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Position of The American Dietetic Association
Position of The American Dietetic Association
E
ating disorders (EDs) are psychi-
ties of EDs, such as epidemiologic fac- atric disorders with diagnostic cri- require expertise in nutritional re-
tors, treatment guidelines, special teria based on psychologic, behav- quirements for the life stage of the
populations, and emerging trends ior, and physiologic characteristics. affected individual, nutritional reha-
highlight the nature of EDs, which Diagnostic criteria from the fourth edi- bilitation treatments, and modalities
require a collaborative approach by tion text revision of the Diagnostic and to restore normal eating patterns.
an interdisciplinary team of mental Multiple components of nutrition
Statistical Manual of Mental Disorders
health, nutrition, and medical spe- assessment performed by RDs can
provide important guidelines for iden-
cialists. RDs are integral members of contribute to treatment plans. For ex-
tification and treatment of EDs (1).
treatment teams and are uniquely ample, a food history may be more
However, there is considerable vari-
qualified to provide medical nutrition practical than laboratory tests and
ability in the severity and the type of more accurate than current food in-
therapy for the normalization of eat-
EDs. A comparison of diagnostic cri- take for determining potential micro-
ing patterns and nutritional status.
teria with proposed revisions for the nutrient deficiencies, specifically in
However, this role requires under-
newest Diagnostic and Statistical anorexia nervosa and bulimia ner-
standing of the psychologic and neu-
robiologic aspects of EDs. Advanced Manual of Mental Disorders edition vosa (8). Motivation or readiness to
training is needed to work effectively (Figure 1) notes binge eating disorder change, determined by motivational
with this population. Further efforts as an independent condition and interviewing, can be used by an RD as
with evidenced-based research must identifies diagnostic thresholds that a client-centered, collaborative ap-
continue for improved treatment out- reflect current research (1-3). Further- proach to enhance intrinsic motiva-
comes related to EDs, along with more, disordered eating may exist tion to change (9). Lower readiness to
identification of effective primary and along a range of symptoms from food change has been associated with low
secondary interventions. restriction to partial conditions and weight status (10). For individuals
This paper supports the “Practice then to full syndromes within the de- with anorexia nervosa, weight gain
Paper of the American Dietetic Asso- fined ED. Of special interest is the mul- rate during inpatient treatment ap-
ciation: Nutrition Intervention in the tidisciplinary approach in the clinical pears to be a potential predictor of
care of individuals with EDs and the outcome (11). Advanced training and
significant role nutrition care plays in alignment with team members assist
0002-8223/$36.00
the prevention of EDs and related RDs in meeting the challenges of car-
doi: 10.1016/j.jada.2011.06.016
complications. ing for individuals with EDs (12).
1236 Journal of the AMERICAN DIETETIC ASSOCIATION © 2011 by the American Dietetic Association
Anorexia nervosa. Types: Restricting or binge-eating/purging
Diagnostic and Statistical Manual of Mental Disorders (DSM) IV
● Exaggerated drive for thinness
● Refusal to maintain a body weight above the standard minimum (eg, 85% of expected weight)
● Intense fear of becoming fat with self-worth based on weight or shape
● Evidence of an endocrine disorder
Proposed for DSM V
● Restricted energy intake relative to requirements leading to a markedly low body weight
● Intense fear of gaining weight or becoming fat or persistent behavior to avoid weight gain, even though at a markedly low weight
● Disturbance in the way in which one’s body weight or shape is experienced
Bulimia nervosa
DSM IV
● Overwhelming urges to overeat and inappropriate compensatory behaviors or purging that follow the binge episodes (eg, vomiting, excessive
exercise, alternating periods of starvation, and abuse of laxatives or drugs)
● Similar to anorexia nervosa, individuals with bulimia nervosa also display psychopathology, including a fear of being overweight
Proposed for DSM V
● Recurrent episodes of binge eating with a sense of a lack of control with inappropriate compensatory behavior
● Self-evaluation is unduly influenced by body shape and weight
● The disturbance does not occur exclusively during episodes of anorexia nervosa.
Binge eating disorder
DSM IV
● Classified under eating disorders not otherwise specified
Proposed for DSM V
● Repeated episodes of overconsumption of food with a sense of a lack of control with a list of possible descriptors such as how much is eaten
and distress about the episode
● Frequency described as at least once a week for 3 months
Eating disorders not otherwise specified
DSM IV
● Considered to be partial syndromes with frequency of symptoms that vary from above diagnostic criteria
● Distinguishing feature of binge eating disorder is binge eating, with a lack of self-control, without inappropriate compensatory behaviors
Proposed for DSM V
● Diagnostic criteria to be established for binge eating disorder
● Possible descriptions of eating problems such as purging disorder and night eating syndrome
Figure 1. Comparison of proposed revisions in diagnostic criteria for eating disorders. Data from references (1,2).
EPIDEMIOLOGIC FACTORS eating pathology and include perceived status and the reverse pattern found
The frequency and distribution of in- pressure for thinness, thin-ideal inter- for binge eating disorder (17). Despite
dividuals affected by EDs is unknown nalization, body dissatisfaction, self-re- consideration that homosexuality
because the condition may exist for a ported dietary restraint, negative af- may be a risk factor for EDs among
considerable time period before clini- fect, and substance use (14).Genet- men, evidence is lacking (18). Age
cal detection. Cases may go unre- ics and neurobiological vulnerabilities trends differ within conditions, with
ported due to the sensitive nature and are emerging as predisposing factors the greatest frequency of anorexia
secretive behaviors associated with (15,16). nervosa and bulimia nervosa occur-
the condition, and epidemiologic re- The National Comorbidity Survey ring during adolescence, whereas
search is lacking from all population Replication study (17) reported life- binge eating disorder occurs well into
groups. Risk factors found to precede time prevalence rates for anorexia adulthood. Evidence also suggests an
an ED diagnosis include sex, ethnicity, nervosa at 0.3% in men and 0.9% in increasing trend in EDs for middle-
early childhood eating and gastrointes- women, for bulimia nervosa 0.5% in aged women (19). In longitudinal re-
tinal problems, elevated weight and men and 1.5% in women, and for search of girls aged 12 to 15 years,
shape concerns, negative self-evalua- binge eating disorder 2% in men and Stice and colleagues (20) found that
tion, sexual abuse and other traumas, 3.5% in women (17). As expected, a 12% of these adolescents experienced
and general psychiatric morbidity (13). diagnosis of anorexia nervosa was as- some form of ED. An important consid-
Prospective studies indicate risk for sociated with lower body mass index eration for prevention of EDs and asso-
Figure 2. Roles and responsibilities of registered dietitians caring for individuals with eating disorders. Data from references (3-6,14,15).
ciated complications is early identifica- toms and problems associated with Insurance Coverage for EDs
tion of altered eating patterns and unhealthy weight management prac- Health care reimbursement and utili-
distorted body image, which may be re- tices that can be associated with in- zation affects availability, accessibil-
vealed through questions with pre- creased risk of binge eating and purg- ity, and quality of care for EDs (4).
teens and adolescents, as well as with ing behaviors (22). Proposed changes Health care providers, including RDs,
adults (6,18,20). in diagnostic criteria for binge eating need to understand health insurance
include the number of binge days (eg, limitations to maximize the treatment
Comorbid Illness and EDs subthreshold binge eating with at benefits to individuals with EDs. Na-
least two uncontrollable binge eating tional legislation such as the previously
Patients with EDs often experience episodes or days per month for at proposed Federal Response to Elimi-
other psychiatric disorders (3,21). Axis nate Eating Disorders Act would ad-
least 3 months) (3,20). Further de-
I psychiatric disorders (including de- dress treatment as well as prevention,
scription of purging disorder and
pression, anxiety, body dysmorphic dis- research, and education needs. Ongo-
night eating syndrome is under re-
order, or chemical dependency) and ing priorities for RDs include educating
view (2,20). The trend of orthorexia
Axis II personality disorders (particu- insurance companies and policy mak-
larly borderline personality disorder) nervosa (not officially recognized in
the fourth edition of the Diagnostic ers about treatment needs for EDs,
are frequently seen in the ED popula- participating in cost-effectiveness anal-
tion (3,4,21). The characteristics of and Statistical Manual of Mental Dis-
orders), an unhealthful fixation about yses and outcome studies, and under-
these conditions increase the complex- standing how to navigate and guide
ity of treatment and necessitate addi- eating so-called healthful foods, ap-
pears to be on the rise (23). The rise in families through the health insurance
tional counseling skills. system.
hospitalizations affecting men, women,
and younger-aged children and restric-
Emerging Patterns of EDs tive eating practices in athletes point to TREATMENT GUIDELINES FOR EDS
Two areas of research on the course of increased need for ED prevention and EDs require a collaborative approach
EDs include the range of ED symp- care (24,25). by an interdisciplinary team of men-