- Email: [email protected]
Nutritional Counseling for Women with Eating Disorders
Marcia Hemn, EdD, R D
BALANCING THE SCALES Nutritional Counseling for Women with Eating Disorders Karen
is a 20-year-old college junior who's captain of her tennis team, a straight-A student, and a frequent volunteer for worthwhile causes around campus. Sometimes, while staying up late to study, she overeats. To rid herself of that bloated feeling, she makes herself throw up in the bathroom.
Emma
is a 14-year-old budding adolescent who loves to dance and play outdoors, but at school some of the girls have told her she looks fat. Although she's within the normal height and weight range for her age, she's starting to skip lunch so she doesn't appear "piggy" or "greedy" in front of the other girls.
Anne
is a career-climber with a prestigiousmiddle management position at age 30 and on the fast track for the corner office. She has been struggling to stay in her size six suits and gets frustrated when forced to buy a size eight. In the past she has dieted, exercised relentlessly, and often skipped meals to maintain her trim figure. Now that she's getting a little older, she's finding it harder and harder to remain diligent in her weight-monitoring routines. She's often tired and just doesn't have the same amount of energy that she used to have.
Which one of these women may have an eating disorder? Possibly all of them. What can nurses do to help? A lot. Although nurses are currently involved in the diagnosis and medical monitoring of women with eating disorders, they also may be the most practical providers of nutrition counseling because of their ongoing, regular patient contact and basic training in patient management, education and nutrition. Although registered dietitians or nutritionists with advanced degrees traditionally have provided nutritional counseling, they're not always on staff in all of the health care settings, and often, insurers may not provide coverage for nutritional counseling sessions. In any given patient population, including adolescent or young adult women, it's likely that as many as three percent have an eating disorder. Although eating disorders usually appear among females, some men are AugusVSeptember 1999
also affected by these disorders (APA, 1993). College-aged women are particularly at high risk; in fact, campus studies demonstrate that as many as 11 to 45 percent of female students engage in binging and/or purging at least once a month (Heatherton et al., 1995; Schotte & Stunkard, 1987). Since the 1970s, referral rates for anorexia have remained relatively unchanged, yet referral rates for bulimia have increased considerably (Fairburn et al., 1993). Women with anorexia nervosa or bulimia nervosa are somewhat alike; they engage in restrictive food intake and purging to achieve weight loss, and ultimately, both of these disorders can be devastating to a woman's health. Common to women struggling with anorexia and bulimia are fears of fat AWHONN Lifolino8
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in food and on their bodies, yet periodically both groups lapse into uncontrollable eating, called hinging. These women also believe that vigilant monitoring of thcir energy balance by manipulating food intake and exercise is necessary to control body weight (Vitousek et al., 1998). In the clinical setting, nurses may see women with characteristics of both types of eating disorders, and women may describe episodes of primarily anorexic o r bulimic symptoms. It’s not uncommon for a diagnosed anorexic, during a course of treatment, to exhibit episodes o f bulimic behaviors.
Abusing Food & Self Restrictive Behaviors
Avoiding highcalorie foods Avoiding high-fat foods Avoiding desserts Avoiding animal protein foods (especiallyred meats and
cheese) Skipping meals (especially breakfast)
Diagnosing Eating Disorders Younger anorexic patients are often diagnosed when regular well-child assessments show failure to gain weight o r weight loss (Robin et al., 1998). Adolescents with early or mild anorexia may still be menstruating with normal weight ranges, and deny unhealthy weight loss methods and purging. However, they may also have a mildly distorted body image and a weight loss goal less than or equal to a body mass index (BMI) of 18. (See “Determining Body Mass Index ”). Regardless of the severity of symptoms, nurses should follow up with questions about dieting, purging behaviors, concerns about body weight, and an assessment of a typical day’s food intake. Minimizing subclinical symptoms and behaviors may stop an early intervention and undermine later treatment if the condition worsens (Kreipe & Uphuff, 1992). Weight loss in formerly normal weight women should be similarly explored. Since bulimic patients usually maintain normal weights and have subtle, if any, outward physical signs, such as dental erosion o r parotid swelling, bulimia is difficult to diagnose during a routine physical exam. Patients who are significantly underweight and regularly engage in purging behaviors are at highest risk for significant medical problems, such as (APA, 1994): normochromic, normocytic anemia impaired renal function cardiovascular abnormalities dental problems osteoporosis Routinely asking patients if they have concerns about their food intake or if they have ever considered purging makes it more likely that patients will disclose their bulimia. Freund et al., (1993), focused on two questions that have been successful in uncovering bulimia during a primary medical history: 1. Are y o u satisfied with your eating patterns? 2. Do you ever eat in secret? Diagnosed patients should have regular medical assessments by a health care practitioner who is knowledgeable about eating disorders because significant complications can result from either malnutrition or purging behaviors. Assessment includes a review of the woman’s medical history, including menstrual function, physical exam, body weight history, current weight (not a selfMmcicl Herriii. EdD. RIA is codirector of the Eatiiig Disorders Tre‘itiiierit Temi ‘it 1Xirtniorrtlt College iii Hnnoivr. N H .
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Purging Behaviors
Self-induced vomiting (the most common)
Abuse of laxatives and/or diuretics Excessive exercise fasting
Spitting out, instead of swallowing, binged food report), and lab screenings, such as serum electrolytes and complete blood counts for low-weight patients. Nutritional counseling is one of several approaches used to treat women with eating disorders. Other approaches include psychotherapy at the individual, family, and group level, as well as psychopharmacology. Optimal care is found in a team approach, directed at the multifactorial etiology of eating disorders, delivered by a group of specialists who provide psychotherapy, nutritional counseling, and often psychiatry. A less costly approach is “stepped-care,” which begins initially with the provision o f low-intensity interventions; if that fails to bring satisfactory results, treatment is then “stepped up” to include other treatment aspects. In cases with significant emaciation (BMI less than 16), physical complications resulting from purging behaviors, e.g., low serum potassium, dizziness, cardiac and gastrointestinal complaints, or known psychological issues, such as dysfunctional family, abuse issues, etc., warrants an immediate referral to psychotherapy and nutrition counseling. In serious cases, when the patient is unresponsive to these interventions and particularly if the woman is experiencing serious physical complications or is at risk for suicide, hospitalization may be necessary. (For an extensive description of a “steppedcare” decision algorithm see Garner & Garfinkel’s ( 1997) Handbook of Treatment for Eating Disorders.)
Exploring Nutritional Counseling Nutritional counseling is effective as the first step in “stepped care” treatment because it is often viewed by patients as less intrusive than psychotherapy and generally less costly. The relatively few articles that have been published about the practical aspects of nutritional counseling for women with eating disorders, have been targeted primarily to psychotherapists, nutritionists, and dieticians-a fact that often frustrates clinicians who seek to stay current with evidence-based care strategies. Improving the nutritional status o f women with eating disorders entails achieving the following goals (Dwyer, 198s): Volume 3, Issue 4
Diagnosing Eating Disorders The fo//uwing criteria have been adapted from the American Psychiatric Association3 Diagnostic & Statistical Manual of Mental Disorders (4th Ed.) Ir994):
RecognizingAnorexia Underweight and refusing to maintain a healthy body weight for age and height Intense fear of gaining weight, becoming overweight, even though underweight
Self-evaluation unduly influenced by body shape and weight Disturbance doesn’t occur exclusively during anorexic episodes Specify Type: -Purging Type: person regularly engages in self-induced vomiting or misuse of laxatives and other diuretics
Disturbance in perceptions of body weight and how body weight -Nonpurging Type: person uses inappropriate compensatory is experienced, or denial of the seriousness of low body weight behaviors, such as fasting or excessive exercise, but hasn’t regularly engaged in vomiting or laxative-type abuse In menstruating females, absence of at least three consecutive cycles Specify Type:
Recognizing Other Forms of Eating Disorders
-Restricting Type: the person hasn’t regularly engaged in binge-eating or purging behaviors
All of criteria for anorexia are met, but patient still has regular menses
-Binge/Purging Type: the person has regularly engaged in binging and/or purging
All anorexia criteria are met; however, despite significant weight loss, the patient’s weight is still within a normal range
Recognizing Bulimia Recurring espisodes of binging, which is characterized by eating in a discrete period of time an amount of food definitely larger than most people would eat, and a lack of control over the episode Recurring behaviors such as vomiting, laxative abuse, diuretics, enemas, fasting, 01 excessive exercise to prevent weight gain 0.
Binge eating and inappropriate compensatory behaviors at least twice a week for 3 months
Reestablished normal dietary patterns and food-related behaviors Stopping weight loss Weight gaining and healthy weight maintenance Avoidance of metabolic consequences of anorexia or bulimia Accurate nutritional information Nutritional counseling should be conducted in the context of a therapeutic relationship in which accurate nutrition information is presented sympathetically, but firmly. Nutrition counseling is an interactive process that’s most successful when the woman under care plays an active role in food planning and decisions. Being a good role model (“practicing what you preach”) can be an asset, but women are most likely to embrace the beliefs and values expressed by clinicians regarding healthy eating, dieting, and body weight issues regardless of whether the clinician discusses her or his own values (Garner et al., 1997).
Counseling Approaches Women need to know that problems they experience as a result of an eating disorder are solvable. They need to know their health care providers have confidence in the solutions being offered and that their difficulties are Augu&eptember
1999
All criteria for bulimia are met; however, binging and inappropriate compensatory behaviors occur less than twice weekly or for less than 3 months Regular use of inappropriate compensatory behavior by a patient after eating small amounts of food Repeatedly chewing and spitting out, but not swallowing, large amounts of food Binge-eating disorder includes recurrent episodes of hinging in the absence of regular use of inappropriate compensatory behaviors characteristic of bulimia
normal for someone with their eating habits and patterns. Successful nutritional counseling involves experimentation between clinician and patient, with planning and follow-up evaluation of each strategy devised. Most clinicians find that behavioral change is more likely if patients actively decide for themselves which action they will take based on the information provided. In most outpatient cases, allowing the woman to make those active decisions under the care and direction of a knowledgeable health care clinician is all that’s necessary for the patient to begin to make behavioral progress and gain weight (if necessary), regardless of the kinds of initial changes made (such as adding a bagel to breakfast or a cookie for an afternoon snack, for example). The clinician’s role is to gently, but persistently, encourage and persuade the woman to make behavioral changes in her best interest. Additionally, clinicians must make clear the initial steps that must be taken to achieve behavioral goals. These steps are usually obvious to health care practitioners but not so to the patient, such as clinical goals (weight gain or purging cessation). Women need to hear again and again that they must gain weight and/or stop purging to protect their health. These admonitions are seldom enough, however, to induce behavioral change. Women need help setting intermediate, achievable, and measurable AWWONN L i f o l i n o 8
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How Eating Disorders Affect the Body S h t W h ~ l d W
Amenorrhea Apathy Cognitive dysfunction Cold intolerance Depression Fatigue Food cravings Insatiable appetite Irritability
Vomiting & laxative abuse can lead to: Bloating Bloodshot eyes Cardiac arrest Dental damage Hair loss Heart failure Scarred hands Sore throat Sudden death
Labile mood Obsessive and ritualized eating
Swollen glands Weight fluctuations
Poor concentration Social withdrawal (Kaplan & Garfinkel. 1993; Mitchell et al., 1997)
goals. Expect women to leave each session with a goal they are quite sure they can accomplish, such as eating breakfast, adding 300 calories to lunch, eating an afternoon snack, or reducing exercise to 20 minutes, to name a few. Women should know that they will be asked about their success and difficulties in achieving the agreed upon goal at their next visit.
Acknowledging Difficulties At first, many women (especially anorexics) aren’t at all sure they want to change their behaviors. Imperative to motivating these women is acknowledging how difficult it is to make changes in food and exercise behaviors. For example, predicting that many women will experience gastrointestinal discomfort (especially fullness) as they experiment with normal eating helps prepare patients to endure these temporary discomforts. Early in nutrition treatment, the clinician should present biological facts about the effects of undereating on psychological and physiological function (McFarland, 1995). Familiarity with the classic study of starved young male conscientious objectors during World War I1 provides ample data on the effect of starvation on physical and mental functioning and food behavior. Keys’ subjects (a very readable version of the study can be found in Garner & Garfinkel, 1997) entered the study in good physical and psychological health. After 6 months of consuming one-half of their normal food intake, the subjects developed labile mood, cognitive dysfunction, poor concentration, social withdrawal, obsessive and ritualized eating behaviors, insatiable appetites, binge eating, food cravings, apathy, depression, irritability, fatigue, and cold intolerance. More recently, severe bone loss has been documented in as many as half of patients with anorexia-related amenorrhea. And estrogen replacement doesn’t prevent progressive osteopenia in anorexic patients. Recovery from anorexia, however, is associated with improved bone density (Klibanski et al., 1995).
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Presenting the Facts Patients find it reassuring to hear mini-lectures on the biological roles of the various nutrients, particularly the essential functions of protein and fat. Clinicians need to emphasize that benefits of better nutrition include protection from obsessions with food, moodiness, and binge eating. For anorexics, additional benefits include relief from cold intolerance, loss of hair, and decreased bone density. Continued education about the likely long-term consequences of loss of menses and dietary solutions is very compelling. Dietary treatment for amenorrhea includes eating patterns that lead to increased body weight. Patients should be reminded that many of their symptoms are the consequence of the eating disorder, and that most of these symptoms quickly resolve when the disordered eating stops. Most bulimic patients aren’t aware that self-induced vomiting and laxative abuse are ineffective in eliminating consumed calories. In one study (Kaye et al., 1993), 17 normal weight bulimic patients were evaluated; although it’s not known how many calories are retained after vomiting, there appeared to be a ceiling on the number of calories retained. Of those 17 persons, whether they had small or large binges (1,549 calories to 3,530 calories in this study), they retained similar amounts of calories (from 1,128 to 1,209) after vomiting. In a different study involving bulimics and laxatives, Bo-Linn et al. (1983) showed that laxative usage after a binge decreased calorie absorption by only 10 percent.
Counseling Strategies There’s a lot nurses can do to counsel women with eating disorders. Asking, “how can I help” emphasizes the collaborative nature of nutrition counseling and allows clinicians to describe how normalizing food intake will diminish bothersome symptoms. Early in the first visit, a detailed dietary history and full exploration of the woman’s eating behaviors, knowledge, and attitudes about food should be undertaken. Initially, nutritional counseling is most effectively provided on a weekly basis. Biweekly, and then monthly, sessions are indicated, as the woman is able to meet and maintain treatment goals with relative ease. Anorexic patients, who are prescribed an intensive weight gain program, may benefit from more frequent sessions. Dietary recalls-”tell me what you ate and drank yesterday”-are helpful at initial and subsequent visits if the patient is unable to commit to keeping food records. Having a set of measuring cups available so that you can discuss serving sizes is helpful, and women should also’be asked about dietary supplement use. Most women who struggle with eating disorders will need help with meal planning because they’ve lost confidence in their ability to eat normally. Meal planning establishes an organized approach to eating that meets nutrient needs and gives patients the confidence to move beyond destructive eating behaviors. For underweight women who aren’t gaining weight in treatment, the initial focus of meal planning is to support an increase in calorie intake. For normal weight patients, reinforcing a normal pattern (three meals and several snacks a day) of eating is primacy. Volume 3,Issue 4
Women and Eating Disorders According to the Harvard Eating Disorders Center, more than five million people in the U.S. suffer with anorexia nervosa, bulimia nervosa, and binge-eating disorders, the majority of whom are female. Here’s a look at the facts surrounding women and eating disorders: Three percent of adolescent and adult women and one percent of men have anorexia nervosa, bulimia nervosa, or binge-eating disorder
A young woman with anorexia is 12 times more likely to die than other women her age without anorexia 15 percent of young women have substantially disordered eating attitudes and behaviors In a study of girls ages 9 to 15, slightly more than half reported exercising to lose weight, slightly less than half reported eating less to lose weight, and approximately one of 20 reported using diet pills or laxatives to lose weight Recent findings indicate that girls who smoke to suppress their appetite are the highest group of new nicotine addicts Eating disorders not only cause emotional suffering, but can also lead to many serious medical complications and in some cases even death About 85 to 90 percent of anorexia and bulimia nervosa cases-and 60 percent of binge-eating disorders-occur in females Onset of these disorders tends to be during adolescence or in the twenties, but eating disorders can affect people in later decades as well as younger children The cause of eating disorders is unknown, although it is likely that a variety of factors-biological, psychological, and sociocultural-impact upon whether any individual may develop an eating disorder
It’s also important to help women see beyond the myths they’ve structured around certain foods. Contrary to common belief among women who suffer with eating disorders, no foods in and of themselves are fattening, forbidden, and addictive. Because women who have eating disorders are most likely to have low intakes of protein, fat, calcium, and calories, dietary interventions should be focused primarily in these areas. The typical women’s fear of fat implies that initial recommendations not be made in that food group; however, helping the patient achieve adequate fat intake over a period of time is crucial. This strategy (timing the introduction of foods that contain fat) avoids intensifying resistance in a woman who is ambivalent about treatment. Using the woman’s current food pattern is a good foundation for meal planning. A few improvements at each visit, aimed at normalizing food intake, are recommended. An effective strategy is to ask, given that her intake is low in a certain nutrient or food group, what she would like to add. The clinician provides a written outline of several “model” days that include the agreed upon dietary improvements. The woman then leaves the session with a copy of the meal plan pattern and the model days. If initial meal plans are inadequate to meet nutrient needs, suggest the temporary use of multiple AugustSeptember 1999
Health Complications with Eating Disorders Obesity is the chief physical complication of binge-eating disorder and obesity can lead to high blood pressure, diabetes, and heart disease Health complications with anorexia nervosa include cardiac abnormalities (slow heart rate, disturbances in the heart’s rhythm), dangerously low blood pressure, dangerously low body temperature, low leukocyte count, chronic constipation, osteoporosis (brittle, weak bones). Additional health complications for teenagers include slowed growth or development, short stature, loss of menstrual periods, infertility, hair loss, and nail destruction With bulimia nervosa, health complications can include electrolyte abnormalities that can lead to heart rhythm disturbances, dehydration, dangerously low blood pressure, menstrual cycle abnormalities, enlarged parotid glands, destruction of dental enamel and cavities, and bowel abnormalities Risk Factors Associated with Eating Disorders Female gender Perfectionistic, rigid, risk-avoidant personality traits Dieting History of obesity or family history of obesity History of an eating disorder and/or family history of an eating disorder Personal or family history of drug and/or alcohol abuse Personal or family history of depression Personal or family history of physical or sexual abuse, teasing, and harassment Elite performance (male and female) Source: Haward Eating Disorders Center (http://www.hedc.org)
vitamins and mineral supplements until the adequacy of dietary intake is ensured. Anorexic patients must be assured that their meal plan protects against undereating and overeating-usually the patient’s significant concern. Bulimics, as well, need to know that the meal plan will reduce their tendency to binge. These patients should be instructed to immediately return to the meal plan and eat the next scheduled meal or snack if they binge. Both anorexic and bulimic patients benefit from hearing that increases in protein and fat at meals contribute to satiety and a decreased likelihood of binging.
Planning vs. Calories Meal planning should be encouraged over calorie counting, which many women with eating disorders already do compulsively. No matter how many calories the patient says she’s eating, if she’s losing weight, she isn’t eating enough and the meal plan should be increased. Some patients, however, need the assurance they receive from counting calories. Counting fat grams is prevalent, too. These behaviors should be tolerated initially if the patient is making progress. Because women with eating disorders are likely to overestimate their intake of caloAWHONN Lifelines
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Disordered Eating vs. Eating Disorders Eating Disorders
Disordered Eating
Essential Distinction
A reaction to life situations; a habit
An illness
Psychological Symptoms
Infrequentthoughts and behaviors about body, foods, and eating that do not lead to health, social, school, and work problems
Frequent and persistent thoughts and behaviors about body, foods, and eating that do lead to heahh, social, school, and work problems
Associated Medical Problems
May lead to transient weight changes or nutritional problems; rarely causes major medical complications
Can result in major medical complications leading to the need for hospitalizationor even death
Treatment
Education and/or self-help group can assist with Requires specific professionalmedical and change; psychotherapy and nutritional counseling mental heatthtreatment can be helpful but are not usually essential Problem may go away without treatment
Problem does not go away without treatment
Source: Harvard Eating Disorders Center [http://w.hedc.org)
ries and fat, it may be necessary occasionally to calculate calories and/or fat grams from food records or dietary recalls. Useful references are the Exchange System (The American Diabetes Association and The American Dietetic Association, 1995) and an extensive food composition reference (Pennnington, 1998). Providing information on normal caloric intake and fat intake is often beneficial. Most adult females need at least 2,000 calories to maintain a healthy weight (adolescents may need mgre); they will need more if they have a high metabolism, are tall and/or very active, or are recovering from anorexia (National Research Council, 1989).Healthy fat intake is approximately 65 grams for someone eating 2,000 calories a day (Healthy People 2000, 1990). A patient recovering from anorexia will likely need 3,000 calories or more per day to restore healthy weight gain (Krahn et al., 1993). At intakes below 1,500 calories, it's very difficult to meet basic nutrient needs. Requiring women with eating disorders to keep detailed records of food intake between visits is often beneficial. Food records are helpful in solving mysteries, such as why a patient isn't gaining weight or which food patterns support binging. Food records can help a bulimic patient arrive at the conclusion that undereating, restrictive eating, and dieting make her prone to binge eating; to reduce this vulnerability she must follow the meal plan. In practice, many anorexics actually eat meals that seem normal, although they may exaggerate the size of their intake and overexercise. Anorexics who aren't gaining weight at the prescribed rate need to be told that whatever they're eating, it's not enough. Binging, which has been defined by professionals as eating an unusual amount of food in a discrete period of time while feeling out of control, must be interpreted as the normal consequence of restrictive eating. Either the patient is allowing too long of a period between meals and snacks, is avoiding certain types of foods (often foods high in calories and/or fat), or isn't meeting her caloric and/or nutrient needs. The patient, on the other 82
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hand, is afraid that liberalizing her eating will result in weight gain. The woman should be reminded that she wouldn't gain weight from normal eating but that weight gain results from significant and chronic overeating. Normalized eating also makes binging less likely. Purging behaviors often also stop once the woman ceases to overeat. Patients, however, should be warned about a temporary change in weight because of "rebound hydration," which occurs when chronic purging is interrupted. Bulimic patients need to hear repeatedly that purging isn't effective in decreasing the absorption of calories and that bulimics typically maintain normal, not thin, body weights (APA, 1994). Patients with eating disorders, especially very lowweight patients, are likely to exercise excessively. Excessive exercise interferes with physical health, as well as interpersonal, social, educational, and work activities.
Determing Body Mass Index According to the National Institute of Health's (1998) Clinical Guidelines on the lndentification and Treatment of Overweight and Obesity in Adults (www.nih.gov1,body mass index (BMI)is "a direct calculation based on height and weight, regardless of gender." Calculate BMI by dividing a person's weight (pounds)by height in inches squared, then take the result and multiply by 704.5.
BMI Guidelines:
< 17.5 Diagnoses of anorexia
20 25
- 24.9 - 29.9
Healthy weights Increased health risk
=- 38 High health risk Volume 3,Issue 4
Exercise regimes that exceed 2 hours a day should be considered excessive. Informing patients of the current general recommendations for exercise, such as 20 to 60 minutes a day, 3 to 5 days a week, is useful (American College of Sports Medicine, 1998). Very underweight anorexics, who aren’t gaining weight as expected, should limit physical activity. Those patients who are unable to comply with exercise limits may need to be hospitalized. Permission to exercise can be used effectively as a reward for maintaining or gaining weight.
Weight Goals Recovery from an eating disorder is dependent on maintenance of a health body weight status. Normalized eating and exercise patterns should lead to maintenance of a weight that’s within normal ranges, is associated with regular menstrual function, and reflects the genetic predisposition of the individual. Minimum healthy weights are best estimated by using Body Mass Index (“See Determining Body Mass Index”) or premorbid body weights in adult patients (APA, 1994). TannerWhitehouse standards are recommended for children (Lask & Bryant-Waugh, 1997). For successful treatment, anorexic patients need interim weight goals. Too much emphasis on long-term weight goals may alarm the patient. However, the patient must understand that if her weight drops below a certain minimum (some clinicians use a BMI of 16 for adult patients), she’s not a candidate for outpatient treatment and would likely be hospitalized. Other indications for hospitalization include (Anderson et al., 1997): Severe or rapid weight loss Treatment-resisting binging Vomiting Laxative abuse For patients who are minors, setting minimum weights (consider BMIs of 19 as a minimum) for athletic participation, scheduling trips, or encouraging school attendance away from home is persuasive and medically justifiable. A discussion of normal weight ranges benefits bulimic patients in correcting overly critical selfassessment of body weight. The typical bulimic patient will fear that cessation of dieting will result in weight gain. Remind the patient that she most likely won’t gain weight as a result of her treatment. Continued weight loss in underweight patients should be interpreted as an indication that current treatment should be increased. Gains of 1 to 2 pounds per week are achievable in outpatient settings. Weight gain is likely to happen nonlinearly-gain 2 pounds, lose 1, gain %, and so forth. Occasionally, the dehydrated patient will experience gains of larger amounts of weight early in treatment. The patient must be reassured that this is normal fluid gain, and that gains in the future will be smaller. If the patient is also receiving therapy from other members of a treatment team, decide which professional is going to be responsible for weight monitoring. That professional is then responsible for communicating the patient’s weights to other members of the team in a timely manner. Because weight gain is a key indicator of progress in anorexia, it’s important that the patient be weighed at least weekly on an accurate, regularly caliAugusVSeptember 7999
brated scale, preferably the same one at about the same time of day. Ideally, patients are weighed in a private room, wearing a gown. Weekly weigh-ins also benefit bulimic patients in allaying their fears about weight gain. Normal weight bulimic patients can be weighed in street clothes without shoes. Many patients benefit initially from “blinded” weigh-ins (standing backwards on the scale). Blinded weigh-ins can assuage the patient’s worries and obsessions with her body weight. In the case of blind weigh-ins, clinicians should indicate to an anorexic patient whether she’s making progress, that is, gaining weight at the expected rate. For bulimic patients and others who are aiming to maintain their weight, weights within a 3 to 5 pound range are called stable. Clinicians should be cautious about making judgments about trends in body weight until at least four consecutive weekly weigh-ins. It’s usually best that patients with eating disorders commit to not weighing themselves, or to weigh themselves no more than once weekly.
Recovery Nutritional rehabilitation is the first step in recovery from an eating disorder, although many patients will need concurrent psychotherapy, and possibly a course of antidepressant therapy to fully recover. Emaciated patients have difficulty profiting from psychotherapy until nutrition rehabilitation is well on its way. Patients should be encouraged to seek psychotherapy particularly if they aren’t making progress within several months of initiating nutrition counseling. Successful nutrition counseling leads to resolution of eating disorder symptoms and the replacement of eating disorder behaviors with easily maintained normal, healthy eating and exercise behaviors. Women with eating disorders are vulnerable for relapse for a number of years, especially during times of stress, such as pregnancy. Women with eating disorders should be encouraged to be alert to increased anxiety about weight and food issues and to seek professional support. Recovered anorexic patients should be encouraged to have occasional weight checks.
Meal Planning Guidelines Daily Pattern
three meals two to three snacks Normal portion sizes 3 to 4 hours between eating times Content
Protein-minimum two (3 02.) servings Calcium-three to four servings Fat-three to four servings Calories-at least 2,000 for females; 2,500 for males Amounts
Rely on hunger and fullness
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BALANCING THE SCALES Nutritional Counseling for Women with Eating Disorders Karen
is a 20-year-old college junior who's captain of her tennis team, a straight-A student, and a frequent volunteer for worthwhile causes around campus. Sometimes, while staying up late to study, she overeats. To rid herself of that bloated feeling, she makes herself throw up in the bathroom.
Emma
is a 14-year-old budding adolescent who loves to dance and play outdoors, but at school some of the girls have told her she looks fat. Although she's within the normal height and weight range for her age, she's starting to skip lunch so she doesn't appear "piggy" or "greedy" in front of the other girls.
Anne
is a career-climber with a prestigiousmiddle management position at age 30 and on the fast track for the corner office. She has been struggling to stay in her size six suits and gets frustrated when forced to buy a size eight. In the past she has dieted, exercised relentlessly, and often skipped meals to maintain her trim figure. Now that she's getting a little older, she's finding it harder and harder to remain diligent in her weight-monitoring routines. She's often tired and just doesn't have the same amount of energy that she used to have.
Which one of these women may have an eating disorder? Possibly all of them. What can nurses do to help? A lot. Although nurses are currently involved in the diagnosis and medical monitoring of women with eating disorders, they also may be the most practical providers of nutrition counseling because of their ongoing, regular patient contact and basic training in patient management, education and nutrition. Although registered dietitians or nutritionists with advanced degrees traditionally have provided nutritional counseling, they're not always on staff in all of the health care settings, and often, insurers may not provide coverage for nutritional counseling sessions. In any given patient population, including adolescent or young adult women, it's likely that as many as three percent have an eating disorder. Although eating disorders usually appear among females, some men are AugusVSeptember 1999
also affected by these disorders (APA, 1993). College-aged women are particularly at high risk; in fact, campus studies demonstrate that as many as 11 to 45 percent of female students engage in binging and/or purging at least once a month (Heatherton et al., 1995; Schotte & Stunkard, 1987). Since the 1970s, referral rates for anorexia have remained relatively unchanged, yet referral rates for bulimia have increased considerably (Fairburn et al., 1993). Women with anorexia nervosa or bulimia nervosa are somewhat alike; they engage in restrictive food intake and purging to achieve weight loss, and ultimately, both of these disorders can be devastating to a woman's health. Common to women struggling with anorexia and bulimia are fears of fat AWHONN Lifolino8
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in food and on their bodies, yet periodically both groups lapse into uncontrollable eating, called hinging. These women also believe that vigilant monitoring of thcir energy balance by manipulating food intake and exercise is necessary to control body weight (Vitousek et al., 1998). In the clinical setting, nurses may see women with characteristics of both types of eating disorders, and women may describe episodes of primarily anorexic o r bulimic symptoms. It’s not uncommon for a diagnosed anorexic, during a course of treatment, to exhibit episodes o f bulimic behaviors.
Abusing Food & Self Restrictive Behaviors
Avoiding highcalorie foods Avoiding high-fat foods Avoiding desserts Avoiding animal protein foods (especiallyred meats and
cheese) Skipping meals (especially breakfast)
Diagnosing Eating Disorders Younger anorexic patients are often diagnosed when regular well-child assessments show failure to gain weight o r weight loss (Robin et al., 1998). Adolescents with early or mild anorexia may still be menstruating with normal weight ranges, and deny unhealthy weight loss methods and purging. However, they may also have a mildly distorted body image and a weight loss goal less than or equal to a body mass index (BMI) of 18. (See “Determining Body Mass Index ”). Regardless of the severity of symptoms, nurses should follow up with questions about dieting, purging behaviors, concerns about body weight, and an assessment of a typical day’s food intake. Minimizing subclinical symptoms and behaviors may stop an early intervention and undermine later treatment if the condition worsens (Kreipe & Uphuff, 1992). Weight loss in formerly normal weight women should be similarly explored. Since bulimic patients usually maintain normal weights and have subtle, if any, outward physical signs, such as dental erosion o r parotid swelling, bulimia is difficult to diagnose during a routine physical exam. Patients who are significantly underweight and regularly engage in purging behaviors are at highest risk for significant medical problems, such as (APA, 1994): normochromic, normocytic anemia impaired renal function cardiovascular abnormalities dental problems osteoporosis Routinely asking patients if they have concerns about their food intake or if they have ever considered purging makes it more likely that patients will disclose their bulimia. Freund et al., (1993), focused on two questions that have been successful in uncovering bulimia during a primary medical history: 1. Are y o u satisfied with your eating patterns? 2. Do you ever eat in secret? Diagnosed patients should have regular medical assessments by a health care practitioner who is knowledgeable about eating disorders because significant complications can result from either malnutrition or purging behaviors. Assessment includes a review of the woman’s medical history, including menstrual function, physical exam, body weight history, current weight (not a selfMmcicl Herriii. EdD. RIA is codirector of the Eatiiig Disorders Tre‘itiiierit Temi ‘it 1Xirtniorrtlt College iii Hnnoivr. N H .
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Purging Behaviors
Self-induced vomiting (the most common)
Abuse of laxatives and/or diuretics Excessive exercise fasting
Spitting out, instead of swallowing, binged food report), and lab screenings, such as serum electrolytes and complete blood counts for low-weight patients. Nutritional counseling is one of several approaches used to treat women with eating disorders. Other approaches include psychotherapy at the individual, family, and group level, as well as psychopharmacology. Optimal care is found in a team approach, directed at the multifactorial etiology of eating disorders, delivered by a group of specialists who provide psychotherapy, nutritional counseling, and often psychiatry. A less costly approach is “stepped-care,” which begins initially with the provision o f low-intensity interventions; if that fails to bring satisfactory results, treatment is then “stepped up” to include other treatment aspects. In cases with significant emaciation (BMI less than 16), physical complications resulting from purging behaviors, e.g., low serum potassium, dizziness, cardiac and gastrointestinal complaints, or known psychological issues, such as dysfunctional family, abuse issues, etc., warrants an immediate referral to psychotherapy and nutrition counseling. In serious cases, when the patient is unresponsive to these interventions and particularly if the woman is experiencing serious physical complications or is at risk for suicide, hospitalization may be necessary. (For an extensive description of a “steppedcare” decision algorithm see Garner & Garfinkel’s ( 1997) Handbook of Treatment for Eating Disorders.)
Exploring Nutritional Counseling Nutritional counseling is effective as the first step in “stepped care” treatment because it is often viewed by patients as less intrusive than psychotherapy and generally less costly. The relatively few articles that have been published about the practical aspects of nutritional counseling for women with eating disorders, have been targeted primarily to psychotherapists, nutritionists, and dieticians-a fact that often frustrates clinicians who seek to stay current with evidence-based care strategies. Improving the nutritional status o f women with eating disorders entails achieving the following goals (Dwyer, 198s): Volume 3, Issue 4
Diagnosing Eating Disorders The fo//uwing criteria have been adapted from the American Psychiatric Association3 Diagnostic & Statistical Manual of Mental Disorders (4th Ed.) Ir994):
RecognizingAnorexia Underweight and refusing to maintain a healthy body weight for age and height Intense fear of gaining weight, becoming overweight, even though underweight
Self-evaluation unduly influenced by body shape and weight Disturbance doesn’t occur exclusively during anorexic episodes Specify Type: -Purging Type: person regularly engages in self-induced vomiting or misuse of laxatives and other diuretics
Disturbance in perceptions of body weight and how body weight -Nonpurging Type: person uses inappropriate compensatory is experienced, or denial of the seriousness of low body weight behaviors, such as fasting or excessive exercise, but hasn’t regularly engaged in vomiting or laxative-type abuse In menstruating females, absence of at least three consecutive cycles Specify Type:
Recognizing Other Forms of Eating Disorders
-Restricting Type: the person hasn’t regularly engaged in binge-eating or purging behaviors
All of criteria for anorexia are met, but patient still has regular menses
-Binge/Purging Type: the person has regularly engaged in binging and/or purging
All anorexia criteria are met; however, despite significant weight loss, the patient’s weight is still within a normal range
Recognizing Bulimia Recurring espisodes of binging, which is characterized by eating in a discrete period of time an amount of food definitely larger than most people would eat, and a lack of control over the episode Recurring behaviors such as vomiting, laxative abuse, diuretics, enemas, fasting, 01 excessive exercise to prevent weight gain 0.
Binge eating and inappropriate compensatory behaviors at least twice a week for 3 months
Reestablished normal dietary patterns and food-related behaviors Stopping weight loss Weight gaining and healthy weight maintenance Avoidance of metabolic consequences of anorexia or bulimia Accurate nutritional information Nutritional counseling should be conducted in the context of a therapeutic relationship in which accurate nutrition information is presented sympathetically, but firmly. Nutrition counseling is an interactive process that’s most successful when the woman under care plays an active role in food planning and decisions. Being a good role model (“practicing what you preach”) can be an asset, but women are most likely to embrace the beliefs and values expressed by clinicians regarding healthy eating, dieting, and body weight issues regardless of whether the clinician discusses her or his own values (Garner et al., 1997).
Counseling Approaches Women need to know that problems they experience as a result of an eating disorder are solvable. They need to know their health care providers have confidence in the solutions being offered and that their difficulties are Augu&eptember
1999
All criteria for bulimia are met; however, binging and inappropriate compensatory behaviors occur less than twice weekly or for less than 3 months Regular use of inappropriate compensatory behavior by a patient after eating small amounts of food Repeatedly chewing and spitting out, but not swallowing, large amounts of food Binge-eating disorder includes recurrent episodes of hinging in the absence of regular use of inappropriate compensatory behaviors characteristic of bulimia
normal for someone with their eating habits and patterns. Successful nutritional counseling involves experimentation between clinician and patient, with planning and follow-up evaluation of each strategy devised. Most clinicians find that behavioral change is more likely if patients actively decide for themselves which action they will take based on the information provided. In most outpatient cases, allowing the woman to make those active decisions under the care and direction of a knowledgeable health care clinician is all that’s necessary for the patient to begin to make behavioral progress and gain weight (if necessary), regardless of the kinds of initial changes made (such as adding a bagel to breakfast or a cookie for an afternoon snack, for example). The clinician’s role is to gently, but persistently, encourage and persuade the woman to make behavioral changes in her best interest. Additionally, clinicians must make clear the initial steps that must be taken to achieve behavioral goals. These steps are usually obvious to health care practitioners but not so to the patient, such as clinical goals (weight gain or purging cessation). Women need to hear again and again that they must gain weight and/or stop purging to protect their health. These admonitions are seldom enough, however, to induce behavioral change. Women need help setting intermediate, achievable, and measurable AWWONN L i f o l i n o 8
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How Eating Disorders Affect the Body S h t W h ~ l d W
Amenorrhea Apathy Cognitive dysfunction Cold intolerance Depression Fatigue Food cravings Insatiable appetite Irritability
Vomiting & laxative abuse can lead to: Bloating Bloodshot eyes Cardiac arrest Dental damage Hair loss Heart failure Scarred hands Sore throat Sudden death
Labile mood Obsessive and ritualized eating
Swollen glands Weight fluctuations
Poor concentration Social withdrawal (Kaplan & Garfinkel. 1993; Mitchell et al., 1997)
goals. Expect women to leave each session with a goal they are quite sure they can accomplish, such as eating breakfast, adding 300 calories to lunch, eating an afternoon snack, or reducing exercise to 20 minutes, to name a few. Women should know that they will be asked about their success and difficulties in achieving the agreed upon goal at their next visit.
Acknowledging Difficulties At first, many women (especially anorexics) aren’t at all sure they want to change their behaviors. Imperative to motivating these women is acknowledging how difficult it is to make changes in food and exercise behaviors. For example, predicting that many women will experience gastrointestinal discomfort (especially fullness) as they experiment with normal eating helps prepare patients to endure these temporary discomforts. Early in nutrition treatment, the clinician should present biological facts about the effects of undereating on psychological and physiological function (McFarland, 1995). Familiarity with the classic study of starved young male conscientious objectors during World War I1 provides ample data on the effect of starvation on physical and mental functioning and food behavior. Keys’ subjects (a very readable version of the study can be found in Garner & Garfinkel, 1997) entered the study in good physical and psychological health. After 6 months of consuming one-half of their normal food intake, the subjects developed labile mood, cognitive dysfunction, poor concentration, social withdrawal, obsessive and ritualized eating behaviors, insatiable appetites, binge eating, food cravings, apathy, depression, irritability, fatigue, and cold intolerance. More recently, severe bone loss has been documented in as many as half of patients with anorexia-related amenorrhea. And estrogen replacement doesn’t prevent progressive osteopenia in anorexic patients. Recovery from anorexia, however, is associated with improved bone density (Klibanski et al., 1995).
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Presenting the Facts Patients find it reassuring to hear mini-lectures on the biological roles of the various nutrients, particularly the essential functions of protein and fat. Clinicians need to emphasize that benefits of better nutrition include protection from obsessions with food, moodiness, and binge eating. For anorexics, additional benefits include relief from cold intolerance, loss of hair, and decreased bone density. Continued education about the likely long-term consequences of loss of menses and dietary solutions is very compelling. Dietary treatment for amenorrhea includes eating patterns that lead to increased body weight. Patients should be reminded that many of their symptoms are the consequence of the eating disorder, and that most of these symptoms quickly resolve when the disordered eating stops. Most bulimic patients aren’t aware that self-induced vomiting and laxative abuse are ineffective in eliminating consumed calories. In one study (Kaye et al., 1993), 17 normal weight bulimic patients were evaluated; although it’s not known how many calories are retained after vomiting, there appeared to be a ceiling on the number of calories retained. Of those 17 persons, whether they had small or large binges (1,549 calories to 3,530 calories in this study), they retained similar amounts of calories (from 1,128 to 1,209) after vomiting. In a different study involving bulimics and laxatives, Bo-Linn et al. (1983) showed that laxative usage after a binge decreased calorie absorption by only 10 percent.
Counseling Strategies There’s a lot nurses can do to counsel women with eating disorders. Asking, “how can I help” emphasizes the collaborative nature of nutrition counseling and allows clinicians to describe how normalizing food intake will diminish bothersome symptoms. Early in the first visit, a detailed dietary history and full exploration of the woman’s eating behaviors, knowledge, and attitudes about food should be undertaken. Initially, nutritional counseling is most effectively provided on a weekly basis. Biweekly, and then monthly, sessions are indicated, as the woman is able to meet and maintain treatment goals with relative ease. Anorexic patients, who are prescribed an intensive weight gain program, may benefit from more frequent sessions. Dietary recalls-”tell me what you ate and drank yesterday”-are helpful at initial and subsequent visits if the patient is unable to commit to keeping food records. Having a set of measuring cups available so that you can discuss serving sizes is helpful, and women should also’be asked about dietary supplement use. Most women who struggle with eating disorders will need help with meal planning because they’ve lost confidence in their ability to eat normally. Meal planning establishes an organized approach to eating that meets nutrient needs and gives patients the confidence to move beyond destructive eating behaviors. For underweight women who aren’t gaining weight in treatment, the initial focus of meal planning is to support an increase in calorie intake. For normal weight patients, reinforcing a normal pattern (three meals and several snacks a day) of eating is primacy. Volume 3,Issue 4
Women and Eating Disorders According to the Harvard Eating Disorders Center, more than five million people in the U.S. suffer with anorexia nervosa, bulimia nervosa, and binge-eating disorders, the majority of whom are female. Here’s a look at the facts surrounding women and eating disorders: Three percent of adolescent and adult women and one percent of men have anorexia nervosa, bulimia nervosa, or binge-eating disorder
A young woman with anorexia is 12 times more likely to die than other women her age without anorexia 15 percent of young women have substantially disordered eating attitudes and behaviors In a study of girls ages 9 to 15, slightly more than half reported exercising to lose weight, slightly less than half reported eating less to lose weight, and approximately one of 20 reported using diet pills or laxatives to lose weight Recent findings indicate that girls who smoke to suppress their appetite are the highest group of new nicotine addicts Eating disorders not only cause emotional suffering, but can also lead to many serious medical complications and in some cases even death About 85 to 90 percent of anorexia and bulimia nervosa cases-and 60 percent of binge-eating disorders-occur in females Onset of these disorders tends to be during adolescence or in the twenties, but eating disorders can affect people in later decades as well as younger children The cause of eating disorders is unknown, although it is likely that a variety of factors-biological, psychological, and sociocultural-impact upon whether any individual may develop an eating disorder
It’s also important to help women see beyond the myths they’ve structured around certain foods. Contrary to common belief among women who suffer with eating disorders, no foods in and of themselves are fattening, forbidden, and addictive. Because women who have eating disorders are most likely to have low intakes of protein, fat, calcium, and calories, dietary interventions should be focused primarily in these areas. The typical women’s fear of fat implies that initial recommendations not be made in that food group; however, helping the patient achieve adequate fat intake over a period of time is crucial. This strategy (timing the introduction of foods that contain fat) avoids intensifying resistance in a woman who is ambivalent about treatment. Using the woman’s current food pattern is a good foundation for meal planning. A few improvements at each visit, aimed at normalizing food intake, are recommended. An effective strategy is to ask, given that her intake is low in a certain nutrient or food group, what she would like to add. The clinician provides a written outline of several “model” days that include the agreed upon dietary improvements. The woman then leaves the session with a copy of the meal plan pattern and the model days. If initial meal plans are inadequate to meet nutrient needs, suggest the temporary use of multiple AugustSeptember 1999
Health Complications with Eating Disorders Obesity is the chief physical complication of binge-eating disorder and obesity can lead to high blood pressure, diabetes, and heart disease Health complications with anorexia nervosa include cardiac abnormalities (slow heart rate, disturbances in the heart’s rhythm), dangerously low blood pressure, dangerously low body temperature, low leukocyte count, chronic constipation, osteoporosis (brittle, weak bones). Additional health complications for teenagers include slowed growth or development, short stature, loss of menstrual periods, infertility, hair loss, and nail destruction With bulimia nervosa, health complications can include electrolyte abnormalities that can lead to heart rhythm disturbances, dehydration, dangerously low blood pressure, menstrual cycle abnormalities, enlarged parotid glands, destruction of dental enamel and cavities, and bowel abnormalities Risk Factors Associated with Eating Disorders Female gender Perfectionistic, rigid, risk-avoidant personality traits Dieting History of obesity or family history of obesity History of an eating disorder and/or family history of an eating disorder Personal or family history of drug and/or alcohol abuse Personal or family history of depression Personal or family history of physical or sexual abuse, teasing, and harassment Elite performance (male and female) Source: Haward Eating Disorders Center (http://www.hedc.org)
vitamins and mineral supplements until the adequacy of dietary intake is ensured. Anorexic patients must be assured that their meal plan protects against undereating and overeating-usually the patient’s significant concern. Bulimics, as well, need to know that the meal plan will reduce their tendency to binge. These patients should be instructed to immediately return to the meal plan and eat the next scheduled meal or snack if they binge. Both anorexic and bulimic patients benefit from hearing that increases in protein and fat at meals contribute to satiety and a decreased likelihood of binging.
Planning vs. Calories Meal planning should be encouraged over calorie counting, which many women with eating disorders already do compulsively. No matter how many calories the patient says she’s eating, if she’s losing weight, she isn’t eating enough and the meal plan should be increased. Some patients, however, need the assurance they receive from counting calories. Counting fat grams is prevalent, too. These behaviors should be tolerated initially if the patient is making progress. Because women with eating disorders are likely to overestimate their intake of caloAWHONN Lifelines
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Disordered Eating vs. Eating Disorders Eating Disorders
Disordered Eating
Essential Distinction
A reaction to life situations; a habit
An illness
Psychological Symptoms
Infrequentthoughts and behaviors about body, foods, and eating that do not lead to health, social, school, and work problems
Frequent and persistent thoughts and behaviors about body, foods, and eating that do lead to heahh, social, school, and work problems
Associated Medical Problems
May lead to transient weight changes or nutritional problems; rarely causes major medical complications
Can result in major medical complications leading to the need for hospitalizationor even death
Treatment
Education and/or self-help group can assist with Requires specific professionalmedical and change; psychotherapy and nutritional counseling mental heatthtreatment can be helpful but are not usually essential Problem may go away without treatment
Problem does not go away without treatment
Source: Harvard Eating Disorders Center [http://w.hedc.org)
ries and fat, it may be necessary occasionally to calculate calories and/or fat grams from food records or dietary recalls. Useful references are the Exchange System (The American Diabetes Association and The American Dietetic Association, 1995) and an extensive food composition reference (Pennnington, 1998). Providing information on normal caloric intake and fat intake is often beneficial. Most adult females need at least 2,000 calories to maintain a healthy weight (adolescents may need mgre); they will need more if they have a high metabolism, are tall and/or very active, or are recovering from anorexia (National Research Council, 1989).Healthy fat intake is approximately 65 grams for someone eating 2,000 calories a day (Healthy People 2000, 1990). A patient recovering from anorexia will likely need 3,000 calories or more per day to restore healthy weight gain (Krahn et al., 1993). At intakes below 1,500 calories, it's very difficult to meet basic nutrient needs. Requiring women with eating disorders to keep detailed records of food intake between visits is often beneficial. Food records are helpful in solving mysteries, such as why a patient isn't gaining weight or which food patterns support binging. Food records can help a bulimic patient arrive at the conclusion that undereating, restrictive eating, and dieting make her prone to binge eating; to reduce this vulnerability she must follow the meal plan. In practice, many anorexics actually eat meals that seem normal, although they may exaggerate the size of their intake and overexercise. Anorexics who aren't gaining weight at the prescribed rate need to be told that whatever they're eating, it's not enough. Binging, which has been defined by professionals as eating an unusual amount of food in a discrete period of time while feeling out of control, must be interpreted as the normal consequence of restrictive eating. Either the patient is allowing too long of a period between meals and snacks, is avoiding certain types of foods (often foods high in calories and/or fat), or isn't meeting her caloric and/or nutrient needs. The patient, on the other 82
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hand, is afraid that liberalizing her eating will result in weight gain. The woman should be reminded that she wouldn't gain weight from normal eating but that weight gain results from significant and chronic overeating. Normalized eating also makes binging less likely. Purging behaviors often also stop once the woman ceases to overeat. Patients, however, should be warned about a temporary change in weight because of "rebound hydration," which occurs when chronic purging is interrupted. Bulimic patients need to hear repeatedly that purging isn't effective in decreasing the absorption of calories and that bulimics typically maintain normal, not thin, body weights (APA, 1994). Patients with eating disorders, especially very lowweight patients, are likely to exercise excessively. Excessive exercise interferes with physical health, as well as interpersonal, social, educational, and work activities.
Determing Body Mass Index According to the National Institute of Health's (1998) Clinical Guidelines on the lndentification and Treatment of Overweight and Obesity in Adults (www.nih.gov1,body mass index (BMI)is "a direct calculation based on height and weight, regardless of gender." Calculate BMI by dividing a person's weight (pounds)by height in inches squared, then take the result and multiply by 704.5.
BMI Guidelines:
< 17.5 Diagnoses of anorexia
20 25
- 24.9 - 29.9
Healthy weights Increased health risk
=- 38 High health risk Volume 3,Issue 4
Exercise regimes that exceed 2 hours a day should be considered excessive. Informing patients of the current general recommendations for exercise, such as 20 to 60 minutes a day, 3 to 5 days a week, is useful (American College of Sports Medicine, 1998). Very underweight anorexics, who aren’t gaining weight as expected, should limit physical activity. Those patients who are unable to comply with exercise limits may need to be hospitalized. Permission to exercise can be used effectively as a reward for maintaining or gaining weight.
Weight Goals Recovery from an eating disorder is dependent on maintenance of a health body weight status. Normalized eating and exercise patterns should lead to maintenance of a weight that’s within normal ranges, is associated with regular menstrual function, and reflects the genetic predisposition of the individual. Minimum healthy weights are best estimated by using Body Mass Index (“See Determining Body Mass Index”) or premorbid body weights in adult patients (APA, 1994). TannerWhitehouse standards are recommended for children (Lask & Bryant-Waugh, 1997). For successful treatment, anorexic patients need interim weight goals. Too much emphasis on long-term weight goals may alarm the patient. However, the patient must understand that if her weight drops below a certain minimum (some clinicians use a BMI of 16 for adult patients), she’s not a candidate for outpatient treatment and would likely be hospitalized. Other indications for hospitalization include (Anderson et al., 1997): Severe or rapid weight loss Treatment-resisting binging Vomiting Laxative abuse For patients who are minors, setting minimum weights (consider BMIs of 19 as a minimum) for athletic participation, scheduling trips, or encouraging school attendance away from home is persuasive and medically justifiable. A discussion of normal weight ranges benefits bulimic patients in correcting overly critical selfassessment of body weight. The typical bulimic patient will fear that cessation of dieting will result in weight gain. Remind the patient that she most likely won’t gain weight as a result of her treatment. Continued weight loss in underweight patients should be interpreted as an indication that current treatment should be increased. Gains of 1 to 2 pounds per week are achievable in outpatient settings. Weight gain is likely to happen nonlinearly-gain 2 pounds, lose 1, gain %, and so forth. Occasionally, the dehydrated patient will experience gains of larger amounts of weight early in treatment. The patient must be reassured that this is normal fluid gain, and that gains in the future will be smaller. If the patient is also receiving therapy from other members of a treatment team, decide which professional is going to be responsible for weight monitoring. That professional is then responsible for communicating the patient’s weights to other members of the team in a timely manner. Because weight gain is a key indicator of progress in anorexia, it’s important that the patient be weighed at least weekly on an accurate, regularly caliAugusVSeptember 7999
brated scale, preferably the same one at about the same time of day. Ideally, patients are weighed in a private room, wearing a gown. Weekly weigh-ins also benefit bulimic patients in allaying their fears about weight gain. Normal weight bulimic patients can be weighed in street clothes without shoes. Many patients benefit initially from “blinded” weigh-ins (standing backwards on the scale). Blinded weigh-ins can assuage the patient’s worries and obsessions with her body weight. In the case of blind weigh-ins, clinicians should indicate to an anorexic patient whether she’s making progress, that is, gaining weight at the expected rate. For bulimic patients and others who are aiming to maintain their weight, weights within a 3 to 5 pound range are called stable. Clinicians should be cautious about making judgments about trends in body weight until at least four consecutive weekly weigh-ins. It’s usually best that patients with eating disorders commit to not weighing themselves, or to weigh themselves no more than once weekly.
Recovery Nutritional rehabilitation is the first step in recovery from an eating disorder, although many patients will need concurrent psychotherapy, and possibly a course of antidepressant therapy to fully recover. Emaciated patients have difficulty profiting from psychotherapy until nutrition rehabilitation is well on its way. Patients should be encouraged to seek psychotherapy particularly if they aren’t making progress within several months of initiating nutrition counseling. Successful nutrition counseling leads to resolution of eating disorder symptoms and the replacement of eating disorder behaviors with easily maintained normal, healthy eating and exercise behaviors. Women with eating disorders are vulnerable for relapse for a number of years, especially during times of stress, such as pregnancy. Women with eating disorders should be encouraged to be alert to increased anxiety about weight and food issues and to seek professional support. Recovered anorexic patients should be encouraged to have occasional weight checks.
Meal Planning Guidelines Daily Pattern
three meals two to three snacks Normal portion sizes 3 to 4 hours between eating times Content
Protein-minimum two (3 02.) servings Calcium-three to four servings Fat-three to four servings Calories-at least 2,000 for females; 2,500 for males Amounts
Rely on hunger and fullness
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