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GUIDEBOOK for NUTRITION TREATMENT of EATING DISORDERS Authored by ACADEMY FOR EATING DISORDERS NUTRITION WORKING GROUP GUIDEBOOK FOR NUTRITION TREATMENT OF EATING DISORDERS ii GUIDEBOOK for NUTRITION TREATMENT of EATING DISORDERS AUTHORED BY ACADEMY FOR EATING DISORDERS NUTRITION WORKING GROUP Jillian G. (Croll) Lampert, PhD, RDN, LDN, MPH, FAED; Chief Strategy Officer, The Emily Program, St. Paul, MN Therese S. Waterhous, PhD, CEDRD-S, FAED; Owner, Willamette Nutrition Source, Corvallis, OR Leah L. Graves, RDN, LDN, CEDRD-S, FAED; Vice President of Nutrition and Culinary Services, Veritas Collaborative, Durham, NC Julia Cassidy, MS, RDN, CEDRDS; Director of Nutrition and Wellness for Adolescent Programs, ED RTC Division Operations Team, Center for Discovery, Long Beach, CA Marcia Herrin, EdD, MPH, RDN, LD, FAED; Clinical Assistant Professor of Pediatrics, Dartmouth Geisel School of Medicine and Owner, Herrin Nutrition Services, Lebanon, NH GUIDEBOOK FOR NUTRITION TREATMENT OF EATING DISORDERS iii TABLE OF CONTENTS 1. Introduction to this Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2. Introduction to Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 3. Working with Individuals and Support Systems . . . . . . . . . . . . . . . . . . 6 4. Nutritional Assessment for Eating Disorders . . . . . . . . . . . . . . . . . . . . . 7 5. Weight Stigma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 6. Body Image Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 7. Laboratory Values Related to Nutrition Status . . . . . . . . . . . . . . . . . . 18 8. Refeeding Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 9. Medications with Nutrition Implications . . . . . . . . . . . . . . . . . . . . . . . 26 10. Nutrition Counseling for Each Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 31 11. Managing Eating Disordered-Related Behaviors . . . . . . . . . . . . . . . . 42 12. Food Plans: Prescriptive Eating to Mindful and Intuitive Eating . . . 46 13. Treatment Approaches for Excessive Exercise/Activity . . . . . . . . . . . . 48 14. Treatment Approach for Vegetarianism and Veganism . . . . . . . . . . . 50 15. Levels of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 16. Nutrition and Mental Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 17. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 GUIDEBOOK FOR NUTRITION TREATMENT OF EATING DISORDERS 1 1. INTRODUCTION TO THIS GUIDE This publication, created by the Academy for Eating Disorders Nutrition Working Group, contains basic information regarding elements of nutrition care for individuals with eating disorders (EDs). The guideline is intended as a resource to clinicians who are providing nutritional interventions as part of a multi-disciplinary team or are otherwise involved in the care of these individuals. It is not intended to be a comprehensive nutrition therapy guide. The information provided is based on available research and current best practices. The basic goal of nutrition therapy in the treatment of all EDs diagnoses is achievement of normal eating behaviors meeting nutritional needs in a regular, balanced, sustainable way without fearful, negative, and distorted thoughts about food, body, and self. 2. INTRODUCTION TO EATING DISORDERS For the purpose of this document, we will focus on the most common diagnosed EDs including: 1. Anorexia Nervosa (AN): Restriction of energy intake relative to an individual’s requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and health status. AN is usually accompanied by disturbance of body image, an intense fear of gaining weight, lack of recognition of the seriousness of the illness and/or behaviors that interfere with weight gain. Nutrition issues in AN: The diets of individuals with AN are typically low in calories, limited in variety, and marked by avoidance or fears about foods high in fat, sugar, and/or carbohydrates. Initially there may be no obvious indicators of malnutrition because of the body’s ability to maintain biological homeostasis even when food intake is inadequate. Regardless of current body weight, eventually starvation leads to a host of complications including negative energy balance, weight loss, inadequate macro- and micro- nutrient intake, organ system failure, and death. Individuals with extreme and extended food restriction should be evaluated for the potentially fatal refeeding syndrome (see Refeeding Syndrome Section). In children and adolescents, interruption of expected growth and development is common. As AN progresses, signs and symptoms of starvation become more evident. ICD-10-CM Code F50.0 F50.01 Restricting Type F50.02 Binge-Eating/Purging Type 2. Bulimia Nervosa (BN): Binge eating, defined as eating a large amount of food in a relatively short period of time with a concomitant sense of loss of control in association with purging/ compensatory behaviors (e.g. self-induced vomiting, laxative or diuretic abuse, insulin misuse, excessive exercise, diet pills) once a week or more for at least three months. Individuals experience an intense fear of weight gain with self-evaluation unduly influenced by body shape GUIDEBOOK FOR NUTRITION TREATMENT OF EATING DISORDERS 2 food intake is often disorganized; meals may be low in calories, fat, and carbohydrates. Binge eating episodes typically include foods that are usually avoided and are high in calories, fat, and carbohydrates. 4. Other Specified Feeding and Eating Disorder (OSFED): OSFED is the diagnosis for EDs that do not meet full criteria for one of the above diagnoses. Individuals with OSFED engage in specific disordered eating behaviors such as restricting intake, purging and/or binge eating. Examples are: Atypical Anorexia Nervosa (significant weight loss and food restriction though BMI for age and gender is in normal range or higher), Bulimia Nervosa (low frequency or limited duration), Binge Eating Disorder (low frequency or limited duration), Purging Disorder (recurrent purging in the absence of binge eating), and Night Eating Syndrome (recurrent episodes of night eating, such as eating after awakening from sleep or by excessive food consumption after the evening meal). ICD-10-CM Code F50.89 5. Unspecified Feeding or Eating Disorder (UFED): In UFED, ED behaviors cause clinically significant distress or impairment, but do not meet full criteria for an ED. This diagnosis is used when there is insufficient information to make a more specific diagnosis (e.g., in emergency rooms). ICD-10-CM Code F50.9 and weight. Lack of recognition of the seriousness of the illness may also be present. Nutrition issues in BN: In early stages of BN, there may be no signs or symptoms of nutritional compromise. In a prolonged course, purging behaviors lead to multiple medical issues (e.g., electrolyte abnormalities, dental erosion, esophagitis, gastritis, ulcers, and arrhythmias). Lack of food variety and food misperceptions are common. Food intake is often disorganized; meals may be low in calories, fat, and carbohydrates. Binge eating episodes usually include foods that are typically avoided and are high in calories, fat, and carbohydrates. ICD-10-CM Code F50.2 3. Binge Eating Disorder (BED): Binge eating, in the absence of compensatory behavior, once a week for at least three months. Binge eating episodes are associated with a sense of loss of control, eating rapidly, eating in the absence of hunger, and/or eating until extremely full. Generally, these episodes are associated with depression, shame, or guilt. ICD-10-CM Code F50.81 Nutrition issues in BED: In the early stages of BED, there may be no obvious nutrition consequences. In a prolonged course, weight gain can occur which may affect health in some individuals. Food misperceptions are common. As in BN, GUIDEBOOK FOR NUTRITION TREATMENT OF EATING DISORDERS 3 IMPORTANT FACTS ABOUT EATING DISORDERS ◗ All EDs are serious disorders with serious disturbances in eating behaviors with potentially life-threatening physical and psychological complications. ◗ All EDs can be associated with serious medical complications affecting every organ system of the body. ◗ All EDs are associated with higher rates of suicide. ◗ The medical consequences of EDs can go unrecognized, even by an experienced clinician. ◗ EDs do not discriminate. They can affect individuals of all ages, genders, ethnicities, body shapes and weights, sexual orientations, and socioeconomic backgrounds. ◗ EDs have a strong heritability factor, though genes alone do not predict who will develop EDs. ◗ Weight is not the only clinical marker of an ED. People who are at low, average, or high weights can have an ED, and individuals at any weight may be malnourished and/or engaging in ED behaviors. ◗ Individuals with an ED may not recognize the seriousness of their illness, and/or may be ambivalent about changing their eating or other behaviors. ◗ All instances of dramatic changes in eating and/ or precipitous weight loss or gain in otherwise healthy individuals should be investigated for the possibility of an ED, as rapid weight fluctuations can be an indicator of a possible ED. ◗ In children and adolescents, failure to gain expected weight or height, and/or delayed or 6. Avoidant/Restrictive Food Intake Disorder (ARFID): ARFID is characterized by one or more of the following: Significant weight loss, nutritional deficiency, dependence on nutritional supplements or marked interference with psychosocial functioning associated with caloric and/or nutrient restriction, but without weight or shape concerns. Individuals with ARFID may limit food intake and variety for many reasons, most commonly due to 1) an apparent lack of interest in eating or food; 2) avoidance based on the sensory characteristics of food (e.g., appearance, smell, and/or texture), and 3) concern about aversive consequences of eating with a history of abdominal discomfort, and/or fear of vomiting or choking. These three classic ARFID presentations do not appear to be mutually exclusive, but instead may co-occur in the same individual. ICD-10-CM Code F50.82 Nutrition concerns in OSFED, UFED and ARFID: Inadequate nutrient intake, interruption of expected growth in the pediatric population, food misperceptions, and fear of eating. Consult for diagnostic code handout, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5®) (American Psychiatric Association, 2013), and ICD-10 for full diagnostic descriptions. GUIDEBOOK FOR NUTRITION TREATMENT OF EATING DISORDERS 4 fatigue, illness, or injury ◗ Marked increase in exercise patterns PHYSICAL SIGNS ◗ Weight and Growth • Marked weight loss, gain, fluctuations UNEXPLAINED CHANGE IN GROWTH CURVES OR BMI PERCENTILES IN A CHILD OR ADOLESCENT ◗ Oral and Dental • Oral trauma/lacerations • Perimyolysis (dental erosion on posterior tooth surfaces) • Dental caries (cavities) • Parotid gland enlargement ◗ Cardiorespiratory • Weakness • Fatigue or lethargy • Hot flashes, sweating episodes • Hypothermia, feeling colder than others • Presyncope (dizziness) • Syncope (fainting) • Chest pain • Heart palpitations • Orthostatic hypotension (a decrease in blood pressure when going from sitting or lying to standing • Bradycardia (heart rates of 50 bpm or lower) • Tachycardia (heart rates of 80 bpm or greater) • Dyspnea (shortness of breath) • Edema (swelling) interrupted pubertal development may indicate an ED. ◗ Individuals and their families are not to be blamed for causing an ED. Families and other supporters can be an individual’s and providers’ best allies in treatment. ◗ Full recovery from an ED is possible. Early detection and intervention are important. PRESENTING SIGNS AND SYMPTOMS Individuals with EDs may present with a variety of indicators or without obvious physical signs or symptoms. The following behavioral, physical, and neuropsychiatric signs are commonly found in EDs. These signs stem from the consequences of restricted food or fluid intake, nutritional deficiencies, binge-eating, and inappropriate compensatory behaviors, such as purging and excessive exercise. BEHAVIORAL SIGNS ◗ Rigid dieting ◗ Refusing to eat certain foods ◗ Avoiding mealtimes or situations involving food ◗ Dependence on oral nutritional supplements ◗ Food rituals ◗ Hiding food ◗ Fasting ◗ Episodes of eating large quantities of food ◗ Self-induced vomiting, misuse of laxatives, diuretics, or other medications, spitting ◗ Excessive, rigid exercise despite weather, GUIDEBOOK FOR NUTRITION TREATMENT OF EATING DISORDERS 5 • Memory loss • Poor concentration • Seizures • Insomnia • Self-harm • Suicidal thoughts, plans or attempts EARLY RECOGNITION Early recognition is key to successful treatment. Consider evaluating an individual for an ED who presents with any of the following: ◗ Precipitous weight changes (significant weight lost or gained) or fluctuations ◗ Sudden changes in eating behaviors (e.g., recent vegetarianism/veganism, gluten-free, lactose free, elimination of certain foods or food groups, eating only “healthy” foods, uncontrolled binge eating, lack of appetite) ◗ Sudden changes in exercise patterns, excessive exercise, or involvement in extreme physical training ◗ Body image disturbances ◗ Desire to lose weight despite low or normative weight ◗ Extreme dieting behavior regardless of weight status ◗ Abdominal complaints in the context of weight loss behaviors ◗ Electrolyte abnormalities without an identified medical cause (especially hypokalemia, hypochloremia, or elevated CO2) ◗ Hypoglycemia ◗ Gastrointestinal • Epigastric discomfort • Abdominal bloating • Lack of appetite/hunger • Early satiety • Gastroesophageal reflux (heartburn) • Hematemesis (blood in vomit) • Hemorrhoids and rectal prolapse • Constipation ◗ Endocrine • Amenorrhea or oligomenorrhea (absent or irregular menses) • Low testosterone • Loss of libido • Infertility • Stress fractures due to low bone mineral density/osteoporosis ◗ Dermatologic • Lanugo hair • Hair loss • Carotenoderma (yellowish discoloration of skin) • Russell’s sign (calluses or scars on the back of the hand) • Poor wound healing • Dry brittle hair and nails ◗ Neuropsychiatric Signs • Body dysmorphia • Depression/Anxiety • Obsessive/compulsive thoughts and/or behaviors GUIDEBOOK FOR NUTRITION TREATMENT OF EATING DISORDERS 6 will be referred to as “supporters.” Dietitians educate supporters by explaining the nature of EDs, discussing etiology, describing levels of care, explaining health and nutritional concerns, and describing how to support a person with an ED,s without inadvertently accommodating the ED. Treatment approaches focused on teaching support people about EDs and how to help, such as the well-established Family Based Treatment (FBT) (Lock and Le Grange, 2019), and more recently Temperament Based Treatment with Supports (Hill et al., 2016; Wierenga et al., 2018), and Emotion-Focused Family Therapy (Strahan et al., 2017), provide evidence that working with the individual’s support system improves outcomes. REFERENCES Hill, L., Peck, S.K., Wierenga, C.E. et al. Applying neurobiology to the treatment of adults with anorexia nervosa. J Eat Disord 4, 31 (2016) doi:10.1186/s40337- 016-0119-x. Lock J, Le Grange D. Family-based treatment: Where are we and where should we be going to improve recovery in child and adolescent eating disorders. International Journal of Eating Disorders. 2019 Apr;52(4):481-7. Strahan E, Stillar A, Files N, Nash P, Scarborough J, Connors L, Gusella J, Henderson K, Mayman S, Marchand P, Orr E, Dolhanty J, & Lafrance A (2017) Increasing parental self-efficacy with emotion-focused family therapy for EDs: a process model, Person-Centered & Experiential Psychotherapies, 16:3, 256- 269, DOI: 10.1080/14779757.2017.1330703 Wierenga CE, Hill L, Peck Knatz S, McCray J, Greathouse L, Peterson D, Scott A, Eisler I, Kaye W. The Acceptability, Feasibility, and Possible Benefits of a Neurobiologically -Informed 5-Day Multifamily Trial for Adults with Anorexia Nervosa. Int J Eat Disord. 2018 Aug:51(8): 863-860. doi:10. 1002/eat.22876. ◗ Bradycardia ◗ Amenorrhea or menstrual irregularities ◗ Unexplained infertility ◗ Type 1 diabetes mellitus with poor glucose control or recurrent diabetic ketoacidosis (DKA) with or without weight loss ◗ Use of compensatory behaviors (i.e., such as self-induced vomiting, dieting, fasting or excessive exercise) to influence weight after eating or binge eating ◗ Inappropriate use of appetite suppressants, caffeine, diuretics, laxatives, enemas, ipecac, artificial sweeteners, sugar-free gum, prescription medications that affect weight (insulin, thyroid medications, psychostimulants, or street drugs) or nutritional supplements marketed for weight loss 3. WORKING WITH INDIVIDUALS AND SUPPORT SYSTEMS Work with individuals’ support systems can take many forms in ED treatment. Support systems can include family, friends, and other individuals in the individual’s life. “Family” refers broadly to biological parents, or other family members, who provide care for a child, adolescent, or adult with an ED. Family might also refer to one’s spouse or other supportive individuals in a person’s life. One crucial aspect of treatment is education of family members and others who are in a supportive role, and determination of how they can be most effective. For the purposes of this guide, supportive individuals in an individual’s life GUIDEBOOK FOR NUTRITION TREATMENT OF EATING DISORDERS 7 dietitians obtain details about quantity, type, and amount of food consumed. Access to food is an essential component of nutritional assessment. Assess for the presence of reliable food storage, food preparation facilities, financial resources, transportation, and stability of living situations; all can have an impact on nutritional status. If resource constraints are identified, connect the individual to available social and public assistance programs. Assess the individual’s experience of shopping, food handling, eating in public, and eating with others, as these might point to other areas for support and intervention. Associations between food insecurity and ED behaviors are increasingly necessary to identify (Becker, 2017; Becker, 2019). 4. NUTRITIONAL ASSESSMENT FOR EATING DISORDERS Nutrition assessment involves evaluating several domains. Nutritional status is assessed utilizing data from medical providers and from nutrition- focused physical examinations (Malone & Hamilton, 2013). Other domains such as dietary intake, activity level, food environment, and ED behaviors are assessed via individual interviews. Nutrition assessments clarify treatment goals by evaluating current physical condition compared to pre-morbid physical growth, development, and status; reviewing laboratory data; exploring limitations to adequate ingestion and absorption of nourishment; and assessing current and historic routes of nutrition procurement and physical activity level. A person can be poorly nourished despite consuming an ample diet if they have certain medical conditions, such as diabetes, malabsorption, or an endocrine disorder. Nutrition assessment can help determine whether certain physical conditions, such as bradycardia, are due to undernutrition or athleticism. Assessment of dietary intake is a crucial part of the nutrition assessment; obtain clear and relevant data from an individual or another person speaking for an individual via interview. Dietitians need to be knowledgeable about the food supply, components of food, food preparation methods, and typical measurements used to quantify food intake. During assessment of dietary intake, GUIDEBOOK FOR NUTRITION TREATMENT OF EATING DISORDERS 8 Nutritional Assessment for Eating Disorders ASSESSMENT COMPONENT TOOLS AVAILABLE Environmental limitations ◗Food security ◗Ability to purchase food ◗Ability to prepare food ◗Home environment ◗ Ways ED interferes purchase or preparation of food Physical evaluation ◗Vital signs, temperature ◗ Nutrition focused physical exam parameters ◗Weight history ◗Weight suppression ◗Historic growth, development ◗ Genetic predisposition for height Physical activity assessment ◗Historic physical activity level ◗Current level of physical activity ◗Role of exercise/activity ED History of reliance of alternate routes of nutrition support USDA Food Security Assessment Nutrition Focused Physical Exams pediatric-nutrition-focused-physical-exam-pocket-guide nutrition-focused-physical-exam-pocket-guide-second- edition-ebook CDC Growth Charts Predicting expected adult height using mid-parental height Male child = (mother’s height in cm + 13 cm) + father’s height in cm/2 Female child = mother’s height in cm + (father’s height in cm -13 cm)/2 RED-S CATTM (Mountjoy et al., 2015) Female Athlete Screening Tool (FAST) (McNulty et al., 2001) Exercise Dependence Scale-Revised (Symons Downs et al., 2004) Ask about use of meal replacement drinks and bars, tube feedings. Nutritional Assessment for Eating Disorders ASSESSMENT COMPONENT TOOLS AVAILABLE GUIDEBOOK FOR NUTRITION TREATMENT OF EATING DISORDERS 9 Assessment of dietary intake ◗Usual intake ◗ Unusual eating behaviors, food rituals or concoctions ◗Assessed nutritional needs ◗Comparison of actual vs assessed needs Assessment of Eating related attitudes ◗Attitudes about food ◗Food rules ◗ Nutrition beliefs including overreliance on nutrition information to make eating decisions ◗Family of origin eating attitudes ◗Family of origin eating patterns ◗Family of origin nutrition beliefs Assess use of nutritional supplementation ◗ Vitamins, minerals, dietary supplements ◗Herbals or teas to enhance metabolism ◗Natural cathartics, emetics 24-hour recall Food Frequency Questionnaire NIH Food Frequency Questionnaire 3-5 day food records Mobile- and web-based program applications Dietary Assessment Instruments instruments-research Diet, Anthropometry and Physical Activity (DAPA) Measurement Toolkit Dietary Reference Intakes Reference_Intakes.aspx Eating Disorder Inventory Eating Attitudes Test Include in 24-hour recall REFERENCES Austin SB, Ziyadeh NJ, Forman S, Prokop LA, Keliher A, Jacobs D. Screening high school students for eating disorders: results of a national initiative. Prev Chronic Dis. 2008 Oct;5(4):A114. Becker, CB, Middlemass, K, Taylor, B, Johnson, C, Gomez, F. Food insecurity and eating disorder pathology. Int J Eat Disord. 2017; 50: 1031– 1040. eat.22735 Becker, C. B., Middlemass, K. M., Gomez, F., & Martinez- Abrego, A. (2019). Eating Disorder Pathology Among Individuals Living With Food Insecurity: A Replication Study. Clinical Psychological Science, 7(5), 1144–1158. Esper DH. Utilization of Nutrition-Focused Physical Assessment in Identifying Micronutrient Deficiencies. Nut Clin Pract. 2015; 30(2): 194-202. DOI: 10.1177/0884533615573054. Garner DM, Garfinkel PE. The Eating Attitudes Test: An index of the symptoms of anorexia nervosa. Psychol Med. 1979;9:273–279. doi: 10.1017/ S0033291700030762. Garner DM, Olmstead MP, Polivy J. Development and validation of a multidimensional ED inventory for anorexia nervosa and bulimia. Int J Eat Disorder. 1983;2:15–34. doi: 10.1002/1098-108X dentistry/nutritional-assessment Larson-Meyer D., Woolf K., & Burke L. (2018). Assessment of Nutrient Status in Athletes and the Need for Supplementation, International Journal of Sport Nutrition and Exercise Metabolism, 28(2), 139-158. DOI: 10.1123/ ijsnem.2017-0338 Malone A, Hamilton C. The Academy of Nutrition and Dietetics/the American Society for Parenteral and Enteral Nutrition consensus malnutrition characteristics: application in practice. Nutrition in Clinical Practice. 2013 Dec;28(6):639-50. McNulty KY, Anderson JM, Affenito SG. Development and validation of a screening tool to identify eating disorders in female athletes. J Am Diet Assoc. 2001 Aug;101(8);886- 92. doi: 10.1016/S0002-8223(01)00218-8. GUIDEBOOK FOR NUTRITION TREATMENT OF EATING DISORDERS 10 Mordarski B, Wolff J, editors. Nutrition Focused Physical Exam Pocket Guide. Academy of Nutrition and Dietetics; 2018. Mountjoy M, Sundgot-Borgen J, Carter S, Constantini N, Lebrun C, Meyer N, Steffen K, Budgett R, Ljunggvist A, Askerman K. RED-S CAT. Energy Deficiency in Sport (RED-S) Clinical Assessment Tool (CAT). Br J Sports Med. 2015 Apr;49(7);421-3. Doi: 10.1136/bjsports-2015-094873. Smolak L, Levine MP. Psychometric properties of the Children’s Eating Attitudes Test. Int J Eat Disord. 1994 Nov;16(3):275-82. Symons Downs, D., Hausenblas, H. A., & Nigg, C. R. (2004). Factorial validity and psychometric examination of the Exercise Dependence Scale-Revised. Measurement in Physical Education and Exercise Science, 8, 183–201. doi:10.1207/s15327841mpee0804 Tabbakh T, Freeland-Graves J. Development and validation of the Multidimensional Home Environment Scale (MHES) for adolescents and their mothers. Eat Behav. 2016 Aug; 22:76-82. doi: 10.1016/j.eatbeh.2016.03.031. WEIGHT ASSESSMENT The major determinant of body weight is genetic (Song et al., 2018). A “biologically appropriate weight” is a weight that is easily maintained without need for dieting or inappropriate food and exercise behaviors, and reflects pre-morbid weight, normal physical and psychological function, genetic predisposition ethnicity, gender, and family history (Herrin & Larkin, 2013). In young individuals, a “biologically appropriate weight” is associated with normal historical development. In adults, a “biologically appropriate weight” is where weight settles when enough food is consumed to attain all required nutrients, and the person is physically and emotionally satisfied. In individuals who GUIDEBOOK FOR NUTRITION TREATMENT OF EATING DISORDERS 11 very similar to the World Health Organization (WHO) Child Growth Standards. As with adults, stature-for-age and weight-for- age and BMI-for-age percentile categories are problematic when applied indiscriminately to children and adolescents because they do not take into account an individual’s genetic predisposition and race-ethnicity, and are not predictive of health risks (Vanderwall et al., 2018). Furthermore, childhood BMI % categories are based on population data from over 50 years ago (Flegal et al., 2011). Nevertheless, weights inconsistent with a child’s pre-morbid growth curve are not likely to be associated with healthy function and growth, adequate nutrition, and improvements in eating disordered behaviors and cognitions. A return to a child’s pre-morbid growth curve is usually the most appropriate goal in treatments aimed at weight restoration. BMI growth curves are best at tracking whether an individual is growing at average velocity. If the curve crosses centiles up or down, the individual is growing faster or slower than average (Cole, 2012). Keep in mind, for example, that a child can be perfectly healthy at the 95th percentile for BMI for age if they are naturally stocky or muscular. CDC percentiles are most helpful for identifying children who are at risk of malnutrition and failure to thrive due to weight loss (i.e., children and adolescents diagnosed with low-weight anorexia, or ARFID). CDC provides a BMI-for age percentile calculator and clinical charts for tracking stature-for-age and weight-for-age and BMI-for-age. lived in higher weight bodies before the onset of their ED, such as those with atypical anorexia, refeeding and weight restoration should proceed with premorbid usual weight taken into account in determining weight restoration goals. In all people, body weight fluctuates day to day about 5-6 pounds (3 kg) due to level of hydration, contents of bowel and bladder, time of day, and time of month for menstruating females. In most US medical settings, adult weights of White, Hispanic, and Black adults are assessed using the US National Institute of Health/World Health Organization Body Mass Index (NIH/ WHO BMI) weight categories (Weir CB, Jan A, 2019). NIH/WHO BMI categories have come under criticism because they do not portray an accurate picture of health for individuals. These BMI categories underestimate the health risks associated with weights classified as underweight and overestimate the health risks associated with weights classified as overweight (Flegal et al., 2018; Flegal et al., 2013). Furthermore, BMI weight categories were developed to assess health risk in populations, not in individuals (Nuttall, 2015). Recent studies of the differences in health risks associated with weight, particularly for Asians and South Asians, supports the need for the development of additional BMI categories (Klatsky et al., 2017). For children up to the age of 19, the Center for Disease Control (CDC) BMI-for-age percentile growth categories are used world-wide and are GUIDEBOOK FOR NUTRITION TREATMENT OF EATING DISORDERS 12 team members up to date. If weight is monitored by someone other than the dietitian, it is imperative that arrangements be made for the data to be received before nutrition visits. When individuals are referred by health providers for “medically necessary weight loss,” dietitians are encouraged to discuss the evidence of poor outcomes for intensive weight loss interventions (Greaves et al., 2017). Dietitians can suggest treatment strategies that focus on improvements in eating behaviors that enhance diet quality. Weight monitoring should be sensitively introduced and conducted. All discussions about weight monitoring and assessment should be based on the tenets of body positivity and similar approaches that embrace acceptance and appreciation of all body types (see the Weight Stigma and Body Image sections.) “Frontwards” weight checks (checks that permit individuals to see the weight) allow for therapeutic discussions about weight and can help dispel related misconceptions. “Frontwards” weight checks are standard protocol in FBT and CBT. In FBT, weights are also shared with family and other support people. Weight checks are also conducted with the individual standing backwards on the scale (also called “blind or backwards” weight checks) so that the number on the scale is not observed. This type of weight check is intended to make body weight and weight checks more neutral, reducing the focus on the number. If this approach is used, the dietitian should CHARACTERISTICS OF A “BIOLOGICALLY APPROPRIATE WEIGHT” ◗ Absence of: • Restricting or dieting • Bingeing • Obsessive or compensatory exercising ◗ Supportive of: • Normal physical and psychological function • Normal growth in young individuals ◗ Consistent with: • Pre-morbid weight • Gender • Ethnicity • Family history WEIGHT AND HEIGHT MONITORING Weight (and height in pediatric individuals) are anthropometric measurements used for tracking growth, monitoring fluid retention and refeeding risk, and indicating whether food intake is adequate. When weight restoration is a goal of treatment, weight changes are essential indicators of medical status and treatment progress. Weight and/or height monitoring is standard practice in the treatment of children and adolescents diagnosed with AN or ARFID and is an integral aspect of FBT (Family Based Treatment) and CBT (Cognitive Behavior Treatment) approaches. If weight has been determined to be clinically important to monitor, the team member who conducts weight monitoring should keep other