Nutrition Counseling in the Treatment of Eating Disorders

Marcia Herrin, Maria Larkin

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135201821
• Edition: 2
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Marcia Herrin and Maria Larkin have collaborated on the second edition of Nutrition Counseling in the Treatment of Eating Disorders, infusing research-based approaches and their own clinically-refined tools for managing food and weight-related issues. New to this edition is a section on nutrition counseling interventions derived from cognitive behavioral therapy-enhanced, dialectical behavioral therapy, family-based treatment, and motivational interviewing techniques. Readers will appreciate the state of the art nutrition and weight assessment guidelines, the practical clinical techniques for managing bingeing, purging, excessive exercise, and weight restoration as well as the unique food planning approach developed by the authors. As a comprehensive overview of food and weight-related treatments, this book is an indispensible resource for nutrition counselors, psychotherapists, psychiatrists, physicians, and primary care providers.

Part I Nutrition Counseling

1 Clinical Features of Eating Disorders

DOI: 10.4324/9780203870600-2

Introduction

Eating disorders (EDs) are biologically-based mental disorders classified and defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 2000). This chapter relies on the DSM-IV and the soon to be published next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). We conclude this chapter with a discussion of the most significant of the proposed DSM-5 criteria for EDs.

The diagnostic criteria for anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), and eating disorder not otherwise specified (EDNOS) are based on psychological, behavioral, and physiological characteristics with the same core features: overvaluation of shape and weight and serious disturbances in eating behaviors. The severity of EDs increases over time, and individuals with EDs have significantly elevated mortality rates, especially those with AN due to associated medical complications or suicide (Arcelus, Mitchell, Wales, & Nielsen, 2011). Like other psychiatric illnesses, EDs have a strong heritability factor, as emerging studies identify chromosomal regions and genes for AN. Twin studies confirm that approximately 50–70% of risk factors for ED are heritable. A family history of an ED, obesity, or anxiety, and depression increases risk. Individuals with a diagnosis of anxiety, depression, post-traumatic stress disorder (PTSD), obsessive–compulsive disorder (OCD), and attention deficit/hyperactivity disorder (ADHD) also have an increased risk (Mehler & Andersen, 2010). (See Chapter 3: The Process of Counseling for more information on these disorders, pp. 59–78.)

The highest onset of AN and BN is during adolescence in westernized societies which value thinness. BED occurs into adulthood, with a growing trend among overweight and obese middle-aged women (Ozier & Henry, 2011; Walsh, 2011). A recent study by Marques et al. (2011) compared the prevalence of EDs across all major ethnic minority groups in the United States. The study confirmed that the lifetime prevalence of AN and BED is similar for all major ethnicities (American African, Asian, Hispanic, and non-Hispanic Whites). BN, however, has higher prevalence rates among Latinos and African Americans. A number of studies indicate that bisexual and gay men are at a higher risk for EDs than heterosexual men. One population-based study (Feldman & Meyer, 2007) found that 15% of gay or bisexual men had at some time suffered from disordered eating, AN, BN or BED compared to less than 5% of heterosexual men. These researchers reported no differences in rates of ED between lesbian, bisexual women, and heterosexual women. Nevertheless, studies of the prevalence of EDs show them to be relatively uncommon, as illustrated in Table 1.1, in part because they are frequently underreported and undertreated.

Table 1.1 Lifetime Prevalence of Eating Disorders in the United States

	Men	Women
AN	.3%	.9%
BN	.5%	1.5%
BED	2%	3.5%
Note: Adapted from “Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Eating Disorders,” by Amy D. Ozier and Beverly W. Henry, 2011, Journal of the American Dietetic Association, 111, p. 1237. Copyright 2011 by American Dietetic Association. Adapted with permission.

In both AN and BN, alterations in brain structure and function as well endocrine abnormalities contribute to many of the clinical features of EDs we describe in this chapter. These clinical features are not only disabling but come with significant medical and social costs. For example, women with AN have higher rates of pregnancy complications than women without an ED, and have higher healthcare utilization than those with other forms of mental illness (Klump, Bulik, Kaye, Treasure, & Tyson, 2009). It is important to recognize the unique eating-disordered characteristics of special populations such as pregnant women. Table 1.2 describes these populations and clinical features. In addition two tables are included to define the classic clinical features of AN, BN, and BED. We further elaborate on the major complications of EDs we find useful for the assessment and treatment (including making medical referrals) as well as for the purposes of psycho-education. We end this chapter by introducing the proposed DSM-5 criteria for EDs and comparing it to the DSM-IV.

Table 1.2 Characteristics of Special Populations at Risk for Eating Disorders

Risk factor	Medical or lay term*	Characteristics
Type I diabetes mellitus (DM)	Diabulemia* Diabetic EDO patients: (Mathieu, 2008)	Intentionally omit insulin in an attempt to lose weight or compensate for a binge. Higher rates of premature diabetic complications and hemoglobin A1c levels. Hyperglycemia results from omission of insulin or binge eating. Most common in BN.
Type II DM		Most common in EDNOS and BED. ED often is undetected because symptoms of DM and ED show similar features.
Athletics	Female athlete triad (FAT)	FAT: Low energy availability, menstrual irregularities, and low bone density.
	Anorexia athletica* (AA)	AA: Female athletes who exercise beyond what is necessary for good health, with extreme focus on weight and diet. Exercise becomes a burden, does not satisfy performance goals, and takes up too much time.
Pregnancy	Pregorexia*	Fear of normal expected weight gain during pregnancy results in reducing calories and increasing exercise.
Food allergies or intolerances	Gluten-free or lactose-free diets	Food avoidance, food fears.
Middle age and menopause		Normative age-related changes and biological shifts may increase body dissatisfaction and disordered eating. Evidence is unclear whether body mass index (BMI), age, or menopause are responsible (Slevec & Tiggeman, 2011).
College students	Drunkorexia*, beer bulimia*	Calorie restriction prior to consumption of alcohol to avoid weight gain. Purging after drinking to get rid of calories.
Vegetarian and vegans		High prevalence of veganism and vegetarianism in disordered-eating and ED populations (Sullivan & Damani, 2000).
Interest in health and nutrition	Orthorexia*	Obsession with healthy eating versus the desire to be thin. Anxiety with eating that impacts quality of life.
Obesity		BED leads to obesity; BED is associated with dieting in the obese; 30% BED in obese patients (Freitas, Lopes, Appolinario, & Coutinho, 2006); 30–60% of BED patients are obese (de Zwann, 2010; Dingemans & van Furth, 2012).
Hypoglycemia		Hypoglycemia can indicate undereating or overexercise.
Ematophobia		Avoids certain foods due to fear of choking or vomiting
Picky eating	Food avoidance emotional disorder (FAED) (Bravender et al., 2007).	Avoidance of food to a marked degree in the absence of the characteristic psychopathology of eating disorders.

Features of Anorexia Nervosa

In western societies, AN afflicts from one-third to 3% of women and is the third most prevalent chronic disease afflicting adolescent girls. Males and older women are affected, but at lower rates. There are two subtypes of AN: restricting and binge/purge. The binge/purge subtype is distinguished from BN by low weight.

Many individuals with the restricting subtype develop purging or binge-eating symptoms, with more than 50% developing bulimic behaviors (Mehler & Andersen, 2010).

A markedly low weight is a unique feature of AN and sets the stage for the clinical complications we discuss below. Individuals with AN characteristically restrict food intake due to an intense fear of weight gain, resulting in an extremely low body weight and symptoms of starvation. They may count calories, weigh themselves obsessively, have body distortion, and see their bodies as bigger than they actually are. Individuals with AN typically tend to be sensitive, perfectionist, and self-critical. We have a number of AN patients who are writers and poets; those who are students do well academically, but feel socially isolated.

Factors that increase an individual’s risk for developing AN consist of teasing or criticism about body size and shape, especially from peers, parents, significant others, or coaches. Other risk factors include: unintentional weight loss, military or sport weight standards, obesity at menarche, trauma or abuse, and a desire to improve athletic performance. The “female athlete triad” is characterized by disordered eating, menstrual irregularity, and loss of bone density, and is seen in competitive female athletes in sports such as running, ballet dancing, cycling and swimming (Ozier & Henry, 2011). (See Chapter 12: Managing Exercise, pp. 260–276.)

Clinical Complications of Anorexia Nervosa

Cardiac Function

Underweight AN patients are at risk for cardiovascular and neurological repercussions. The most serious of these are the electrocardiographic abnormalities that can signal the risk of sudden death. AN patients may experience chest pain indicative of mitral value prolapse as the heart reduces in size. Mitral value prolapse occurs in 30–50% of patients with severe AN (Mehler & Andersen, 2010, pp. 131–132). This condition is not usually medically dangerous, but as a precaution, patients should be medically assessed for signs of heart failure.

When caloric intake is extremely inadequate, the body adapts by losing cardiac muscle in an attempt to preserve other muscle. As a result, blood pressure drops and the likelihood of cardiac failure increases. Patients with heart rates below 40 beats/minute should be under close medical supervision. The following symptoms indicate cardiac impairment: weakness, dizziness, cognitive impairment, overall fatigue, and light-headedness on standing or changing positions (e.g., moving from lying down to sitting; Mehler & Andersen, 2010, pp. 131–132). If our patients complain of these symptoms, we express concern and inform the patient’s medical practitioner immediately. If the patient also has low blood pressure and feels light-headed, he or she might need hospitalization. With refeeding and weight restoration, cardiac structure and function as well as exercise capacity return to normal without long-term consequences (Mont et al., 2003; Mehler & Andersen, 2010, p. 133).

Hormonal Changes

Many of the physical signs and symptoms in AN are the result of endocrine dysfunction (i.e., hypothalamic–pituitary dysregulation, hypothalamic amenorrhea, and hypothalamic–pituitary adrenal axis dysregulation). For example, sensitivity to cold, hypotension, and low heart rate indicate hypothyroidism. These symptoms are ameliorated with weight restoration and without the need for thyroid medications (Mehler & Andersen, 2010). Diminished libido may be the result of reduced androgen levels and, in men, low testosterone.

In AN, amenorrhea, also called hypothalamic or functional amenorrhea, occurs in some but not all patients, as there is a highly variable “individual susceptibility of the gonadal axis to undernutrition” (Miller, 2011, p. 2939). Further, amenorrhea may be masked by the use of prescription medications used for birth control. Hypothalamic amenorrhea reflects a state of estrogen deficiency, which can occur with dieting, with excess exercise, and with or without significant weight loss (Mehler, Cleary, & Gaudiani, 2011). Although no longer recommended as a diagnostic test, estrogen deficiency is sometimes assessed by a progestin challenge test. Withdrawal bleeding within 10 days of the challenge indicates that amenorrhea is caused by an estrogen deficiency. A lack of withdrawal bleeding, on the other hand, demonstrates a more profound estrogen deficiency or possibly an unrelated medical problem. It is now well accepted that the prescription of estrogen–progesterone medications do not result in clinical improvements i...