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ACADEMY OF NUTRITION AND DIETETICS Pocket Guide to Eating Disorders SECOND EDITION Jessica Setnick, MS, RD, CEDRD SAMPLE Not for Print or Resale  Academy of Nutrition and Dietetics Pocket Guide to Eating Disorders Second Edition Jessica Setnick, MS, RD, CEDRD Academy of Nutrition and Dietetics Chicago, IL SAMPLE Not for Print or Resale  Academy of Nutrition and Dietetics Pocket Guide to Eating Disorders, Second Edition ISBN 978-0-88091-980-7 (print) ISBN 978-0-88091-981-4 (ebook) Catalog Number 436X17 (print) Catalog Number 436X17e (eBook) Copyright © 2017, Academy of Nutrition and Dietetics. All rights reserved. No part of this publication may be used for commercial exploitation (for example, by resale to others) without the prior written consent of the publisher. The views expressed in this publication are those of the authors and do not necessarily reflect policies and/or offi- cial positions of the Academy of Nutrition and Dietetics. Mention of product names in this publication does not constitute endorsement by the authors or the Academy of Nutrition and Dietetics. The Academy of Nutrition and Dietetics disclaims responsibility for the application of the information contained herein. 10 9 8 7 6 5 4 3 2 1 For more information on the Academy of Nutrition and Dietetics, visit www.eatright.org. SAMPLE Not for Print or Resale  Contents Reviewers...........................................................................................iv Chapter 1: Eating Disorders and the Dietitian ......................1 Chapter 2: Nutrition Assessment for Eating Disorders ....19 Chapter 3: Nutrition Diagnosis for Eating Disorders ........ 74 Chapter 4: Nutrition Intervention for Eating Disorders: Food and/or Nutrient Delivery and Nutrition-Related Medications ........................................... 85 Chapter 5: Nutrition Intervention for Eating Disorders: Nutrition Education ..............................................................122 Chapter 6: Nutrition Intervention for Eating Disorders: Nutrition Counseling ............................................................145 Chapter 7: Nutrition Intervention for Eating Disorders: Coordination of Care ............................................................160 Chapter 8: Nutrition Monitoring and Evaluation ............178 Appendixes ...................................................................................187 Appendix A: Nutrition Care Process Summary ............187 Appendix B: Guide to Restrictive Eating Styles ...........189 Appendix C: Caffeine Content in Common Foods, Beverages and Drugs ............................................................196 Appendix D: Additional Resources ..................................203 Index ...............................................................................................208 SAMPLE Not for Print or Resale  Reviewers Ruth Leyse-Wallace, PhD, RDN Alpine, CA April Winslow, MS, RDN, CEDRD San Jose, CA SAMPLE Not for Print or Resale  Chapter 1 Eating Disorders and the Dietitian Introduction Whether it is in your patient population, among cowork- ers or colleagues, in family members or friends, or even in strangers, registered dietitian nutritionists (RDNs) are often the first to identify dysfunctional eating behav- ior. Whether or not the treatment of eating disorders falls within your specialty practice area, at some point in your career, you are bound to encounter situations that require your understanding of this complex issue. They are simply too common to avoid.1 Rough estimates suggest at least 13.5 million Americans meet criteria for anorexia, bulimia, or binge eating disor- der.1-4 A 2005 survey of 1,500 American adults reported that 4 of 10 either had or knew someone who had an eat- ing disorder.2 As an RDN, eating disorders may be more common among your peers than in the general commu- nity.5,6 You may even have been motivated to enter the field because of past experiences with your own or a loved one’s eating disorder.7 Sadly, only a small fraction of those with eating disorders ever enter, much less complete, treatment.8 The reasons are many and include: • denial of the illness and its severity (called anosog- nosia); • fear that recovery will require weight gain or other undesirable consequences; • feeling ashamed of behaviors and hiding them from fear of embarrassment; • cost of treatment and inadequate insurance coverage; and SAMPLE Not for Print or Resale  Chapter 1 2 • general lack of awareness of eating disorders among those in the medical profession. Because modern society’s fixation on image and appearance can seem to condone, encourage, and reward pathological attempts at weight control, eating disorders are sometimes unnoticed until they are life threatening. A woman with anorexia is 12 times more likely to die at a young age9 and 59 times more likely to commit suicide10 than a woman of the same age without anorexia. Even in death, an eating disorder can remain undiagnosed, as the cause of death may be listed as a more immediate compli- cation, such as heart failure or cardiac arrest. Eating disorders do not discriminate. They afflict indi- viduals of every race, age, and socioeconomic status. Although most research subjects to date have been female, the eating-disorder research community is slowly becom- ing more inclusive. Patterns may appear, but there is no “typical” eating disorder patient. It is dangerous and uneth- ical for an RDN to rule out an eating disorder solely on the basis of gender, economic status, weight, age, appearance, mental capacity, or any other single factor. Because nutritional rehabilitation is a cornerstone of eating disorder recovery,11 your influence as an RDN is powerful.1,12,13 Through education, you can raise aware- ness of the factors known to cause eating disorders and of their early warning symptoms; through assessment, you can identify eating disorders at their earliest stages; and through intervention, you can change the course of lives. This book is intended to prepare you for when you encounter an individual with an eating disorder in your pro- fessional life. The Nutrition Care Process (NCP) format is followed throughout. The NCP is comprised of 4 steps and is outlined in detail in Appendix A; refer to Box 1.1 for a brief outline of the steps of the NCP. SAMPLE Not for Print or Resale  Eating Disorders and the Dietitian 3 Box 1.1 Nutrition Care Process14 Step 1—Nutrition Assessment Nutrition assessment data have been organized into 4 domains: • Food/Nutrition-Related History • Anthropometric Measurements • Biochemical Data, Medical Tests, and Procedures • Nutrition-Focused Physical Findings • Patient/Client History Step 2—Nutrition Diagnosis Nutrition diagnoses have been organized into 3 domains: • Intake • Clinical • Behavioral-Environmental Step 3—Nutrition Intervention Nutrition intervention strategies have been organized into 4 domains: • Food and/or Nutrient Delivery • Nutrition Education • Nutrition Counseling • Coordination of Nutrition Care Step 4—Nutrition Monitoring and Evaluation Nutrition monitoring and evaluation outcomes are organized into 4 domains: • Food/Nutrition-Related History Outcomes • Anthropometric Measurement Outcomes • Biochemical Data, Medical Tests, and Procedure Outcomes • Nutrition-Focused Physical Finding Outcomes SAMPLE Not for Print or Resale  Chapter 1 4 Terminology “Eating disorders” is the umbrella term currently used to describe abnormal and maladaptive eating and related behaviors with psychological and biological underpin- nings. In the United States, the American Psychiatric Association (APA) oversees the establishment of criteria for defining psychiatric conditions. These are updated and published periodically in the Diagnostic and Statistical Manual of Mental Disorders, which is currently in its fifth edition (DSM-5).15 Because the underlying cause or causes of eating disorders have not been confirmed, the current categorization of eating disorders is based on signs, symp- toms, and behaviors. This system can be problematic, as individuals with similar or even identical symptoms may have different causative factors, different neurochemi- cal imbalances, different disease processes, and different needs for treatment. This is one of the reasons why individ- ualization of treatment is so essential. In the DSM-5, more eating disorder types are described than ever before. These include anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant/restrictive food intake disorder (ARFID), night eating syndrome, purging disorder, and others. Each have their own diagnostic crite- ria, some more detailed than others (see Boxes 1.2 through 1.6, pages 6–10).15 Five of these diagnoses are grouped into a category called “other specified feeding and eating disorders” (OSFED). These are purging disorder, night eating syndrome, “atyp- ical” anorexia, and bulimia and binge eating disorder “of low frequency or limited duration.” In the past, these might have been categorized as “eating disorders not otherwise specified” (EDNOS). As with EDNOS, it is important to note that OSFED is not an eating disorder in itself, and also that those eating disorders within the OSFED cate- gory should not be considered less severe eating disorders. SAMPLE Not for Print or Resale  Eating Disorders and the Dietitian 5 They simply are variations of eating disorders that are not as well-defined as some of the others. Further research is needed on all of the disorders in this category. The DSM-5 introduced another new category, “unspec- ified feeding and eating disorders.” This is not an actual disorder but rather a diagnostic code that can be used when a practitioner is unable to determine the details of a patient’s eating disorder, for example, if the individual is unresponsive, uncooperative, or mentally altered. It is intended simply to be a placeholder until more information can be gathered. Etiology of Eating Disorders Binge eating, self-induced vomiting, excessive exercise, starvation, and other eating disorder behaviors are harmful and destructive, so why do they begin, and why do they per- sist? The answers are under investigation, and there are no definite answers yet. The effects of eating disorders on the body and brain are far better understood than their causes. It appears that both genetic and environmental influences contribute to the development of eating disorders,11 but because research is generally initiated after the onset of the eating disorder and sample sizes are often small, it is unclear how much each factor plays a role. Biological Factors Early family studies suggested some heritability of eating disorders,16,17 and later studies showed genetic markers are similar among family members with anorexia.18 Twin stud- ies have suggested that genetic contributions toward eating disorders may change during puberty,19 that boys with a female twin are more likely to develop an eating disorder than those with a male twin,20 and that binge eating dis- order and bulimia may share genetic factors.21 Neonatal SAMPLE Not for Print or Resale  Chapter 1 6 complications and the mother’s health during pregnancy may also influence later eating disorder development.22 Box 1.2 DSM-5 Criteria for Anorexia Nervosa A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that mini- mally expected. B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. C. Disturbances in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the serious- ness of the current low body weight. Specify Type Restricting During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (self- induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. Binge eating/purging During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (self-induced vom- iting or the misuse of laxatives, diuretics, or enemas). Specify Severity Based on Body Mass Index (BMI) Mild: ≥17 Moderate: 16–16.99 Severe: 15–15.99 Extreme: <15 Reprinted with permission of the American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. SAMPLE Not for Print or Resale  Eating Disorders and the Dietitian 7 Box 1.3 DSM-5 Criteria for Bulimia Nervosa A. Recurrent episodes of binge eating. An episode of binge eat- ing is characterized by both of the following: (1) Eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time and under similar circumstances. (2) A sense of lack of control over eating during the episode (eg, a feeling that one cannot stop eating or control what or how much one is eating). B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behavior both occur, on average, at least once a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. Specify Severity Based on Average Number of Compensa- tory Behavior Episodes per Week Mild: 1–3 Moderate: 4–7 Severe: 8–13 Extreme: 14 or more Reprinted with permission of the American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. SAMPLE Not for Print or Resale  Chapter 1 8 Box 1.4 DSM-5 Criteria for Binge Eating Disorder A. Recurrent episodes of binge eating, characterized by both of the following: (1) Eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. (2) A sense of lack of control over eating during the episode (eg, a feeling that one cannot stop eating or control what or how much one is eating). B. The binge eating episodes are associated with three (or more) of the following: (1) Eating much more rapidly than normal. (2) Eating until uncomfortably full. (3) Eating large amounts of food when not feeling physically hungry. (4) Eating alone because of feeling embarrassed by how much one is eating. (5) Feeling disgusted with oneself, depressed, or very guilty afterward. C. Marked distress regarding binge eating is present. D The binge eating occurs, on average, at least once a week for 3 months. E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior and does not occur exclusively during the course of bulimia or anorexia nervosa. Specify Severity Based on Average Number of Binge Eating Episodes per Week Mild: 1–3 Moderate: 4–7 Severe: 8–13 Extreme: 14 or more Reprinted with permission of the American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. SAMPLE Not for Print or Resale  Eating Disorders and the Dietitian 9 Box 1.5 DSM-5 Criteria for Avoidant/Restrictive Food Intake Disorder A. An eating or feeding disturbance (eg, apparent lack of interest in eating or food; avoidance of eating based on the sensory characteristics of food; concern about adverse consequences of eating) as manifested by persistent failure to meet appro- priate nutritional and/or energy needs associated with one (or more) of the following: (1) Significant weight loss (or failure to achieve expected weight gain or faltering growth in children). (2) Significant nutritional deficiency. (3) Dependence on enteral feeding or oral nutritional supplements. (4) Marked interference with psychological functioning. B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice. C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced. D. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating distur- bance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention. Reprinted with permission of the American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. SAMPLE Not for Print or Resale  Chapter 1 10 Box 1.6 DSM-5 Criteria for Other Specified Feeding and Eating Disorders Atypical Anorexia Nervosa All of the criteria for anorexia nervosa are met except that despite significant weight loss the individual’s weight is within or above the normal range. Bulimia Nervosa of Low Frequency and/or Limited Duration All of the criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory behaviors occur on average less than once a week and/or for less than 3 months. Binge eating Disorder of Low Frequency and/or Limited Duration All of the criteria for binge eating disorder are met except that the binge eating occurs on average less than once a week and/or for less than 3 months. Purging Disorder Recurrent purging behavior to influence weight or shape (eg, self-induced vomiting; misuse of laxatives, diuretics or other medications) in the absence of binge eating. Night Eating Syndrome Recurrent episodes of night eating as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. There is awareness and recall of the eating. The night eating is not better explained by external influences such as changes in the individual’s sleep-wake cycle or by local social norms. The night eating causes significant distress and/or impairment in functioning. The disordered pattern of eating is not better explained by binge eating disorder or another men- tal disorder including substance abuse and is not attributable to another medical disorder or to an effect of medication. Reprinted with permission of the American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. Regarding the perpetuation of eating disorder behav- iors once they have begun, we are starting to understand SAMPLE Not for Print or Resale