metropolitan State College of Denver, Denver, CO; e-mail: reiterc@mscd .edu. mental disorders.4,6 More than 7 million girls and women in addition to 1 million boys and men in the United States are expected to suffer from an eating disorder during their lifetime.7 Eating disorders strike early in life, with 10% being diagnosed prior to age 10 and about one- third being diagnosed during the preteen and adolescent years. Eighty-six percent of all eating disorders are diagnosed before children leave their teen years.7 The prevalence of eating disorders among athletes appears to be growing, with data revealing rates 10-50 times higher than previously thought.8 As shown in Table 1, anorexia nervosa (AN) and bulimia nervosa (BN) share most clinical features9 as described by the American Psychiatric Association in its Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR).10 The outcome on body weight of the balance of undereat- ing to overeating is the major feature distinguishing AN from BN.9,10 In addition, patients may migrate across diagnostic categories, “crossing over” from one disorder to the other.9 Within all ages and genders, the diagnosis of AN or BN pales in contrast to a diagnosis of an “atypical” eating disorder, defined as “eating disorder not-otherwise-specified” (EDNOS). EDNOS includes patients with binge eating disorder (BED)10 and who do not meet the specific criteria for AN or BN or are unable to describe or comprehend their disordered eating behavior.4 The same or similar processes apparent in AN and BN promote or maintain the EDNOS.9 Thus, treatment goals are similar, and patients with Nutrition professionals are essential members of the multidisciplinary clinical team treating individuals with eating disorders. They possess knowledge and expertise that includes nutrition, physiology, and skills for promoting behavior change relative to the psycho-socio-cultural aspects of eating. This review provides an overview of the current state of the art in the practice of nutrition therapy for eating disorders, providing guidance in nutrition assessment, interventions, monitoring and interpretation of information and data, awareness of emerging roles for nutrition, and important considerations regarding professional boundaries practiced in the field of eating disorders. Training and experience in nutrition therapy specific to eating disorders promote a positive outcome in patients. Nutrition professionals are involved in all levels of care, including individual and group treatment in inpatient hospitalization or residential programs, partial hospitalization, and outpatient programs. It is beyond the scope of this article to address specific nutrition considerations relevant to individuals. Additional research is needed to delineate the most effective strategies for nutrition therapy in the treatment of eating disorders. (Nutr Clin Pract. 2010;25:122-136) Keywords: nutrition therapy; eating disorders; eating; anorexia; anomxia nervosa; bulemia; bulimia nervosa Nutrition Therapy for Eating Disorders Christina Scribner Reiter, MS, RD, CSSD1 ; and Leah Graves, RD, LD, FAED2 Financial disclosure: none declared. Invited Review at Aston University - FAST on August 22, 2014ncp.sagepub.comDownloaded from
Nutrition Therapy for Eating Disorders / Reiter, Graves 123 various diagnoses are frequently treated together in group settings. Eating disorders are thought to arise from the inter- play of genetics, biology, and psycho-socio-cultural factors.11 A strong link between psychological problems and food selection and eating behavior has long been recog- nized.5 Poor nutrition has been postulated as both a con- tributor to the development of eating disorders, as well as a consequence. Evidence from the classic Keys semi- starvation study, in which malnutrition was imposed on psychologically healthy men, illustrates the development of dramatic emotional changes with food restriction that include depression, anxiety, and attitudes and behaviors related to food, some of which persisted after refeeding.7,12 In addition, more recent studies on quality and composition of the diet suggest that nutrition may be implicated in the development and treatment of mood disorders seen in eating-disordered patients.7 Depression coupled with negative emotions and altered appetite regulation is associated with impaired physical activity and increased appetite,13 which may lead to binge eating. Obesity is associated with poor nutrition,14 alcohol abuse, and mood, anxiety, and personality disorders that include major depression, dysthmia, and obsessive-compulsive disorder, among others.15 Alcohol consumption among eating-disordered individuals may pose problematic and potentially life-threatening consequences, even if alcohol consumption is not more frequent or in higher quantities than in non–eating-disordered individuals.16 Obesity is coded as a medical condition and is not included in the DSM-IV. As such, psychological issues5 included in the etiology,10 maintenance, or response to obesity may not be fully addressed in treatment.17 In fact, although “binge eating” is defined by DSM-IV, clinicians specializing in eating disorders recognize that loss of control over eating is more related to psychological distress than is the actual amount of food consumed.18 Song and Fernstrom13 review psychological issues following bariatric surgery, reporting that about 10% of obese individuals have BED, about 27% have a lifetime incidence of BED, and 66% have a lifetime history of an Axis I diagnosis. Clearly, all people who are underweight or obese do not have an eating disorder; obese individuals with BED are in a distinct category of obesity.19 Among the obese, those with BED have a higher incidence of severe psychopathology and impairement of social functioning than obese individuals who do not exhibit BED.19,20 Although many patients may believe that weight loss will improve Table 1. Types of Eating Disorders Anorexia Nervosa Bulimia Nervosa Eating Disorder Not Otherwise Specified Unwillingness to maintain body weight at a minimally normal weight for age and height Self-evaluation unduly influenced by body shape and weight A sense of lack of control during This “other” category may include any of the following: Subsydromal Binge eating Individuals of eating disorders: disorder: normal weight Intense fear of gaining weight or becoming fat that does not diminish with weight loss Disturbance in the way in which one’s body weight or shape is experienced, undue emphasis on body weight or shape on self- evaluation, or denial of the seriousness of the low body weight Absence of at least 3 consecutive menstrual cycles Subtype Restricting type: lack of regular binge eating or purging behavior recurrent episodes of binge eating, which occur at least twice a week for at least 3 months Use of compensatory behaviors to prevent weight gain (eg, self- induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise) at least twice a week for at least 3 months The disturbance does not occur exclusively during episodes of anorexia nervosa individuals who exhibit most but not all of the DSM-IV-TR criteria for anorexia nervosa or bulimia nervosa Recurrent binge eating less frequent than described for bulimia nervosa without regular compensatory behavior; this behavior causes distress and may be accompanied by obesity, body image dissatisfaction, low self-esteem, or depression who: a. purge after eating b. chew and spit out food rather than swallowing it to prevent weight gain; eating disorder Psychiatric impairment related to the abuse of diet pills and diuretics Obsessive preoccupation with cosmetic surgery to deal with issues of shape and weight Subtype Binge eating/ purging type: regular binge eating or purging behavior Purging type: use of self-induced vomiting or the misuse of laxatives, diuretics, or enemas Nonpurging type: use of compensatory behaviors other than regular use of purging, such as fasting or excessive exercise at Aston University - FAST on August 22, 2014ncp.sagepub.comDownloaded from
124 Nutrition in Clinical Practice / Vol. 25, No. 2, April 2010 psychological function, the improvement appears to be transient,12 with existing psychiatric disorders persisting after bariatric surgery.21 Ifland et al22 suggest that overweight and obesity may be the result of food addiction for many people. Obesity may be resistant to treatment due to the myriad of factors that appear to contribute to its etiology, including genetics, metabolism, biological pathways in the brain, behavior, food habits, physical activity, environment,20 and the use of pharmacotherapies that promote weight gain, such as atypical antipsychotic medications21 that promote weight gain. Functional neu- roimaging suggests that obese individuals may have a delayed awareness of satiety and altered chemical neuro- mediators that contribute to a sense of loss of control in eating, appetite drive, and craving similar to addiction.20 Neurobiology further suggests that obsessive-compulsive and impulsive traits may be common to BN and BED. Shared neurobiology and psychosocial factors suggest that treatments for substance abuse may be effective for overeating that leads to obesity,20,22 as evidenced by comparison of the 7 core features of substance dependence, defined in the DSM-IV, to overconsumption of refined foods.22 Recently, a single broad diagnostic category encom- passing all eating disorders has been suggested,6 as there are more similarities than differences among core features of eating disorders.23 Etiological factors; physical, medical, and laboratory findings; and prevalence data for eating disorders are available at http://www.psychiatryonline. com.10 Treatment guidelines for AN and BN are delineated by the American Psychiatric Association (APA).24 Both the APA24 and the National Institute for Clinical Excellence (NICE)25 in the United Kingdom recommend nutrition rehabilitation for eating disorders and the treatment of subthreshold eating disorders based on the eating disorder most similar to the patient’s presentation. Nutrition Therapy The National Institutes of Health defines nutrition counseling as “a process by which a health professional with special training in nutrition helps people make healthy food choices and form healthy eating habits.”26 Varying levels of nutrition advice may be provided by physicians, nurses, psychotherapists, athletic trainers, strength and conditioning coaches, and “nutritionists.” Yet, registered dietitians (RDs) are considered to be the most uniquely qualified and trained to provide nutrition therapy across the full continuum of disordered eating and at various levels of care.27 Nutrition professionals, specifically RDs, are integral team members in the treatment of eating disorders. All healthcare team members should recognize the risk factors and signs for development of eating disorders: •• Dietary habits including avoidance of specific foods or food groups, picky eating •• Exercise habits or athletes involved in sports that emphasize thin body build, body building, or body appearance •• Sociocultural values, including perception of health or beauty, that influence drive for thin- ness, negative body image, and/or body dissatisfaction •• Perceived pressure to perform such as in aca- demics or athletics •• Psychological factors, including temperament, anxiety disorders, low self-esteem, self-regulation, attachment issues, and history of abuse •• A more complete description can be found in the APA’s practice guideline for treating patients with eating disorders.24 The nutrition professional assists with medical monitoring, understanding medications and pharmacotherapies, and using medical nutrition protocols toward providing optimal nutrition and the normalization of eating.27 Nutrition professionals who identify themselves as being an advanced or specialty-level practitioner may work in various practice settings (eg, hospitals, residential treatment programs, private practice, community/ public health, education, or research) and are expected to implement scientific evidence-based practice that extends beyond entry-level knowledge and experience. A “specialist” in nutrition therapy for eating disorders con- centrates on this aspect of the nutrition profession and often works in a position requiring skills and training that expand beyond those expected of a generalist. The American Dietetic Association (ADA) has approved practice-specific Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for some areas in dietetics,28 but at the time of this writing, there is no SOP or SOPP for the specialist in eating disorders. The Behavioral Health Nutrition (BHN) ADA practice group has recommended that the SOP and SOPP for Behavioral Health Care (originally published in 2006) be reviewed and revised to include eating disorders as 1 of 4 distinct practice areas.29 Many different approaches to the treatment of eating disorders, including nutrition therapy, have been and continue to be used, some with more empirical evidence than others. The nutrition professional may be the first professional to be consulted by a patient and identify signs and symptoms of an eating disorder (ED). Although a variety at Aston University - FAST on August 22, 2014ncp.sagepub.comDownloaded from
Nutrition Therapy for Eating Disorders / Reiter, Graves 125 of healthcare providers may contribute to the assessment, diagnosis and coding are made by qualified medical and mental health professionals in accordance with the most current DSM criteria.10 Thus, ethical guidelines29 exclude the RD from diagnosing an eating disorder. An interdisci- plinary team approach is recommended for treatment of eating disorders.24 The nutrition professional should disclose his or her qualifications and philosophical approach, seek appropriate counsel, and make referrals as part of the management team. The patient will benefit from being engaged as a valued collaborator in making informed decisions regarding goal setting and methods employed in his or her treatment.5,30 Psychotherapeutic Considerations in Nutrition Therapy The competent nutrition counselor helps the patient recognize and understand the complex role an eating disorder plays in his or her life. As such, the nutrition therapist assists patients in recognizing that disordered eating may meet their need for safety or the relief of pain.5 Nutrition counseling guides patients in identifying problematic behaviors and setting realistic and achievable nutrition- related goals to support clients in making behavior changes.5,31 Nutrition education includes conversations about discrepancies between knowledge, beliefs, and behaviors, ultimately empowering the patient to normal- ize eating and make healthier decisions.5 The goal of nutrition therapy is nutrition rehabilitation. Recovery indicators include reaching and maintaining a healthful body weight, normalization of eating patterns and perceptions of hunger and satiety, and the correction of malnutrition-affected biological and psychological function.24 To this end, the nutrition therapist assesses the current and past patterns of dietary intake, including timing of meals, portion size, and food- or body-related rituals. Nutrition therapy assists clients in making changes related to food intake, supplement use, compensatory behaviors, physical activity, and the patient’s relationship with his or her body. Strategies include exploring potential solutions to problems, taking risks, assertiveness, getting needed support, and setting boundaries. More specifically, patients become competent in eating in various social situations and selecting food from all food groups in appropriate amounts to meet nutrition needs. Nutrition needs and dietary patterns consider physical activity, growth and/or development, achieving and maintaining a healthful weight range,32,33 and attending to coexisting conditions that may affect food selection, such as allergy, intolerance, metabolic syndrome, polycystic ovary syndrome, disabilities, or family history for risk of disease. It is imperative that the nutrition therapist consider the multitude of factors that affect food intake, including lifestyle and socioeconomic factors, personal values, interpersonal relationships and skills, trauma history, body image, self-esteem, substance abuse, and participation in sports. The success of nutrition therapy is affected by identifying and taking advantage of resources. Those resources might include access to healthy food, knowledge of food selection and preparation, and sources of support such as family, friends, and the work- place. In acting as an agent of change, the nutrition therapist must initially establish a therapeutic alliance by seek- ing to fully understand and empathize with the various aspects of the client’s struggle.5 Development of a strong, mutually trusting, and nonjudgmental relationship begins at the initial assessment.4 A helping model puts the counselor in the position of teaching and coaching, focusing on developing a greater sense of competence through positive regard, reassurance, and support as patients and family members explore potential solutions.4,5,34 Blonna and Watter34 have identified 3 sets of individual skills that are the basis of effective healthcare counseling: “attending skills” (culturally appropriate body language) are essential to establishing a safe and open counseling relationship; “responding skills” keep patients involved, allowing the nutrition counselor to understand issues from the client’s perspective; and “influencing skills,” which are imperative in facilitating change. A number of counseling approaches to develop or expand personal5 or coping skills33,35 that are supported by evidence, primarily from the psychological literature, are employed.5 For the majority of cases, the application of therapeutic modalities that are useful for an eating disorder will apply as patients migrate from one diagnostic classification to another.9 Behavioral approaches offer an opportunity for change that can potentially extend beyond the “physical” changes of food selection or body weight to emotional and relational changes (eg, sense of self-confidence or safety with food). Unfortunately, it is common for patients to receive treatment from clinicians who are not trained in therapeutic modalities.36 Unless the nutrition therapist is specifically trained or credentialed in counseling, he or she may not have adequate knowledge and skill to succeed in facilitating change,5 particularly among eating-disordered patients who experience extreme fear and anxiety related to distrust, disgust, or a sense of loss of control. The fundamental goal in applying psychotherapeutic strategies is that clients will recognize and understand conscious and unconscious thoughts and beliefs, as well as the moods or behaviors that affect eating and physical activity. The “stages of change” model by Prochaska et al37,38 guides treatment to facilitate change in thoughts, feel- ings, and behaviors based on a concept known as the “processes of change.” Motivational interviewing (MI) is a counseling style that is designed to promote motivation to change. MI has been show to be effective in eating at Aston University - FAST on August 22, 2014ncp.sagepub.comDownloaded from
126 Nutrition in Clinical Practice / Vol. 25, No. 2, April 2010 disorders and obesity treatment.20 Implementation of the principles of cognitive behavior therapy (CBT) and social cognitive theory/social learning theory facilitate change in diet for weight management, diabetes, and cardiovascular disease.37 CBT was identified as effective for BN and “similar syndromes” by the 2004 Cochrane review of psychotherapy for eating disorders.39 CBT is considered a stronger approach than others when used alone.40 CBT has been specifically adapted for application to eating disorders25 and has been shown to be effective when administered by dietitians in a group setting for reducing binge eating and improving depression, body image, and self-esteem among obese women.17 However, the efficacy of CBT alone for eating disorders is limited,6 and CBT combined with other counseling approaches is likely necessary for some, if not most, patients.41 Incorporation of individual or group CBT, dialectical behavior therapy (DBT), or psychoeducation in nutrition therapy is intended to promote greater understanding of the mental, emotional, spiritual, and medical aspects of the eating disorder. Self-monitoring, therapeutic repeti- tion/clarification, role-play, modeling, imagery, and real-life performance may be used to enhance skill and reduce anxiety and guilt.5 Many clinicians describe their approach as a mixed (eclectic) approach and may include narrative therapy, self-disclosure, or a feminist approach.42 Nutrition therapy groups are routinely offered along with individual therapy in treatment centers, and pose advantages as well as the possible disadvantages of contagion and exposure to competition, which is undesirable. The nutrition therapist balances education with collaboration and interaction among group members to provide new or increased understanding and experimentation. Patients then go outside to practice before returning to process the experience back in the group.5 Some faith-based inpatient programs have shown superior results when spirituality oriented CBT was used as compared to secular CBT.43 Supporting and using one’s spirituality in reducing mealtime anxiety and disorders related to food, particularly among spiritually devout patients, can promote successful outcomes. Individuals with eating disorders are often ambivalent and resistant to treatment,25 and severe eating disorders are known for their protracted course.9 Among some patients, “maintaining processes” that include clinical perfectionism, pervasive low core self-esteem, mood intolerance, and interpersonal difficulties interact with the core psychopathology of eating disorders and contribute to treatment resistance.9 For these reasons, nutrition therapy should be coordinated and concurrent with mental health professionals33 who use psychological assess- ments related to motivation, mood, anxiety, personality, and substance use disorders that influence the clinical course and outcome24 of nutrition therapy. In fact, assessment of personality and temperament may be key to implementing a treatment approach (eg, dialectical behavior therapy) that is likely to promote positive change as well as develop realistic expectations regarding the course of illness and recovery.23 Expanded Responsibilities The expanded responsibilities of the nutrition professional do not include counseling for complex psychological and interpersonal issues such as trauma. However, nutrition professionals may find themselves in a position to counsel eating-disordered patients on physical activity or dental health. Nutrition deficiencies; purging behaviors; use of caffeinated, carbonated, or sweetened drinks; and the use of vinegar and lemon to reduce hunger level are examples of relational links between nutrition, oral health, and the eating disorder. Referrals to oral healthcare providers experienced in eating disorders for oral hygiene and treatment of discomfort or pain should be considered when applicable. Attention to oral health is important in dealing with altered oral aesthetics, body image, and self-esteem, and affects the patient’s choice in food/beverage and ultimately nutrition status. Thus, a bidirectional relationship exists between nutrition and oral health.44 Patients, families, and other members of the multidisciplinary treatment team frequently look to the nutrition therapist for guidance on balancing physical activity and energy intake. Although nutrition professionals do not develop exercise prescriptions unless specifically certified to do so,45 it is appropriate to discuss the use and misuse of activity among patients with inadequate energy intake, osteoporosis, or related bone disorders to reduce health risk.25 Again, referral to a physical therapist or athletic trainer knowledgeable about eating disorders may be appropriate. Addiction Models For years, nutrition therapists and their patients have operated on the premise that people respond to foods dif- ferently and benefit from a personalized nutrition plan. Evidence is emerging to suggest that manipulation of both macronutrients and micronutrients may affect cognition, mood, and behavior. Although not currently standard, some eating disorder units follow routine nutrient supplement plans. More evidence is needed to determine optimal levels of macronutrients and micronutrients within this population. Some weight management and treatment programs for BN and BED operate from an addictions model based on evidence that food affects the same neuronal systems as do substances typically associated with abuse. Specific food and environmental conditions may result in at Aston University - FAST on August 22, 2014ncp.sagepub.comDownloaded from
Nutrition Therapy for Eating Disorders / Reiter, Graves 127 physiological and behavioral responses similar to substance dependence (addiction).1,20,22 Nutrition choices may affect body mass index (BMI) and influence mood through the serotonergic system.46 It is known that binge eating increases in response to perceived stress and associated negative mood.46 Munsch et al46 suggest that binge eating may be the result of a complex relationship between mood and the influence of that mood on loss of control over eating and nutrition or vice versa. Furthermore, they urge caution in interpretation of studies on nutrition and mood because naturally occurring, chronic negative mood may illicit a different response than that induced in a laboratory setting. Corwin and Grigson1 compare DSM-IV-TR criteria for substance dependence to the concept of food addiction using the following: •• Progressive use over time •• Withdrawal symptoms •• Use more than intended •• Tried to cut back •• Time pursuing, using, recovering •• Missed important activities •• Continued despite the consequences According to the authors of this article, it appears that concern related to highly palatable foods being inherently addictive in and of themselves is without support, but the pattern of intake of these foods (repetitious, intermittent, “gorging”) may increase the likelihood of eliciting loss of control in eating. Animal studies offer insight regarding potential for food addiction related to neuropathways acti- vated by highly palatable diets (fat and sugar) and key reward pathways.22,47 Others identify environments that mimic classic conditioning48 or associate problems in interpersonal relationships, sense of not belonging or lack of fulfillment, not being loved, feeling afraid or incompetent, and the drive to feel nurtured and safe as driving forces to becoming dependent on foods to meet needs.49 Overall, it appears that treatment which includes attention to quality and availability of food, inclusion of family members, behavioral strategies that include motivation and readiness to change, and physical activity are all components of a program that recognizes potential influences of neuro- psycho-social underpinnings of food on reward pathways.20 Patients frequently present concerns regarding the effect of psychotropic medications and weight change to the nutrition therapist. Although medications may be related to weight change in scientific literature, the actual risk for and magnitude of weight change is influenced by individual characteristics of patients, course of illness or treatment, or effects of past medications. Furthermore, the mechanisms of actions related to medications and weight change are largely unknown.18 Population Factors Athletes The prevalence of disordered eating among athletes is debated, with reports that range from 1% to 62% among female athletes and 0%-57% among male athletes.50 Athletes may be at higher risk for developing an eating disorder because of the very traits that make them good at their sport (perfectionism, competitiveness, concern with performance) and emphasis on leanness.51 There is also a possibility that individuals with preexisting eating disorders may gravitate toward sports that support their desire to achieve a certain physique.8 Although the extent of disordered eating among athletes is unclear, a wide variety of maladaptive eating, attitudes, and behaviors have been reported among athletes attempting to alter body weight or composition. Athletes pose an added challenge to healthcare providers and athletic personnel in identifying either subclinical or full-syndrome eating disorders. Some dietary and weight control maneuvers practiced by athletes are transient and safely managed as part of the physiologic demands of the sport. However, others are persistent and pose a threat to health, performance, and even life.52 The nutrition therapist working with athletes must be knowledgeable about dietary regimens practiced within various sports, as well as identifying nutrition issues and challenges that affect health and performance. The primary goal of dietary counseling for the athlete is to provide for optimal food and fluid intake.53 An eating- disordered athlete is at risk of inadequate energy and nutrient intake to meet the demands of the sport, even if weight is within a desirable range.52 The Female Athlete Triad identified by the American College of Sports Medicine describes a complex interrelationship between “energy availability,” menstrual status, and bone health.50,52,53 Low energy availability among female athletes who present with the female athlete triad may sim- ply reflect the challenge to eat enough to meet the energy needs of their sport rather than an actual eating disorder.50 The deleterious effect of the triad on bone mineral density is analogous to that in AN.54 When working with an eating-disordered athlete, collaboration with the medical and coaching staff and using medical nutrition protocols to advance recovery is recommended. For more information about managing disordered eating in athletes, see the National Athletic Trainers’ Association position statement.52 Pregnancy An individual with AN, BN, or EDNOS may become pregnant and experience unfavorable outcomes related to inadequate nutrition and purging behaviors such as excessive exercise and use of laxatives, diuretics, or appetite at Aston University - FAST on August 22, 2014ncp.sagepub.comDownloaded from
128 Nutrition in Clinical Practice / Vol. 25, No. 2, April 2010 suppressants. However, as many as 70% of pregnant women with eating disorders report a reduction or full remission of eating disorder symptoms during pregnancy. One of the most predictive factors in pregnancy outcome is weight gain during pregnancy.55 In May 2009, the Institute of Medicine (IOM) updated guidelines for weight gain during pregnancy that are based on prepregnancy BMI rather than the Metropolitan Life Insurance tables (Table 2).56 These new guidelines may present a challenge for individuals whose coping mechanisms include an eating disorder. After birth, data regarding breast milk produc- tion and lactation by women with EDNOS, or with a history of EDNOS, are lacking. Mothers with AN are at risk of underfeeding their infants either by diluting the for- mula or prolonged breastfeeding and delayed introduction to solids.55 Some women may exacerbate their symptoms to avoid weight gain with pregnancy. Nutrition professionals should collaborate with obstetrical practi- tioners in reinforcing nutrition intake to support weight gain and enable the mother to differentiate her own nutrition needs from those of her infant, as well as making appropriate referral to other healthcare professionals (see Table 3).55 Target Weights Determining a target body weight range for undernour- ished eating-disordered patients is a challenging aspect in the treatment plan. Outcome research has yet to provide an empirically supported guide for target weight. For the underweight patient, there is disagreement in the literature regarding weight criteria considered “remission.” Recent data suggest that beginning weight restoration early in treatment yields a better outcome.57 Failure to achieve complete weight restoration increases risk for relapse, with patients struggling with symptoms of their disorder for a longer period of time.32,58-60 Nutrition therapists are often consulted to recommend target weight ranges (also referred to as expected body weight [EBW] or ideal body weight [IBW]) to the treatment team. The nutrition therapist is uniquely qualified to evaluate weight goals in the context of a patient’s nutrition state and developmental stage.25 However, team consensus is essential in providing a consistent message about recommendations and treatment goals. If a team does not show unity, one of the most compelling meas- ures to push compliance with treatment is lost, with potential to disempower caregivers and increase the risk that the eating disorder will interfere with weight restoration. Unity can be achieved in structured treatment settings by including the patient as a member of goal setting within the treatment team. The outpatient setting may require greater coordination among treatment team members who are not geographically close or can be achieved by a conference call. It is important to remember that there is wide varia- tion of normal weight within the population, including both children and adults. Some patients may meet “normal” weight parameters and actually be underweight given their biological heritage. As a result, most clinicians are making recommendations considering family history, patient growth and development, patient weight history, and actual patient functionality. Unfortunately, patients or family members often engage in negotiation to limit the weight restoration process. The extent of weight restoration may be limited by a patient’s willingness to accept recommendations, current care environment, and treatment resources. Numerous and complex factors may be included in determining a target weight range. Although BMI is com- monly considered a screening tool for risk of weight- related disease61 and monitoring growth,62 it is not considered a tool for rigidly predicting an individual’s healthiest weight at any given life stage or lifestyle or for determining level of care needed. Many treatment groups reach consensus among the team based on a patient’s ability to function both biologically and psychologically. Biologically, patients would need to achieve a body weight that supports body processes (eg, patient has normal hor- mone function, reproductive function, and laboratory values). Biological functionality limits the risk of bone loss and other medical complications.33 Psychologically, patients need to maintain mood stability and cognitive processing adequate to make use of psychotherapy. Many therapists identify when a patient is weight restored by the quality of the patient’s work in psychotherapy. Other factors included in determining and reassessing the target weight range may include pelvic ultrasound to Table 2. Institute of Medicine Guidelines for Weight Gain During Pregnancy Prepregnancy BMI Weight Category BMI, kg/m2 (World Health Organization) Weight Gain Recommendation Underweight (BMI <18.5) 28-40 pounds Normal weight 18.5-24.9 25-35 pounds Overweight 25-29.9 15-25 pounds Obese ≥30 11-20 pounds Reprinted from Institute of Medicine. Weight Gain During Pregnancy: Reexamining the Guidelines. Reprinted with permis- sion from National Academies Press, Copyright 2009, National Academy of Sciences. BMI, body mass index. at Aston University - FAST on August 22, 2014ncp.sagepub.comDownloaded from
Nutrition Therapy for Eating Disorders / Reiter, Graves 129 assess ovarian and uterine size and function in female patients, prior weight history before the eating disorder, family norms, physical activity, and eating in response to body cues. Finally, for female patients, the weight at which healthy menstruation occured prior to the eating disorder is only an indicator, as ovulation and menstruation may not resume until a higher weight is attained.24,63 Ultimately, target weight ranges are goals that are informed but not necessarily a fixed number. The only way to truly know if rehabilitation is achieved is to have a patient pur- sue the recommended goal(s), and to reevaluate target weights throughout the treatment process. One school of thought is to recommend a target weight as if the patient has the ability to remain in treatment until full recovery is achieved. If treatment time is limited, a goal for the episode of care can be determined. The value in this approach is to support the patient through multiple levels of care by not colluding with avoidance of recommendations. Coordination among treatment teams is essential when a patient is in a structured treatment setting, such as an inpatient or a residential setting, and then transitioning to the outpatient setting. Energy Requirements Determining energy needs for patients with eating disorders presents a challenge. For patients with eating disorders, attempts to correlate energy requirements using equations typically used for determining energy expendi- ture in hospitalized patients and general populations have been unsuccessful.64-66 Indirect calorimetry is the most accurate method for determining energy requirements in patients with AN and BN.64,67,68 However, most clinicians do not use indirect calorimetry. The cost, availability, and portability of state-of-the-art equipment limit its use in many settings. Lower cost, handheld, indirect calorimeters offer an affordable option, but research in a healthy population is very limited,69 and these units have not been studied in an eating-disorder population. One possible limitation in using the handheld units for determining resting metabolic rate (RMR) among eating-disorder patients is their reliance on using a con- stant for respiratory quotient (RQ), a comparison of oxygen consumption and carbon dioxide output. The RQ is used to verify valid measurements with the traditional indirect calorimeters. The respiratory metabolic compen- sation that occurs in eating disorders may affect both components of RQ. A technology that assumes RQ, in contrast to measuring it, may limit accuracy of data. Clinicians may take a thorough nutrition history and then develop an eating/feeding plan to meet the treatment goal(s). For example, while working toward either weight restoration or weight maintenance, the nutrition therapist edits the meal plan to achieve treatment goals or adapts the equations used to predict energy needs based on clinical experience. Many factors must be considered in determining how much energy to recommend or provide for patients. Overly aggressive feeding can be lethal to the chronically malnourished patient. Underweight patients must be carefully rehabilitated to prevent complications from refeeding. Overfeeding a patient whose body has down- regulated in response to negative energy balance can result in refeeding syndrome,70 a constellation of challenges to multiple body systems that can be dangerous early in care. Patients may experience hypophosphatemia, hypokalemia, hypocalcemia, hypomagnesemia, and fluid retention as well as thiamine deficiency. Judicious monitoring and cautious provision of energy can limit the likelihood of refeeding syndrome.70 The general practice is to begin the refeeding process cautiously. Inpatient programs often start feedings on reduced calorie regimens, typically 30-40 kcal/kg/d (often 1000-1200 kcal among low-weight patients),24 with the initial goal being medical stabilization and safety rather than weight recovery. This phase of treatment may last 1-3 weeks.33 A balance of energy nutrients and supplementation of vitamins and minerals is essential to ease the patient out of a catabolic state and into an anabolic one without electrolyte disturbance. As carbohydrate intake increases among chronically calorie-restricted patients, metabolism suddenly shifts from fat utilization (low insulin environment) to an increase in plasma insulin. Insulin drives an influx of Table 3. Making a Referral of a Client With an Eating Disorder for Continuation of Care Consider Resources for Making a Referral Credentials and experience Professional listservs and member lists: The Academy for Eating Disorders (http://www.aedweb.org) National Eating Disorder Association (http://www.nationaleatingdisorders. org) International Association of Eating Disorder Professionals (iaedp.com) The American Dietetic Association (http://www.eatright.org) Availability Colleague and Treatment Center Recommendations Philosophy Referral lists: Eating Disorder Referral and Information Center (http://www .edreferral.com) Something Fishy (http://www .something-fishy.org) at Aston University - FAST on August 22, 2014ncp.sagepub.comDownloaded from
130 Nutrition in Clinical Practice / Vol. 25, No. 2, April 2010 phosphorus to meet the demands for phosphorylated intermediates in glycolysis. The use of phosphorus to build high-energy compounds (eg, adenosine triphos- phate [ATP]) also increases, with resultant hypophosphatemia. In addition, potassium and magnesium enter the cell while sodium is driven extracellularly. Plasma expansion increases risk of heart failure.71 Interestingly, a cooperative patient with adequate appetite and reasona- ble food tolerance may require limited access to food, sodium, and fluid to provide safe progression in rehabilitation without complication. Patient access to sodium and simple sugars (gum, candy, breath mints, and even cough drops) may therefore need to be limited to reduce risk of refeeding syndrome.71 This can prove to be challenging in orally fed patients who have relied on personal control of oral intake and whose psychological tolerance of the process may be limited. An experienced nutrition therapist can skillfully provide feeding with inclusion of all energy nutrients, limiting the risk of refeeding syndrome. Nutrition education assists the patient in understanding the need for caution at this stage of care and expecting more flexibility in eating during the next phase of care. The risk of refeeding syndrome increases with more invasive feeding methods. Thus, the goal is to provide balanced eating using the oral route as a first preference, enteral route as a second preference, and parenteral route as a last preference.70 Patients who need enteral intervention often tolerate continuous drip feedings better than bolus feedings, especially early in the rehabilitation process. Carefully monitoring the patient’s therapeutic response via laboratory data, vital signs, daily weights per protocol, and fluid intake and output is essential to manage refeeding risk. Once medical stability is achieved, weight restoration at a rate of 2-3 lb per week for hospitalized patients and 0.5-1 lb per week for patients in outpatient treatment is generally accepted and desire- able.24,25,33 Forced treatment and feeding should be considered a life-saving rescue effort.25,32,33 Body weight gain among AN patients may be difficult to achieve, particularly in the outpatient setting. Tolerance for a low body weight is lower when treating children and teens compared with adults; inpatient care may be recommended even though weight loss is not severe enough to avert irre- versible impacts on growth and development.24 Rapid weight restoration is likely to carry greater psychological distress for the patient, although it may meet demands of insurers.32 The literature suggests that structured treatment programs provide a secure and consistent environment that imparts the “key ingredients” of “predictability and confidence.”32 Underfeeding in this population can slow treatment progress for a variety of reasons. Downregulation of metabolic rate continues, resulting in limited growth, endocrine impairment, and ability to use psychotherapy. Furthermore, children and adolescents who have reached a healthy weight will benefit from a meal plan that includes increased energy necessary to support future growth and development.25,72 Patients with anorexia nervosa may require more energy than expected to achieve weight restoration, with energy needs at 70-100 kcal/kg/d for some patients.24 One explanation is that patients are compelled to sabotage efforts, fearing loss of the eating disorder and becoming overweight or obese.73 Patients may interfere with the weight restoration process through dishonesty, discarding food, exercising, or vomiting. Conversely, some patients will actually have a higher than expected energy demand. An increased thermic effect of food73,74 and challenges with absorption of nutrition have been postulated as con- tributors to the increased energy demand. The focus of nutrition rehabilitation in normal-weight BN patients is on normalization of eating behavior, establishing a consistent eating pattern, and consumption of a diet that is energy neutral. Research suggests that BN patients may be more metabolically efficient, requiring fewer calories than their non–eating-disordered peers.75 Although indirect calorimetry is the most accurate method of determining energy needs,76 most clinicians use adjusted energy equations, a thorough diet history, and clinical skill to establish energy goals. For patients who have not used binging or purging behaviors, increased energy needs may persist for a period after weight restoration is complete.77,78 This need is thought to be related to slow normalization of neuroendo- crine processes. Thus, consistent nutrition therapy to assist the patient with weight maintenance is recommended to consolidate progress and prevent relapse. How, when, and to what degree one should intervene in the treatment of excess adiposity is controversial. Risks that should be considered include hypertension, impaired glucose tolerance or diabetes, dyslipidemia, cardiovascular disease, and obstructive sleep apnea.79 Although osteoporosis is not included in this list, there is emerging evidence that higher levels of body fat mass are related to chronic systemic inflammation and accelerated bone resorption.80 Cognitive limitations induced by malnutrition include potentiating of mood disorders as well as limitation in executive function. Patients often note poor attentiveness that resolves when adequate energy is available. This provides the clinician with a positive outcome of the renutri- tion process that is not weight related. Macronutrient Composition Currently, there is no recommendation for macronutrient distribution specific to the eating-disordered population. Nutrition therapy includes individualized planning to assist each patient in addressing cognitive distortions with regard to the nutrition quality of food, specifically carbohydrate, protein, and fat. Meal planning should at Aston University - FAST on August 22, 2014ncp.sagepub.comDownloaded from
Nutrition Therapy for Eating Disorders / Reiter, Graves 131 include adequate carbohydrate with a focus on energy utilization throughout the day. Although many patients focus only on the nutrition relevance of each food, achieving dietary quality can be complicated. The nutrition therapist will assist patients in attending to personal taste preferences and the inclusion of discretionary calories within the realm of a balanced diet with the goal of promoting flexibility, limiting dietary restraint, and achieving satiation. Although most patients know that dietary protein provides the amino acid substrates important for lean tissue synthesis and repair, roles for protein and amino acids in multiple metabolic roles, including thermogenesis and glycemic regulation, are emerging.81 Evidence of the role of precursor amino acids in neurotransmitter synthesis can assist the nutrition therapist in helping patients include quality sources of protein in the diet.82 Several researchers have investigated the role of amino acids in the treatment of depression.82-86 Although dietary manipulation studies have indicated promise, to date, effect on mood appears to be limited.87 More research is necessary to apply this science to actual food prescriptions. However, an explanation of the effect that energy and protein insufficiency play in the bioavailability of amino acid building blocks for the synthesis of neurotransmitters such as serotonin and dopamine underscores the potential for nutrition to exacerbate mood disorders and is an effective construct for nutrition therapy. Inclusion of dietary protein at each meal plays an important role in achieving satiety81 and a more sustained energy curve, which can appeal to patients struggling with frank binge eating or fear of binge eating. Dietary fat is frequently avoided in the eating- disordered population; however, it is essential to a balanced eating plan. ω-3 Fatty acids have gained much recent attention. ω-3 Intake alters the structure and functional integrity of membranes in central nervous tissue.87 The precise mechanisms by which cognitive function is influenced by ω-3 fatty acids is unclear, but most theorhetical mechanisms involve neurotransmitters.85 Evidence suggests that limited ω-3 fatty acid intake may be linked to mental disorders, primarily depression, in the general population.87-91 For the patient at risk of cardiovascular disease, 250-1000 mg of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) may be effective,92 whereas the recommended dose for treating mental disorders such as depression ranges from 1.5-9.6 g daily.89 Thus, although ω-3 fatty acids have not specifically been implicated in the treatment of eating disorders7 and the optimal intake remains under investigation, ω-3 fatty acids may be useful in treating some symptoms (eg, elevated serum triglyceride levels, insulin sensitivity, mood disorders) and are frequently included in the treatment plan for individuals with eating disorders.7 ω-3 Fatty acids remain in tissue membranes for weeks.92 Given the health benefits of inclusion of ω-3 fatty acids in the diet, ω-3-rich foods as sources of fat are routinely incorporated into meal planning. In addition, the inclusion of dietary fat limits the respiratory load for severely malnourished patients89 and provides a protein-sparing effect. However, dietary fat intake must be carefully balanced with the issue of early satiety in the eating-disordered population. The satiety effect of dietary fat can be helpful to some patients who are experiencing impulses to binge eat as an aid in the prevention of overeating. Introduction of fat in the diet as an antibinge nutrient can assist patients with fat phobia. Micronutrients Eating-disordered patients often have limited intake of vitamins and minerals,93-95 potentially leading to micronutrient deficiency,24 although frank deficiency occurs less often than expected. Various micronutrient deficiencies have been found among patients who restrict food intake.7 An association between B vitamin deficiency and mood disorders typical of eating disorders has led to supplementation with niacin, vitamin B12, and folic acid and reported improvement in appetite and mental state.7 A thorough diet history can evaluate insufficiency of micronutrient intake. It is common practice to routinely supplement patients with a complete multivitamin/mineral preparation during treatment. Many treatment teams routinely evaluate serum vitamin and mineral levels supplementing additional micronutrients, including folic acid, thiamine, vitamin B12, zinc, vitamin D, and calcium. Evidence of sustained deficiency of folic acid and zinc after weight recovery96 suggests supplementation may be recommended beyond the rehabilitation phase of treatment. Bone health is of concern due to overwhelming evidence of bone loss in this population.54,97,98 To date, vitamin D and calcium intake do not appear to be primary predictors of bone mineral density among adolescents with AN.54 Annual bone density scans have become standard with most treatment teams for patients who have experienced a 6-month or greater interruption in menses.54 Vitamin D supplementation should be in response to actual laboratory evaluation of serum 25-hydroxyvitamin D. Many experts now recommend a dose of 1000 IU (25 mcg) per day to maintain normal vitamin D levels; greater doses are needed to promote vitamin D repletion for individuals with levels reflecting vitamin D deficiency or insufficiency.99 Consensus among researchers is that a target level of 35-40 ng/mL is an ideal serum level for health and the prevention of a variety of concerns, including bone health, dental health, muscle strength, and a variety of at Aston University - FAST on August 22, 2014ncp.sagepub.comDownloaded from
132 Nutrition in Clinical Practice / Vol. 25, No. 2, April 2010 other conditions.99 Thus, vitamin D status is routinely assessed in the eating-disordered population. Meal Plans Nutrition therapy addresses variety in food selections, desensitization to binged and/or purged foods, and normalization of eating behavior, including social eating. The use of structured eating plans to establish consistent intake allowing for provision of essential nutrition and satiety and limiting dietary restraint and fluid loading is common practice, although to our knowledge, research has not identified the most effective type of plan for any individual. Two common foundations for developing meal plans are MyPyramid and Exchange Lists for Meal Planning. Although MyPyramid is not intended as a “therapeutic diet,” it may be appropriate for improving eating habits among eating-disordered individuals. However, Krebs- Smith and Kris-Etherton100 point out that the professional must be aware of certain issues related to its use. MyPyramid is a product of the US Department of Agriculture and was designed to guide the general public in food selection to provide nutrient adequacy and reduce risk of chronic disease. The Exchange Lists were developed as a joint effort between the American Diabetes Association and the American Dietetic Association. Foods within each nutrient- dense food group can be traded (or “exchanged”) with another food within that group, plus additional tallying of added fats, energy-supplying sweeteners, and alcohol to achieve a specified energy and macronutrient intake.100 MyPyramid offers both opportunities and drawbacks for the eating-disordered patient. MyPyramid emphasizes that nutrients should come from nutrient-dense foods, as foods provide a variety of healthful benefits in addition to nutrients. MyPyramid reinforces moderation and variety in food choices as well as balance between energy intake and physical activity. If using MyPyramid eating plans, nutrition professionals should consider that 12 energy levels up to 3200 kcal/d are provided. Food group recommendations assume limited processed foods, no added salt, and selection of foods in their most nutrient-dense form that are free of any added fat or energy-containing sweeteners; meats are the leanest, trimmed cuts, and milk products are the lowest in fat (eg, skim milk was used in calculating energy provided rather than regular cheese).100 Many individuals with eating disorders will need a meal plan at some point in the recovery process that provides more than 3200 kcal/d; RDs possess the skills to modify existing plans to meet individual needs. The discretionary energy allowance provided is minimal relative to the typical American’s intake of fats and added energy-containing sweeteners, and may not support the notion that “all foods can fit” without explanation.100 Energy intake is the basis of the 12 food patterns provided. This is generally not helpful to the eating-disordered patient as it may reinforce calorie counting and monitoring body weight.100 Guidelines are available from national organizations (such as the Clinical Guidelines on Overweight and Obesity,American Diabetes Association, American Heart Association, American Institute for Cancer Research, and the National Cholesterol Education Program) that outline macronutrient recommendations (eg, 15%-21% of calories from protein, 28%-31% from fats, and 53%-58% from carbohydrate) similar to the MyPyramid recommendations.100 Whatever system the nutrition therapist uses for guiding food intake toward normal, updates to treatment plan and reassessment must be ongoing. Emerging Research Exposure to internal and environmental stress interrupts the development of gut flora, with increasing stress resulting in more pronounced damage and increased risk of inflammatory and allergic disease.101 The body’s natu- ral gut flora are affected by various factors, including stress, chronic constipation, antibiotics, and excess alcohol use.7 Studies of adolescents under challenging life circumstances, including those with AN, suggest that including probiotics such as those in yogurt can result in beneficial effects on immunologic markers.101 Lactic acid derived from milk, other dairy products, or capsules is well tolerated and improves absorption of minerals,7 improves immune function,7,101 and reduces the inflammatory response102 and severity of constipation7 such as that related to irritable bowel syndrome (IBS). Individuals with an eating disorder may be at higher risk of developing IBS.103 Long-Term Complications The literature indicates a long course of illness for many patients with eating disorders.104 Prompt and adequate intervention is affiliated with improved clinical outcomes.104 Long-term complications of eating disorders involve growth interruption, bone loss, cardiovascular abnormality, compromised reproductive function, gastro- intestinal challenges, and death,24,105,106 which are caused in part by ongoing nutrition disturbances. Patients require consistent medical monitoring and ongoing care to manage any lingering effects of the eating disorder.107 Nutrition status is challenged over a significant period of time; therefore, therapy with an experienced nutrition therapist is recommended to limit risk24,27 and minimize long-term complications of the eating disorder. Clinical complications of eating disorders affect the following24 : at Aston University - FAST on August 22, 2014ncp.sagepub.comDownloaded from
Nutrition Therapy for Eating Disorders / Reiter, Graves 133 •• Electrolyte balance •• Cardiovascular system •• Gastrointestional system •• Reproductive system •• Metabolism •• Nutrition status •• Skeletal and dental health •• Muscular strength •• Body weight and composition •• Cognition •• Growth Sudden death related to eating disorders cannot be predicted by length of illness. Low serum albumin and BMI lower than the 60th percentile (BMI ≤12) are the strongest risk factors. Additional considerations include electrolyte imbalance, excessive exercise with low body weight, hematemesis, frequent attempts to purge by vomiting or laxative use, inadequate (or excessive) fluid intake, rapid weight loss, and presence of and type of food restriction (high protein and low carbohydrate).33 Interpretation of vital signs, anthropometric measurements, systems function, and evidence of self-injurious behavior, family interac- tions, and attitudes regarding food, exercise, and appearance requires collaboration with other professionals.24 Prevention Because most eating disorders develop during adolescence,7 timing is critical to successful prevention efforts. Registered dietitians hold positions where they may contribute to eating disorder prevention in a variety of settings. It is well known that changes in knowledge do not necessarily translate into change in attitude or behavior and that there is evidence that providing information about eating disorders may increase risk.51 Shaw et al101 reviewed eating disorder prevention programs and identified the following as successful characteristics of programs reducing the risk of eating pathology: (1) target high-risk individuals (vs universal), (2) include interactive programs (such as those that include cognitive behavioral strategies, guided discovery, and active dissonance- induction11,102 ) and promote internalization of concepts, and (3) consist of multisession interventions delivered by trained professionals to participants 15 years or older. Health professionals have been concerned that efforts to prevent or treat overweight or obesity among children may inadvertently contribute to the development of eating disorder behaviors, poor body image, weight bias, or unhealthy weight gain.102,103,105 Recent research suggests that moderate calorie restriction does not pose a psychological risk among children105 or adults,103 but this conclu- sion is preliminary as an abundance of evidence suggests that emphasizing appearance and weight can promote eating disorder symptoms.102 Neumark-Sztainer106 describes recommendations for both preventing obesity and eating disorders, all of which are directly applicable to the expertise of dietitians: (1) discourage dieting and encourage sustainable eating and physical activity programs, (2) promote a positive body image, (3) encourage frequent and enjoyable family meals, (4) encourage families to avoid “weight talk” and do more at home to facilitate healthy eating and physical activity, and (5) address weight mis- treatment among overweight teens and their families. Although preliminary evidence suggests that highly palatable, energy-dense foods may promote loss of control regarding food intake among some people or conditions,22,47 nutrition therapists can safely manage the food addiction theory and counsel patients and parents by emphasizing (1) that overrestriction of these foods increases preference and eating in the absence of hun- ger108 and (2) that science supports the principles of a balanced diet, including a variety of foods in moderation. The media have a powerful influence on adolescent desire for change, including change of eating behavior. Including media literacy in nutrition education will help teens gain knowledge of factors that influence their food choice and eating behaviors.109 Nutrition services and classroom nutrition education are vehicles for integrating obesity and eating disorder prevention.110 Coordination Across the Continuum of Care An RD experienced in the treatment of eating disorders is integral to a complete course of care.27 The nutrition professional working with eating-disordered patients should begin with a proper medical diagnosis and then provide the patient with a clear description of treatment options.110 Although most eating-disordered patients can be treated in an outpatient setting,33 the availability of treatment, evidence of symptom improvement or lack thereof, and medical–psychiatric risk are important to the decision to recommend a higher level of care.32,33 At all treatment levels, utilization of a stepwise approach should move the patient from a high level of structure, providing predictability and confidence, toward greater flexibility and self-trust as one moves toward recovery.32 Criteria for level of care is provided by the American Psychiatric Association.24 Eating disorders are complex, multifactorial ill- nesses that are difficult to successfully treat. A coordinated, well-planned approach by a multidisciplinary treatment team that includes a protocol for transition between levels of care and providers is recommended for optimal care.13,14,24,32 Transition to a lower level of care is fraught with opportunities that pose a risk for, and contribute to, relapse.32 Continued care beyond the rehabilitation phase is required to assist patients with establishment of new lifestyle habits with regard to nutrition and general health practices. It is the at Aston University - FAST on August 22, 2014ncp.sagepub.comDownloaded from
134 Nutrition in Clinical Practice / Vol. 25, No. 2, April 2010 responsibility of clinicians to make appropriate referrals and maintain communication. Recommendations for the Future Nutrition professionals treating individuals with mental disorders, including eating disorders, must be willing to stay current regarding the use of nutrition as both a first line of defense and adjunct treatment. It is essential that the nutrition therapist treating eating disorders stay abreast of, and contribute to, emerging evidence and therapeutic strategies that prove to be effective. Workshops, seminars, formal or self-education, and infor- mal or formal supervision are all routes to gaining knowledge and enhancing counseling skill. Clearly, treatment involves decisions in terms of selecting appropriate treatment regimens. The first principle of medicine is primum non nocere (above all, do no harm).111 The potential benefits, as well as risks, in all aspects of nutrition therapy—from assessment, to intervention, and even to prevention—to reduce the risk of causing uninten- tional harm must be considered by all healthcare practi- tioners. Thus, the effective nutrition therapist will be in a position to model calculated risk-taking by using strategies that are based on good decision making with the goal of making each experience the best it can be.112 The state of treatment knowledge related to eating disorders is limited, and additional empirical evidence is needed to identify effective nutrition strategies. We encourage clinicians to publish research, including single case studies, as these may further understanding of treatment acceptance, relapse, and recovery rates.40 Acknowledgments The authors acknowledge Cindy Heiss, PhD, RD, and Ovidio Bermudez, MD, FAED, for review of this manuscript. 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315 Nutrition in Clinical Practice Volume 25 Number 3 June 2010 315 © 2010 American Society for Parenteral and Enteral Nutrition 10.1177/0884533610374593 http://ncp.sagepub.com hosted at http://online.sagepub.com Erratum Rollins MD, Scaife E, Jackson W, Mulroy C, Book L, Meyers R. Elimination of Soybean Lipid Emulsion in Parenteral Nutrition and Supplementation With Enteral Fish Oil Improve Cholestasis in Infants With Short Bowel Syndrome. Nutr Clin Pract. 2010;25:199-204. (Original DOI: 10.1177/0884533610361477) In the above article, on page 202, 2 amounts in Table 2 appear incorrectly. Under “20% soybean lipid emulsion,” in the “linoleic” line, the amount should be 0.1 g/mL instead of 1.1 g/mL. In the “total fat(kcal/ml)” line, the amount should be 2.0 g/mL instead of 0.2 g/mL.

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