Nutritional Management of Eating Disorder
What is eating disorder?
Eating disorder is illness in which the people experience severe disturbances in their eating behaviors and related thoughts and emotions. People with eating disorders typically become preoccupied with food and their body weight. In many cases, eating disorders occur together with other psychiatric disorders like anxiety, panic, obsessive compulsive disorder and alcohol and drug abuse problems. New evidence suggests that heredity may play a part in why certain people develop eating disorders, but these disorders also afflict many people who have no prior family history.
Some common eating disorders
Anorexia: It refers to loss of appetite, especially as a result of diseases.
Anorexia Nervosa : A disease characterized by refusal to maintain a minimally normal body weight, intense fear of gaining weight, body image distortion.
Binge : An episode of eating marked by three particular features:
- The amount of food eaten is larger than most persons would eat under similar circumstances,
- The excessive eating occurs in a discreet period, usually less than 2 hours and
- The eating is accompanied by a subjective sense of loss of control.
Binge Eating Disorder: A disorder characterized by the occurrence of binge eating episodes at least twice a week for a 6 month period.
Bulimia Nervosa: A disorder characterized by repeated episodes of binge eating followed by inappropriate compensatory methods such as purging, including self-induced vomiting or misuse of laxatives, diuretics, or non purging including fasting or engaging in excessive exercise.
Eating Disorder not Otherwise Specified: A diagnostic criteria for eating disorders that fail to meet full criteria anorexia nervosa or bulimia nervosa.
Purging: It is a method intending to reverse the effect of binge eating. This may involve self-induced vomiting, which is the most common purging method. Additional methods may include laxatives, enema and diuretic abuse.
Complex eating disorder characterized by obsessive pursuit of thinness through dieting with extreme weight loss and disturbance of body image is known as Anorexia Nervosa
It is characterized by:
- Voluntary restriction of food,
- Distorted body image,
- Fear of gaining weight.
DIAGNOSTIC CRITERIA FOR ANOREXIA NERVOSA
- Weight loss of at least 15% of total body weight ( or Body Mass Index < 17.5)
- Avoidance of high-calorie foods
- Distortion of body image so that patients regard themselves as fat even when grossly underweight.
- Amenorrhoea for at least 3 months.
- In postmenarchal females, amenorrhoea i.e. absence of at least three consecutive menstrual cycles.
MEDICAL COMPLICATION OF ANOREXIA NERVOSA
- The patients deny hunger, thinness or fatigue despite profound weight loss.
- They may be preoccupied with food and may take pleasure in cooking and serving meals for others.
- They generally have constipation and are intolerant to cold. Patients are hypothermic and often wear more clothing than is environmentally appropriate
- In severe cases, the bones protrude through the skin, as there is hardly any body fat.
- The skin may be dry and scaly
- Palms may be yellow because of carotenemia (high level of yellow pigment carotene in blood)
- Body hair is increased. Frank hirsutism (excessive growth of course hair in women)
- Oedema may be present
- Parotid glands may be enlarged.
This eating disorder refers to binge eating followed by purging, resulting in an average or overweight body due to the residual amount of calorie.
It is characterised by
- Low self-esteem
- Over concern about shape and weight
- Extreme dieting
- Binge eating
- Compensatory purging (self-induced vomiting, laxatives or diuretics).
DIAGNOSTIC CRITERIA FOR BULIMIA NERVOSA
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time (e.g., within any 2 hour period ), an amount of food that is definitely larger than most people would eat during similar period of time under similar circumstances.
- A sense of lack of control over eating during an episode e.g. A feeling that one cannot stop eating or control what or how much one is eating.
- Self-evaluation is unduly influenced by body shape and weight.
- Recurrent inappropriate compensatory behaviour to prevent weight gain such as self-induced vomiting, misuse of laxatives diuretics or other medications; fasting or excessive exercise.
- The binge eating and inappropriate compensatory behaviours both occurs, on an average, at least twice a week for 3 months.
- The disturbance does not occur exclusively during episodes of anorexia nervosa.
MEDICAL COMPLICATION OF BULIMIA NERVOSA
- Menstrual irregularities
- Swollen glands
- Frequent fluctuations in weight
- Inability to voluntarily stop eating feeling guilty and ashamed about eating
- Depressive moods
- Overeating in reaction to emotional stress
- Cardiac arrhythmias
- Renal impairment from hypokalemia
- Muscular paralysis
- Urinary infection epileptic seizure
- Tetany ( from hypokalaemic alkalosis )
- Swollen salivary glands
- Eroded dental enamel
- Injury to my enteric plexuses of large bowel
BINGE EATING DISORDER
Binge eating disorder is a psychiatric disorder in which a subject:
- Periodically does not control over consumption of food,
- Eats an unusually large amount of food at one time,
- Eats much more quickly during binge episodes than during normal eating episodes,
- Eats until physically uncomfortable,
- Eats large amount of food, even when they are not really hungry
- Always eats alone during binge eating episodes, in order to avoid discovery of the disorder.
- Often eats alone during of normal eating , owing to feelings of embarrassment about food
- Feels disgusted, depressed or guilty after binge eating.
EATING DISORDER NOT OTHERWISE SPECIFIED (EDNOS)
A diagnostic category for eating disorders that fail to meet full criteria for anorexia nervosa or bulimia nervosa is termed as eating disorder not otherwise specified. Patients who fall under eating disorder not otherwise specified constitute about 50% of the population suffering with eating disorder. If the patient left untreated may develop full-fledged anorexia nervosa or bulimia nervosa.
DIAGNOSTIC CRITERIA FOR EATING DISORDERS NOT OTHERWISE SPECIFIED
- For females, all of the criteria for anorexia nervosa are met expect that the individual has regular menses.
- All the criteria for anorexia nervosa are met except that, despite significant weight loss, individual’s current weight is in the normal range.
- All the criteria for bulimia nervosa are met except that the binge eating and the inappropriate compensatory mechanism occur at a frequency of less than twice a week or for duration of less than 3 months.
- The regular use of inappropriate compensatory behaviour by an individual of normal body weight after eating small amount of food.
- Repeatedly chewing and spitting out , but not swallowing , larger amounts of food.
- Binge eating disorder, recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviours characteristic of bulimia.
TREATMENT OF EATING DISORDERS
The treatment of eating disorders can be said to have three components:
- Psychological Management.
- Medical and Biochemical Management, and
- Nutritional Management.
- Establish good and caring relationship with patient
- Cognitive behavioural psycho therapies
- Family therapy is more effective than individual psychotherapy in adolescents
- Supportive care therapy
Medical and Biochemical management
- Antidepressant drug therapy.
- Deep Brain Stimulation (DBS) for chronic and treatment refractory Anorexia nervosa.
- DBS was associated with improvements in mood, anxiety, affective regulation, and anorexia nervosa related obsessions and compulsions.
- Restrictions of variety of acceptable foods
- Restrictions of use of alcohol
- Establish normal pattern of food intake
- Maintain body weight within a normal weight
- Encourage a nutritional intake appropriate to the individuals’ need.
- Use of vitamin, mineral supplements
- Include exercise schedule
- Establish presence conditions that may affect nutritional requirements ( such as infection or any trauma, growth )
- Calculate rate of weight loss or gain
- Nutritional management considered in terms of three consecutive phases- Resuscitation; Repair; Repletion.
Resuscitation- First, identify and correct medical emergencies such as hypothermia, hypoglycaemia, electrolyte disturbance, dehydration and cardiovascular function as far as possible. Infections may also be treated.
Repair- The tissue/organ functions cannot be restored unless the cellular activity has been repaired. In this context, the correction of multiple specific nutrient deficiencies needs to be corrected.
Repletion- The ultimate objective of treatment is to return body composition to normal. But, abnormal body composition can only be corrected safely when the cellular machinery has been adequately repaired. Any aggressive attempts to drive weight gain at an early stage of treatment or correction of abnormal blood biochemistry are potentially dangerous. Hence, slow and systematic repletion and treatment regimen needs to be considered.
In case of Anorexia Nervosa:
INITIAL INTAKE: Most severely ill patient’s intake levels should usually start 1000 kcal – 1600 kcal/ day.
WEIGHT GAIN PHASE: Intake may have to be increased to as high as 2200-2500 kcal/ day. This calorie intake will lower when weight increases.
CARBOHYDRATES: Intake should be 65-70% of total energy.
PROTEINS: Intake should be 1gm/kg ideal body weight.
FATS: A dietary fat intake range of 25-30% of calories is recommended.
MICRONUTRIENTS: The use of prophylactic thiamine supplements in oral form is recommended for in- patients and those undergoing rapid weight gain. It is recommended to give 25mg per day. Vitamin D requirements are higher than average. Vitamin D supplements are also recommended.
In case of Bulimia Nervosa:
INITIAL INTAKE: Most severely ill patients intake levels should usually start 1000 kcal – 1600 kcal/ day.
WEIGHT LOSS PHASE: Intake may have to be decreased to as low as 1200-1400 kcal/ day. This calorie intake will higher when weight decreses.
CARBOHYDRATES: Intake should be 55-60% of total energy.
PROTEINS: Intake should be 1.2-1.5 grm/kg ideal body weight.
FATS: A dietary fat intake range of 25-30% of calories is recommended. Small amount of dietary fat may be encouraged at each meal.Further, it would be beneficial to include some sources of essential fatty acids in the diet.
Nutrition counselling can be used to accomplish a variety of goals, such as reducing behaviours related to the eating disorder, minimizing food restrictions, correcting nutritional deficiencies, increasing the variety of foods eaten and encouraging healthy and not excessive exercise pattern. Nutritional Education is an important aspect of the treatment. The patients report an extremely good knowledge of food and nutrition.
About 50% of the patients recover fully from anorexia nervosa and achieve normal weight, 30% improve but have a partial recovery and 20% will have lifelong problems with eating patterns. Older age of onset, long duration of illness, extreme weight loss and significant depression result in poor prognosis. Bulimia has even poorer prognosis because of medical dangers and severe psychiatric disturbances. The suicide rate also high in bulimia patients.Almost 40% of treated patients remains bulimic after one and half year of treatment. About 2/3 experience relapses within a year of recovery. The outcome criteria e.g., weight, food intake, proper body image, menstruation and social, psychological and sexual adjustments must be assessed for a number of year after recovery. Early intervention and better treatment strategies have helped in reducing the mortality from eating disorders.
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