mnt in eating disorders. the ideal body image media promotion media promotion social acceptance...
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MNT in MNT in Eating Eating DisorderDisorderss
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The Ideal Body ImageThe Ideal Body Image
Media Media promotionpromotion
Social Social acceptanceacceptance
Influence and Influence and stress on stress on young young individualsindividuals
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Food: More Than Just Food: More Than Just NutrientsNutrients Linked to personal emotionsLinked to personal emotions ComfortComfort Release of natural opioidsRelease of natural opioids RewardReward
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Eating Disorders (APA Eating Disorders (APA Diagnoses)Diagnoses) Anorexia nervosaAnorexia nervosa Bulimia nervosaBulimia nervosa Eating disorder not otherwise Eating disorder not otherwise
specified (EDNOS)specified (EDNOS) Binge eating disorder (BED)Binge eating disorder (BED)
Schebendach in Krause, 12th ed., p. 564)
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Genetic Link?Genetic Link?
Identical twins have a higher Identical twins have a higher chance of eating disorderschance of eating disorders
Fraternal twins are less likelyFraternal twins are less likely
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Profile of AnorexiaProfile of Anorexia Usually occurs between the ages of 12-Usually occurs between the ages of 12-
1818 Typically white femaleTypically white female Lifetime prevalence among women is .3 Lifetime prevalence among women is .3
to 3.7%, depending on criteria usedto 3.7%, depending on criteria used 5%-10% are male5%-10% are male Middle-upper socioeconomic classMiddle-upper socioeconomic class Often coexists with other psychiatric Often coexists with other psychiatric
disorders: major depression or dysthymia disorders: major depression or dysthymia (50-75%), anxiety disorders, OCD (40%)(50-75%), anxiety disorders, OCD (40%)
5-20% mortality rate, mostly from heart 5-20% mortality rate, mostly from heart failure or arrhythmiasfailure or arrhythmias
Schebendach in Krause, 12th Ed, p 564
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Anorexia Nervosa: Anorexia Nervosa: Psychological FeaturesPsychological Features
PerfectionismPerfectionism Harm avoidanceHarm avoidance Feelings of ineffectivenessFeelings of ineffectiveness Inflexible thinkingInflexible thinking Overly restrained emotional Overly restrained emotional
expressionexpression Limited social spontaneityLimited social spontaneity
Schebendach in Krause, 12th Ed., p. 564
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Anorexia NervosaAnorexia Nervosa
Food ritualsFood rituals– Cuts food in small piecesCuts food in small pieces– Rearranges food on plateRearranges food on plate
Eliminates foods graduallyEliminates foods gradually– 300-600 calories a day300-600 calories a day– Diet pop, sugarless gumDiet pop, sugarless gum
Prolonged exerciseProlonged exercise Preoccupation with foodPreoccupation with food Cooks for othersCooks for others Hungry, but refuses to eatHungry, but refuses to eat
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Diagnostic CriteriaDiagnostic Criteria
American Psychiatric American Psychiatric Association Diagnostic Association Diagnostic and Statistical Manual and Statistical Manual of Mental Disorders of Mental Disorders (DSM) criteria are the (DSM) criteria are the standardstandard
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AN APA Diagnostic AN APA Diagnostic CriteriaCriteria Weight <85% standardWeight <85% standard Intense fear weight gain/fat although underweightIntense fear weight gain/fat although underweight Distorted body imageDistorted body image Women: amenorrhea: absence of 3 consecutive Women: amenorrhea: absence of 3 consecutive
periodsperiods Restricting typeRestricting type
– Not regularly engaged in binge eating-purging Not regularly engaged in binge eating-purging behaviorbehavior
Binge eating/purging typeBinge eating/purging type– Regularly engaged in binge eating and purging Regularly engaged in binge eating and purging
behaviorbehavior
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AN Diagnostic CriteriaAN Diagnostic Criteria
Weight deficit is necessary (<85% of Weight deficit is necessary (<85% of expected)expected)
If AN develops in childhood or early If AN develops in childhood or early adolescence, failure to make expected adolescence, failure to make expected weight gains instead of weight loss weight gains instead of weight loss may occurmay occur– Stunting possible in prepubertal childrenStunting possible in prepubertal children– Growth charts are essentialGrowth charts are essential
Amenorrhea may not be useful in Amenorrhea may not be useful in younger patients as menarche may be younger patients as menarche may be delayeddelayed
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Related Psych Related Psych Disorders in ANDisorders in AN Depression: May be due, in part, to Depression: May be due, in part, to
the psychological stress of starvationthe psychological stress of starvation Obsessive-compulsive disorder: may Obsessive-compulsive disorder: may
be exacerbated by malnutritionbe exacerbated by malnutrition Comorbid personality disorders: poor Comorbid personality disorders: poor
impulse control, substance abuse, impulse control, substance abuse, mood swings, and suicide tendenciesmood swings, and suicide tendencies
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Prevalence of ANPrevalence of AN
More prevalent in industrialized More prevalent in industrialized countries that idealize a thin body countries that idealize a thin body type although expected to type although expected to become more widely distributedbecome more widely distributed
Lifetime prevalence among Lifetime prevalence among women is .5% to 3.7%, depending women is .5% to 3.7%, depending on criteria usedon criteria used
Prevalence among men is one Prevalence among men is one tenth of that among womententh of that among womenSchebendach in Krause, 12th edition, p. 564
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Risk Periods for Risk Periods for Anorexia NervosaAnorexia Nervosa
Age 14 – Age 14 – puberty, high puberty, high schoolschool
Age 18 – college, Age 18 – college, full time jobsfull time jobs
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Pathophysiology of ANPathophysiology of AN
Physical and Physical and psychological psychological consequences consequences of malnutritionof malnutrition
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Pathophysiology of ANPathophysiology of AN
Depleted fat stores; muscle Depleted fat stores; muscle wastingwasting
AmenorrheaAmenorrhea
CheilosisCheilosis
Postural hypotension; Postural hypotension; dehydration or edemadehydration or edema
Bradycardia; hypothermia Bradycardia; hypothermia
Sleep disturbancesSleep disturbances
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Pathophysiology of Pathophysiology of AN: OsteopeniaAN: Osteopenia Reduced bone mineral densityReduced bone mineral density May result in vertebral May result in vertebral
compression, fracturescompression, fractures Caused by estrogen deficiency, Caused by estrogen deficiency,
elevated glucocorticoid levels, elevated glucocorticoid levels, malnutrition, reduced body massmalnutrition, reduced body mass
Affects males and femalesAffects males and females
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Pathophysiology of ANPathophysiology of AN
Low body temperature/cold Low body temperature/cold intoleranceintolerance
Lower metabolism: low thyroid Lower metabolism: low thyroid hormonehormone
Bone marrow hypoplasia (50% of Bone marrow hypoplasia (50% of AN patients) results in leukopenia, AN patients) results in leukopenia, anemia, thrombocytopeniaanemia, thrombocytopenia
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Pathophysiology of Pathophysiology of AN: Cardiovascular AN: Cardiovascular Decreased heart rate <60 bpmDecreased heart rate <60 bpm
– Fatigue, faintingFatigue, fainting Decreased blood pressure <70 Decreased blood pressure <70
mm/Hg systolic; orthostatic mm/Hg systolic; orthostatic hypotensionhypotension
Reduction in heart massReduction in heart mass Mitral valve prolapse related to Mitral valve prolapse related to
hypovolemia or cardiomyopathyhypovolemia or cardiomyopathy– Death from CHFDeath from CHF
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Pathophysiology of ANPathophysiology of AN
Iron deficiency anemiaIron deficiency anemia Increased infectionsIncreased infections Dry skin, hairDry skin, hair Yellow skin due to Yellow skin due to
hypercarotenemiahypercarotenemia Desquamation, hair loss, alopeciaDesquamation, hair loss, alopecia
HirsutismHirsutism Lanugo: fine body hairsLanugo: fine body hairs
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Pathophysiology of Pathophysiology of AN: GIAN: GI Bloating, abnormal fullness Bloating, abnormal fullness
after eatingafter eating ConstipationConstipation Digestive enzymes lowDigestive enzymes low
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Pathophysiology of ANPathophysiology of AN
Electrolyte imbalance Electrolyte imbalance → heart → heart failure, deathfailure, death– Low intake potassiumLow intake potassium– Loss in vomiting, diureticsLoss in vomiting, diuretics– Refeeding syndrome: Refeeding syndrome:
electrolyte imbalances caused electrolyte imbalances caused by too-rapid refeedingby too-rapid refeeding
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Bulimia NervosaBulimia Nervosa
An illness characterized by repeated An illness characterized by repeated episodes of binge eating followed episodes of binge eating followed by inappropriate compensatory by inappropriate compensatory methods methods – Purging, including self-induced Purging, including self-induced
vomiting or misuse of laxatives, vomiting or misuse of laxatives, diuretics, diuretics, or enemasor enemas
– Non-purging including fasting or Non-purging including fasting or engaging in excessive exerciseengaging in excessive exercise
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Bulimia Nervosa APA Bulimia Nervosa APA CriteriaCriteria
Characterized by recurrent episodes of Characterized by recurrent episodes of binge/purge eatingbinge/purge eating
Average ≥ 2 binges/purge cycles/weekAverage ≥ 2 binges/purge cycles/week– Uncontrollable eating during bingeUncontrollable eating during binge– Purge regularly: vomiting, laxatives, Purge regularly: vomiting, laxatives,
diuretics, strict dieting, fasting, vigorous diuretics, strict dieting, fasting, vigorous exerciseexercise
Continues at least 2x/wk for ≥ 3 Continues at least 2x/wk for ≥ 3 monthsmonthsAmerican Psychological Association. DSM-IV-TR, ed 4, Washington DC, 2000
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Bulimia Nervosa Bulimia Nervosa PrevalencePrevalence Lifetime prevalence of BN among Lifetime prevalence of BN among
young adult women is 1% to 3%young adult women is 1% to 3% Rate of occurrence in males is Rate of occurrence in males is
10% of that in females10% of that in females Rarely seen in childhoodRarely seen in childhood
Schebenbach, in Krause, 12th edition, p. 565
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Bulimia Nervosa Bulimia Nervosa PrevalencePrevalence
5% of college women 5% of college women 20% of college women exhibit 20% of college women exhibit
symptoms (Sx)symptoms (Sx) 50% of those with anorexia 50% of those with anorexia
nervosa develop bulimia nervosanervosa develop bulimia nervosa Gorging and purging/vomitingGorging and purging/vomiting Susceptible populations—athletes, Susceptible populations—athletes,
actors, dancers, wrestlers, runnersactors, dancers, wrestlers, runners
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Profile of BulimiaProfile of Bulimia
Young (usually female) adults (college Young (usually female) adults (college students)students)
May be predisposed to becoming May be predisposed to becoming overweightoverweight
Usually at or slightly above normal weight Usually at or slightly above normal weight Tried frequent weight-reduction diets as a Tried frequent weight-reduction diets as a
teenteen ImpulsiveImpulsive Often goes undiagnosedOften goes undiagnosed
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Profile of Bulimia Profile of Bulimia NervosaNervosa Other psychological disorders, Other psychological disorders,
including major depression, including major depression, dysthymia, anxiety disorders, dysthymia, anxiety disorders, personality disorders, substance personality disorders, substance abuseabuse
Low self esteemLow self esteem GuiltGuilt Preoccupied with foodPreoccupied with food Recognize behavior is abnormalRecognize behavior is abnormal
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Binge DefinitionBinge Definition
Eating, in a discrete period of Eating, in a discrete period of time (e.g., within any 2-hour time (e.g., within any 2-hour period) an amount of food that is period) an amount of food that is definitely larger than most people definitely larger than most people would eat under similar would eat under similar circumstancescircumstances
A sense of lack of control over A sense of lack of control over eating during the episodeeating during the episode
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BingeBinge
Relieves stressRelieves stress Common binge foods:Common binge foods:
– High carbohydrate, high fatHigh carbohydrate, high fat– Convenience foodsConvenience foods– Cakes, cookies, ice creamCakes, cookies, ice cream– Soft, easier to purgeSoft, easier to purge
High food billsHigh food bills
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PurgePurge
Laxatives, enemasLaxatives, enemas– Act on large intestineAct on large intestine– 90% of calories are absorbed in 90% of calories are absorbed in
small intestinesmall intestine– Damages large intestine Damages large intestine → →
constipationconstipation
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VomitingVomiting
Most commonly used compensatory Most commonly used compensatory behavior (80%-90% of BN)behavior (80%-90% of BN)
33-75% of calories still absorbed33-75% of calories still absorbed Fingers down throat Fingers down throat
– Damaged knucklesDamaged knuckles Syrup of IpecacSyrup of Ipecac
– Toxic to heart, liver, kidneysToxic to heart, liver, kidneys– Poison if taken repeatedlyPoison if taken repeatedly
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VomitingVomiting
TeethTeeth– Stomach acid erodes Stomach acid erodes
enamelenamel– Pain, decayPain, decay
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DiureticsDiuretics
Water lossWater loss Electrolyte lossElectrolyte loss NO fat loss! NO fat loss!
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Hypergymnasia: Hypergymnasia: Excessive ExerciseExcessive Exercise Compulsive exercise: that which Compulsive exercise: that which
significantly interferes with life significantly interferes with life activitiesactivities
Occurs at inappropriate times or Occurs at inappropriate times or in inappropriate settingsin inappropriate settings
Continues despite injury or other Continues despite injury or other medical complicationsmedical complications
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Symptoms of BNSymptoms of BN
Usually normal weight and secretive in Usually normal weight and secretive in behaviorbehavior
Scarring of the dorsum of the hand Scarring of the dorsum of the hand used to stimulate the gag reflex, used to stimulate the gag reflex, known as Russell’s Signknown as Russell’s Sign
Parotid gland enlargementParotid gland enlargement Erosion of dental enamel with Erosion of dental enamel with
increased dental caries resulting from increased dental caries resulting from gastric acid in the mouthgastric acid in the mouth
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Pathophysiology of Pathophysiology of BN: VomitingBN: Vomiting DehydrationDehydration AlkalosisAlkalosis HypokalemiaHypokalemia Sore throat, esophagitis, mild Sore throat, esophagitis, mild
hematemesishematemesis Abdominal painAbdominal pain
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Pathophysiology of Pathophysiology of BN: VomitingBN: Vomiting Subconjunctival hemorrhageSubconjunctival hemorrhage Mallory-Weiss esophageal tearsMallory-Weiss esophageal tears Esophageal ruptures (rare)Esophageal ruptures (rare) Acute gastric dilatation or ruptureAcute gastric dilatation or rupture Salivary gland infectionsSalivary gland infections
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Pathophysiology of Pathophysiology of BN: Laxative AbuseBN: Laxative Abuse DehydrationDehydration Elevation of serum aldosterone Elevation of serum aldosterone
and vasopressin levelsand vasopressin levels Rectal bleedingRectal bleeding Intestinal atonyIntestinal atony Abdominal crampsAbdominal cramps
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Pathophysiology of Pathophysiology of BN: Diuretic AbuseBN: Diuretic Abuse DehydrationDehydration HypokalemiaHypokalemia
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Pathophysiology of BNPathophysiology of BN
Cardiac arrhythmias related to Cardiac arrhythmias related to electrolyte and acid-base electrolyte and acid-base imbalance caused by vomiting, imbalance caused by vomiting, laxative, and diuretic abuselaxative, and diuretic abuse
Ipecac may cause irreversible Ipecac may cause irreversible myocardial damage and sudden myocardial damage and sudden deathdeath
Menstrual irregularitiesMenstrual irregularities
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Vicious Cycle of Vicious Cycle of Bulimia Bulimia
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Eating Disorder Not Eating Disorder Not Otherwise Specified Otherwise Specified (EDNOS)(EDNOS) A diagnostic category for eating A diagnostic category for eating
disorders that fail to meet full disorders that fail to meet full criteria for either anorexia nervosa criteria for either anorexia nervosa or bulimia nervosaor bulimia nervosa
May have partial symptoms of May have partial symptoms of either AN or BNeither AN or BN
For example, all criteria for AN may For example, all criteria for AN may be met except patient has regular be met except patient has regular menses menses
OR significant weight loss but wt OR significant weight loss but wt still in normal rangestill in normal range
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Physical Physical Manifestations of Manifestations of Eating DisordersEating Disorders
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Treatment of Eating Treatment of Eating DisordersDisorders
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AN: Treatment AN: Treatment
NutritionNutrition Increase food intake to raise the BMRIncrease food intake to raise the BMR Prevent further weight lossPrevent further weight loss Restore appropriate food habitsRestore appropriate food habits Ultimately weight gainUltimately weight gain Some weight restoration and treatment Some weight restoration and treatment
of malnutrition may make of malnutrition may make psychotherapy more effectivepsychotherapy more effective
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AN: TreatmentAN: Treatment
PsychologicalPsychological Cognitive behavior therapyCognitive behavior therapy Determine underlying emotional Determine underlying emotional
problemsproblems Reject the sense of Reject the sense of
accomplishment associated with accomplishment associated with weight lossweight loss
Family therapy, support groupFamily therapy, support group
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Nutrition Assessment Nutrition Assessment in Eating Disordersin Eating Disorders
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Assessment of Intake Assessment of Intake in Eating Disordersin Eating Disorders Calories compared with DRICalories compared with DRI Evaluate macronutrient mix Evaluate macronutrient mix
(carbohydrate, protein, fat)(carbohydrate, protein, fat) Evaluate micronutrient intake compared Evaluate micronutrient intake compared
with DRIwith DRI Estimate fluids and compare with needsEstimate fluids and compare with needs Evaluate alcohol, caffeine, drugs, Evaluate alcohol, caffeine, drugs,
dietary supplementsdietary supplements
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Dietary Intake in ANDietary Intake in AN
Generally inadequate caloric Generally inadequate caloric intake, <1000 kcals/dayintake, <1000 kcals/day
Tend to avoid fatTend to avoid fat Many follow a vegetarian lifestyleMany follow a vegetarian lifestyle
– Identify whether vegetarian lifestyle Identify whether vegetarian lifestyle coincided with onset of diseasecoincided with onset of disease
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Dietary Intake in BNDietary Intake in BN
Highly variable; in one study Highly variable; in one study mean intake of 4446 kcals; 44% mean intake of 4446 kcals; 44% overeating, 19% undereatingovereating, 19% undereating
When not binge eating may follow When not binge eating may follow a low fat dieta low fat diet
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Eating Behavior in Eating Behavior in AN/BNAN/BN Unusual or ritualistic behaviorsUnusual or ritualistic behaviors Unusual food combinationsUnusual food combinations Nontraditional utensilsNontraditional utensils Excessive spices, vinegar, lemon juice, Excessive spices, vinegar, lemon juice,
noncaloric sweetenersnoncaloric sweeteners Meal spacing, length of time allocated Meal spacing, length of time allocated
for a mealfor a meal BN: may eat quicklyBN: may eat quickly AN: may eat in excessively slow mannerAN: may eat in excessively slow manner
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AN/BN Eating AttitudesAN/BN Eating Attitudes
Food aversionsFood aversions ““Safe” foodsSafe” foods Magical thinkingMagical thinking Binge trigger foodsBinge trigger foods Ideas on appropriate amounts of foodIdeas on appropriate amounts of food Misconception that purging Misconception that purging
eliminates all calories from a binge eliminates all calories from a binge episodeepisode
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Lab AssessmentLab Assessment
Visceral proteins: generally Visceral proteins: generally normal in ANnormal in AN
Lipids: elevated cholesterol and Lipids: elevated cholesterol and abnormal lipid profile; may be due abnormal lipid profile; may be due to hepatic dysfunction, decreased to hepatic dysfunction, decreased bile acid secretion, hypothalamic bile acid secretion, hypothalamic dysfunction, eating patternsdysfunction, eating patterns– Does not warrant prescription of low Does not warrant prescription of low
fat, low cholesterol dietfat, low cholesterol diet– Reassess after weight restoredReassess after weight restored
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Lab AssessmentLab Assessment
Serum glucose: low due to lack of Serum glucose: low due to lack of precursors for gluconeogenesis precursors for gluconeogenesis and productionand production
Low T3 syndrome: low levels of Low T3 syndrome: low levels of active form of thyroid hormone; active form of thyroid hormone; resolves with refeedingresolves with refeeding
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Vitamin-Mineral Vitamin-Mineral AbnormalitiesAbnormalities Hypercarotenemia: in AN restrictors; Hypercarotenemia: in AN restrictors;
mobilization of lipid stores, catabolic mobilization of lipid stores, catabolic changes, metabolic stress; normalizes changes, metabolic stress; normalizes with rehabwith rehab
Deficiency diseases rare in AN, possibly Deficiency diseases rare in AN, possibly due to use of supplements, catabolic due to use of supplements, catabolic state, use of nutrient-dense foodsstate, use of nutrient-dense foods
Osteopenia and osteoporosis are Osteopenia and osteoporosis are commoncommon
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Metabolic ChangesMetabolic Changes
AN: low metabolic rates (REE 62-70% AN: low metabolic rates (REE 62-70% of expected, or 700-1000 kcals)of expected, or 700-1000 kcals)
Refeeding causes increases in REERefeeding causes increases in REE Elevated diet-induced thermogenesis Elevated diet-induced thermogenesis
(DIT) and (DIT) and ↑ REE may require high ↑ REE may require high calorie prescriptions in nutritional calorie prescriptions in nutritional rehabrehab
BN: unpredictable metabolic rateBN: unpredictable metabolic rate Helpful to measure REE using indirect Helpful to measure REE using indirect
calorimetrycalorimetry
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Anthropometric Anthropometric AssessmentAssessment AN patients meet criteria for marasmus AN patients meet criteria for marasmus
(depleted adipose and somatic protein (depleted adipose and somatic protein stores but intact visceral proteins)stores but intact visceral proteins)
Body composition: underwater weighing Body composition: underwater weighing or DEXA; BIA of questionable validityor DEXA; BIA of questionable validity
Skinfolds from 4 sites (triceps, biceps, Skinfolds from 4 sites (triceps, biceps, subscapular, suprailiac crest)subscapular, suprailiac crest)
MAMCMAMC
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Body Weight Body Weight AssessmentAssessment Goal weight determined by various Goal weight determined by various
methods (NCHS growth tables to age methods (NCHS growth tables to age 18)18)
Daily preprandial early morning weight Daily preprandial early morning weight in hospitalin hospital
Gowned weight on the same scale Gowned weight on the same scale once a week in outpatient (pt should once a week in outpatient (pt should void and urine specific gravity checked void and urine specific gravity checked or patient examined to determine if or patient examined to determine if bladder is full)bladder is full)
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Management of Eating Management of Eating DisordersDisorders Multidisciplinary team including Multidisciplinary team including
physicians, nutritionists, physicians, nutritionists, psychotherapistspsychotherapists
May include inpatient medical or May include inpatient medical or psychiatric hospitalization, partial psychiatric hospitalization, partial hospitalization and residential hospitalization and residential treatment, intensive outpatient, treatment, intensive outpatient, or outpatient programsor outpatient programs
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Treatment GoalsTreatment Goals
AN: weight gain and correction of AN: weight gain and correction of malnutrition disorders; normalization malnutrition disorders; normalization of eating patterns and behaviorsof eating patterns and behaviors
BN: weight maintenance in the short BN: weight maintenance in the short term even if patient is overweight until term even if patient is overweight until eating habits are stabilizedeating habits are stabilized
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Factors Affecting Factors Affecting Weight Gain in ANWeight Gain in AN Fluid balanceFluid balance
– Polyuria seen in starvationPolyuria seen in starvation– Edema from starvation or refeedingEdema from starvation or refeeding– Hydration ratio in tissuesHydration ratio in tissues
Metabolic rateMetabolic rate– Resting energy expenditureResting energy expenditure– Postprandial energy expenditurePostprandial energy expenditure
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Factors Affecting Factors Affecting Weight Gain in ANWeight Gain in AN Energy cost of tissue gainedEnergy cost of tissue gained
– Lean body massLean body mass– Adipose tissueAdipose tissue
Previous obesityPrevious obesity Physical activityPhysical activity
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Nutritional Care in ANNutritional Care in AN
Often require hospitalization to begin Often require hospitalization to begin refeedingrefeeding
Some require enteral feedings, but Some require enteral feedings, but most can be rehabbed with oral most can be rehabbed with oral feedingsfeedings
Goal is increase in energy intake with Goal is increase in energy intake with weight gainweight gain
Energy intake must be increased Energy intake must be increased gradually while minimizing caloric gradually while minimizing caloric expenditureexpenditure
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Nutritional Care in ANNutritional Care in AN
Initial calorie prescriptions 1000-Initial calorie prescriptions 1000-1600 kcals, or 30-40 kcals/kg1600 kcals, or 30-40 kcals/kg
Increase 100 to 200 kcals q 2-3 Increase 100 to 200 kcals q 2-3 days; may be as high as 70-100 days; may be as high as 70-100 kcal/kg/daykcal/kg/day
Hospitalized patients: goal is 2-3 Hospitalized patients: goal is 2-3 lb/weeklb/week
Outpatients: 1 pound/weekOutpatients: 1 pound/weekAPA Practice Guidelines for the Treatment of Eating Disorders, January, 2006
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Refeeding SyndromeRefeeding Syndrome
Refeeding malnourished patients with AN can Refeeding malnourished patients with AN can result in life-threatening hypophosphatemia, result in life-threatening hypophosphatemia, cardiac arrhythmia, and deliriumcardiac arrhythmia, and delirium
May be precipitated by high-calorie feeding May be precipitated by high-calorie feeding regimensregimens
Patients weighing less than 70% desirable Patients weighing less than 70% desirable body weight at greatest riskbody weight at greatest risk
Serum phos, mg, K+, calcium must be Serum phos, mg, K+, calcium must be closely monitored and supplements provided closely monitored and supplements provided as neededas needed
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Energy Needs in ANEnergy Needs in AN
70-100 kcals/kg may be needed for 70-100 kcals/kg may be needed for continued weight gain (depends on continued weight gain (depends on REE and type of tissue gained)REE and type of tissue gained)
AN more physically active than AN more physically active than controls; require controls; require ↑ ↑ kcals for weight kcals for weight maintenancemaintenance
May require 3000-4000 kcals/day May require 3000-4000 kcals/day later in wt restoration (males 4000-later in wt restoration (males 4000-4500)4500)
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Energy Needs in ANEnergy Needs in AN
If unsuccessful in weight gain, If unsuccessful in weight gain, evaluate for discarding food, vomiting, evaluate for discarding food, vomiting, exercising, increased motor activity, exercising, increased motor activity, metabolic resistancemetabolic resistance
Use indirect calorimetry in fasting and Use indirect calorimetry in fasting and post-prandial statepost-prandial state
Once at goal rate, 40-60 kcals/kg Once at goal rate, 40-60 kcals/kg should promote wt maintenance and should promote wt maintenance and continued growth and development in continued growth and development in adolescentsadolescents
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Macronutrient MixMacronutrient Mix
Fat intake of 25%-30% of calories is Fat intake of 25%-30% of calories is recommended as added fat or less obvious recommended as added fat or less obvious sources (whole milk or peanut butter)sources (whole milk or peanut butter)
Protein: 15%-20% of calories; RDA for age Protein: 15%-20% of calories; RDA for age and sex in grams/kg of IBW; high biological and sex in grams/kg of IBW; high biological value sources; vegetarian diets should be value sources; vegetarian diets should be discouraged during rehabdiscouraged during rehab
Carbohydrate: 50%-55%; include sources of Carbohydrate: 50%-55%; include sources of insoluble fiber to relieve constipationinsoluble fiber to relieve constipation
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MicronutrientsMicronutrients
Vitamin-mineral supplements: may Vitamin-mineral supplements: may have increased need in anabolism; have increased need in anabolism; 100% RDA multivitamin with 100% RDA multivitamin with minerals (iron may minerals (iron may ↑ constipation)↑ constipation)
Encourage calcium-rich foods and Encourage calcium-rich foods and Vitamin DVitamin D
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MNT in ANMNT in AN
Early treatment: caloric intake usually Early treatment: caloric intake usually low, can be provided in 3 meals per low, can be provided in 3 meals per day; snacking may relieve some day; snacking may relieve some physical discomfortphysical discomfort
Later treatment: as caloric prescription Later treatment: as caloric prescription increases, snacks become unavoidableincreases, snacks become unavoidable
Defined formula liquid supplements Defined formula liquid supplements may be helpful; patients may be more may be helpful; patients may be more willing to accept them than large willing to accept them than large volumes of foodvolumes of food
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MNT in BNMNT in BN
Immediate goal interruption of Immediate goal interruption of the binge and purge cycle with the binge and purge cycle with weight maintenanceweight maintenance
Rarely hospitalized except for Rarely hospitalized except for electrolyte disturbanceselectrolyte disturbances
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Energy Needs in BNEnergy Needs in BN
May be hypocaloric; poor correlation May be hypocaloric; poor correlation between predicted and actual REEbetween predicted and actual REE
Measured REE preferable; provide Measured REE preferable; provide calories at 120%-130% measured REEcalories at 120%-130% measured REE– Signs of low metabolism: history of chronic Signs of low metabolism: history of chronic
dieting, low T3 level, cold intolerancedieting, low T3 level, cold intolerance– In presence of low metabolism, provide In presence of low metabolism, provide
1500-1600 kcals/day) or determine average 1500-1600 kcals/day) or determine average calories/day based on current intakecalories/day based on current intake
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Energy Needs in BNEnergy Needs in BN
Monitor anthropometric status and Monitor anthropometric status and adjust caloric prescription for weight adjust caloric prescription for weight maintenancemaintenance
Avoid weight reduction diets until Avoid weight reduction diets until eating patterns and body weight are eating patterns and body weight are stabilizedstabilized
May be on low-calorie intakes for May be on low-calorie intakes for longer periods than anorectic longer periods than anorectic patientspatients
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Monitoring of BN Monitoring of BN PatientsPatients Bingeing, purging, restrained Bingeing, purging, restrained
intake impair recognition of intake impair recognition of hunger and satiety cueshunger and satiety cues
Many patients with BN are afraid Many patients with BN are afraid to eat early in the day as they to eat early in the day as they might binge latermight binge later
May digress from meal plan after a May digress from meal plan after a binge, attempting to compensatebinge, attempting to compensate
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Macronutrients in BNMacronutrients in BN
Protein: 15-20% of calories; meet Protein: 15-20% of calories; meet RD in g/kg IBW; HBV sourcesRD in g/kg IBW; HBV sources
Carbohydrate: 50%-55% of Carbohydrate: 50%-55% of calories; encourage insoluble fibercalories; encourage insoluble fiber
Fat: 25%-30% of caloriesFat: 25%-30% of calories– Provide source of essential fatty Provide source of essential fatty
acidsacids MVI: multivitamin with mineralsMVI: multivitamin with minerals
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Cognitive Behavioral Cognitive Behavioral TherapyTherapy Structured psychotherapeutic Structured psychotherapeutic
method alters attitudes and problem method alters attitudes and problem behaviorsbehaviors
Identifies and replaces negative, Identifies and replaces negative, inaccurate thoughtsinaccurate thoughts
Typically a 20-week intervention thatTypically a 20-week intervention that– Establishes a regular eating patternEstablishes a regular eating pattern– Evaluates and changes beliefs about Evaluates and changes beliefs about
shape and weightshape and weight– Prevents relapsePrevents relapse
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Female Athlete TriadFemale Athlete Triad
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Three ComponentsThree Components
Eating disorderEating disorder Lack of menstrual periodsLack of menstrual periods OsteoporosisOsteoporosis
– Bones like 60-year-oldBones like 60-year-old– Caused by low estrogenCaused by low estrogen– Often irreversibleOften irreversible– Early warning: stress fracturesEarly warning: stress fractures
Also meet criteria for EDNOSAlso meet criteria for EDNOS
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Female Athlete TriadFemale Athlete Triad Female athletes Female athletes
participating in participating in appearance-based appearance-based and endurance and endurance sportssports
Seen in 15% Seen in 15% swimmers, 62% swimmers, 62% gymnasts, and 32% gymnasts, and 32% of all other sportof all other sport
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Female Athlete TriadFemale Athlete Triad
Performance thinness: the Performance thinness: the commonly held belief that achieving commonly held belief that achieving a lower weight and percentage of a lower weight and percentage of body fat will enhance performancebody fat will enhance performance
Appearance thinness: trend to Appearance thinness: trend to reward thinner athletes in reward thinner athletes in adjudicated sports such as adjudicated sports such as gymnastics and figure skating gymnastics and figure skating
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Treatment for Female Treatment for Female Athlete TriadAthlete Triad Reduce preoccupation with food, Reduce preoccupation with food,
weight, and body fatweight, and body fat Increase meals and snacks Increase meals and snacks
graduallygradually Rebuild body to healthy weightRebuild body to healthy weight Establish regular mensesEstablish regular menses Decrease training Decrease training
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Binge-Eating Disorder Binge-Eating Disorder (Compulsive (Compulsive Overeating)Overeating)
Complex and serious eating disorderComplex and serious eating disorder Occurs in ~30% -50% of subjects in Occurs in ~30% -50% of subjects in
weight control programs (40% are males)weight control programs (40% are males) More common with obese individuals More common with obese individuals
with history of restrictive dietingwith history of restrictive dieting ~50% exhibit clinical depression~50% exhibit clinical depression Not preoccupied with body shapeNot preoccupied with body shape Onset adolescence or early 20sOnset adolescence or early 20s
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Binge Eating Disorder Binge Eating Disorder Diagnostic Criteria Diagnostic Criteria (APA)(APA) Recurrent episodes of Recurrent episodes of
binge eating in the binge eating in the absence of the regular absence of the regular use of inappropriate use of inappropriate compensatory behaviors compensatory behaviors characteristic of BNcharacteristic of BN
At least 2x week over 6 At least 2x week over 6 month periodmonth period
Distress, disgust, guilt, Distress, disgust, guilt, depressiondepression
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Binge-Eating Disorder Binge-Eating Disorder (Compulsive (Compulsive Overeating)Overeating) Eat more rapidly than usualEat more rapidly than usual Eat until uncomfortableEat until uncomfortable Eat when not hungryEat when not hungry Cannot control bingesCannot control binges Embarrassed, guilty after bingeEmbarrassed, guilty after binge
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Binge Eating ProcessBinge Eating Process
PreconditionPrecondition Trigger phaseTrigger phase Maintenance phaseMaintenance phase Ending phaseEnding phase Post-binge phase Post-binge phase
(consequences)(consequences)
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Characteristics of a Characteristics of a Binge-EaterBinge-Eater Consider self as hungrier than normalConsider self as hungrier than normal Isolate self to eat large quantitiesIsolate self to eat large quantities Triggered by stress, depression, Triggered by stress, depression,
anxiety, loneliness, anger, frustrationanxiety, loneliness, anger, frustration Usually binge on “junk” foodsUsually binge on “junk” foods Eat without regards to biological needEat without regards to biological need Food is used to reduce stress, provide Food is used to reduce stress, provide
feeling of power and well-beingfeeling of power and well-being
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Treatment for Binge-Treatment for Binge-EatingEating
Learn to eat in Learn to eat in response to response to hungerhunger
Learn to eat in Learn to eat in moderationmoderation
Avoid restrictive Avoid restrictive diets which can diets which can intensify intensify problemsproblems
Increase activityIncrease activity
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Treatment for Binge-Treatment for Binge-EatingEating
Increase self-acceptance and Increase self-acceptance and improved body imageimproved body image
Address hidden emotionsAddress hidden emotions Overeaters AnonymousOvereaters Anonymous AntidepressantsAntidepressants
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BaryophobiaBaryophobia
““The fear of becoming heavy”The fear of becoming heavy” Children are given a low-fat, restricted Children are given a low-fat, restricted
diet in hopes to ward off obesity or diet in hopes to ward off obesity or heart diseaseheart disease
Detrimental to children; affect growth Detrimental to children; affect growth and developmentand development
Self-imposed restrictive diets by young Self-imposed restrictive diets by young adults to avoid obesityadults to avoid obesity
Lack of appropriate nutrition Lack of appropriate nutrition information information
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Treatment for Treatment for BaryophobiaBaryophobia Nutrition educationNutrition education Nutrition required for proper Nutrition required for proper
growthgrowth Appropriateness of sweets and Appropriateness of sweets and
fats in the dietfats in the diet
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Childhood Eating Childhood Eating DisordersDisorders DSM criteria not appropriate in DSM criteria not appropriate in
young childrenyoung children Cases of AN reported in children as Cases of AN reported in children as
young as 8 years oldyoung as 8 years old BN rare in childhoodBN rare in childhood C/o nausea, abdominal pain, C/o nausea, abdominal pain,
difficulty swallowing, concerns about difficulty swallowing, concerns about weight, shape, and body fatnessweight, shape, and body fatness
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Five Warning Signs of Five Warning Signs of Childhood Eating Childhood Eating DisorderDisorder Decreasing weight goalDecreasing weight goal Increasing criticism of the bodyIncreasing criticism of the body Increasing social isolationIncreasing social isolation Disruption of menstruationDisruption of menstruation Reports of purging in the context Reports of purging in the context
of dietingof dieting
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Eating Disorders in Eating Disorders in Dietetics StudentsDietetics Students There is some evidence that the There is some evidence that the
prevalence of disordered eating is prevalence of disordered eating is higher in dietetics students than higher in dietetics students than in other majors, though the in other majors, though the research has been mixedresearch has been mixed
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Eating Disorders in UG Eating Disorders in UG College StudentsCollege Students Worobey and Schoenfeld Worobey and Schoenfeld
surveyed 165 undergraduate surveyed 165 undergraduate women (mean age 21.6women (mean age 21.6++4.9 4.9 years and 46 men (22.4years and 46 men (22.4++6.6 6.6 years) from dietetics, exercise years) from dietetics, exercise science, dance, psychology, and science, dance, psychology, and biology/nursing biology/nursing
Worobey J, Schoenfeld D. Eating disordered behavior in dietetics students and students in other majors. JADA 1999;99:1100-1102
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Eating Disorders in UG Eating Disorders in UG College Students College Students Nursing/biology majors had Nursing/biology majors had
significantly higher BMI and significantly higher BMI and weightweight
Dietetics students scored highest Dietetics students scored highest on Cognitive concerns and on Cognitive concerns and binge/purge behaviorbinge/purge behavior
Worobey J, Schoenfeld D. Eating disordered behavior in dietetics students and students in other majors. JADA 1999;99:1100-1102
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Eating Disorders in Eating Disorders in College StudentsCollege Students Dietetics and dance majors Dietetics and dance majors
scored highest on Life scored highest on Life InterferenceInterference
Dance students scored highest on Dance students scored highest on Excessive ExerciseExcessive Exercise
Worobey J, Schoenfeld D. Eating disordered behavior in dietetics students and students in other majors. JADA 1999;99:1100-1102
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Eating Disorders in Eating Disorders in College StudentsCollege Students Fredenberg et al surveyed 5 Fredenberg et al surveyed 5
groups of students in DPD groups of students in DPD dietetics, CP dietetics, non-food dietetics, CP dietetics, non-food home economics curricula, home economics curricula, college basketball or volleyball college basketball or volleyball programs, and sororitiesprograms, and sororities
Fredenberg JP, Berglund PT, Dieken HA. Incidence of eating disorders among selected female university students. J Am Diet Assoc 1996;96:64-65.
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Eating Disorders in Eating Disorders in College StudentsCollege Students
Fredenberg and colleagues found no Fredenberg and colleagues found no significant differences among the groups of significant differences among the groups of college women surveyed in EAT scores (Eating college women surveyed in EAT scores (Eating Attitude Test.)Attitude Test.)
However, 17.7% of DPD students had EAT However, 17.7% of DPD students had EAT scores symptomatic of eating disorders scores symptomatic of eating disorders compared with 3.3% and 2.9%, respectively compared with 3.3% and 2.9%, respectively for CP and home economics students (NS)for CP and home economics students (NS)
This was lower than in a previous study (24%) This was lower than in a previous study (24%) (Drake et al, JADA, 1989)(Drake et al, JADA, 1989)
Worobey J, Schoenfeld D. Eating disordered behavior in dietetics students and students in other majors. JADA 1999;99:1100-1102
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PrognosisPrognosis
Mortality has declined for AN from 10% Mortality has declined for AN from 10% to 2%.to 2%.
20% to 30% will have a lifelong struggle 20% to 30% will have a lifelong struggle with foodwith food
Bulimics may need long-term counseling Bulimics may need long-term counseling to correct underlying philosophies and to correct underlying philosophies and beliefs.beliefs.
Family counseling is useful for both AN Family counseling is useful for both AN and bulimia.and bulimia.
High relapse rate after treatmentHigh relapse rate after treatment
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Topics for Nutrition Topics for Nutrition EducationEducation
Impact of malnutrition on growth and Impact of malnutrition on growth and developmentdevelopment
Impact of malnutrition on behaviorImpact of malnutrition on behavior Set-point theorySet-point theory Metabolic adaptation to dietingMetabolic adaptation to dieting Restrained eating and disinhibitionRestrained eating and disinhibition Causes of bingeing and purgingCauses of bingeing and purging What does “weight gain” mean?What does “weight gain” mean?
Modified from Schebendach J, Nussbaum MP: Nutrition management in Adolescents with eating disorders. Adoles Med: State Art Rev 3 (3): 556, 1992.
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Topics for Nutrition Topics for Nutrition Education —cont’dEducation —cont’d
Impact of exercise on caloric expenditureImpact of exercise on caloric expenditure Ineffectiveness of vomiting, laxatives, and Ineffectiveness of vomiting, laxatives, and
diuretics in long-term weight controldiuretics in long-term weight control Portion controlPortion control Food exchange systemFood exchange system Social dining and holiday diningSocial dining and holiday dining Food Guide PyramidFood Guide Pyramid Hunger and satiety cuesHunger and satiety cues Interpreting food labelsInterpreting food labels Nutrition misinformationNutrition misinformation
Modified from Schebendach J, Nussbaum MP: Nutrition management in Adolescents with eating disorders. Adoles Med: State Art Rev 3 (3): 556, 1992.
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Dying To Be ThinDying To Be Thin
Normal to be concerned about diet, Normal to be concerned about diet, health, and body weighthealth, and body weight
Weight normally fluctuates Weight normally fluctuates Treat physical and emotional Treat physical and emotional
problems earlyproblems early Discourage restrictive dietsDiscourage restrictive diets Correct misconception about foodsCorrect misconception about foods Thin is not necessary betterThin is not necessary better
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SummarySummary
Nutritional intervention supports Nutritional intervention supports psychologic strategypsychologic strategy