Cap Nova Publishers

Effects of Multiprofessional Treatment on
Clinical Symptoms, Food Intake, Eating

Patterns, Eating Attitudes and Body Image
of Brazilian Bulimic Patients
Marle dos Santos Alvarenga(1), Fernanda Baeza Scagliusi(2) and Sonia

Tucunduva Philippi(3)
1) Eating Disorders Unit of Clinics Hospital, Department of Psychiatry, Institute of Psychiatry,
University of São Paulo
2) School of Physical Education and Sport, University of São Paulo and Eating Disorders Unit of
Clinics Hospital, Department of Psychiatry, Institute of Psychiatry, University of São Paulo
3) Department of Nutrition, School of Public Health, University of São Paulo
Abstract
Eating disorders (ED) have been treated in Brazil since 1992 with the creation of the ED Unit of the
University of São Paulo, a public service that has treated 1,794 patients, mainly white, reasonable educated
and aged between 21 and 40 years.
Food intake and eating patterns and behaviors are disturbed in bulimia nervosa (BN). Food intake is defined
as the food and nutrients that compose the diet, while eating patterns are the meal frequency, regularity and
schedules, and eating behaviors are the attitudes, beliefs and relationship with food. In Brazil, the effect of
multiprofessional treatment in BN had never been examined. Even in developed nations, only the frequency of
bulimic symptoms has been evaluated. The Eating Disorder Inventory, Three-Factor Eating Questionnaire,
Dutch Eating Behavior Questionnaire and Restraint Scale were used to analyze eating behaviors, although
these questionnaires focus especially in dietary restraint, leaving the other eating behaviors’ aspects
uncovered.
Methods: Thirty-nine women with BN (according to DSM-IV criteria) were followed. Treatment was
composed by 12 weeks of cognitive-behavior therapy, pharmacotherapy and nutrition counseling.
Measurements were made before and after treatment, and after three months. Patients recorded their food
intake and occurrence of compulsions and purges in a diary. They fulfilled the EAT, BITE and BSQ, and also
an eating attitudes questionnaire, especially developed for this research. Non-parametric statistics were used to
test for differences among the three moments.
Results: We observed an improvement in clinical symptoms; at the end of following 97.5% of the patients did
not fulfill criteria for BN anymore. Scores of EAT, BSQ and BITE-symptoms decreased after treatment and
even more after the later following. Nutrients intake did not alter, even though energy content of the meals
2 Marle dos Santos Alvarenga, Fernanda Baeza Scagliusi and Sonia Tucunduva Philippi
followed by vomit decreased. Number of meals increased and patients did more meals seated, with company
and less anxious. The belief of automatically gaining weight after a meal, and guilty and worry after eating a
“forbidden” food decreased. Nevertheless, most of them remained hating the hunger sensation, having
difficulties with food choices and not believing that they could have a normal diet and a normal weight.
Conclusion: Based on the questions used to assess eating attitudes, we are now developing an eating attitudes
questionnaire, which will be psychometrically tested. This study supports the idea of the importance of food
issues and behaviors in ED, because even the patients that had a clinical improvement remained with a
complicated relationship with food, which can contribute to relapses.
Introduction
Just as in other developing countries, Brazil is undergoing a nutritional transition. Nutritional

transition represents the changes that take place for centuries regarding nutritional patterns that result
from shifts in the structure of the diet followed by the population. These changes are related to
economic, social, and demographic changes, and they result in health changes as well (Popkin, 1993).
These transitions can be seen worldwide, given globalization of current habits and consumption patterns.
However, studies show that the pace of change in countries undergoing less development has been
markedly quicker, with a notable progression from malnutrition to obesity.
Particularly in Brazil, where great economic and demographic changes took place in the last decades
- from 1960 on (Monteiro et al., 2002; 2004) - we see the presence of malnutrition along with obesity. In
many studies regarding nutritional transition obesity and other chronic diseases are the main focus, but
as appointed by Nasser (1988) and Yager (2000) the increasing prevalence of eating disorders (ED) is
also a characteristic feature of nutrition transition.
There are no specific data regarding prevalence of ED in Brazil. Case reports from developing
countries are rare; thus, it gives the wrong impression that these disorders are rare in non-developed
countries (Negrão and Cordás, 1996). It is estimated that the prevalence of ED in Brazil is similar to that
observed in western countries for young women: 0.5% for anorexia nervosa; 1.0% for bulimia nervosa,
and 2-5% if partial syndromes are considered (Hay, 2002). Anyhow, it is known that the incidence of ED
has been increasing in less developed countries (Nasser et al., 2001). Vilela et al. (2004) used some
screening questionnaires to evaluate the prevalence of possible eating disorders and inappropriate eating
behaviors in Brazilian children and adolescents aged 7 to 19 years old. According to the Eating Attitudes
Test, 13.3% of the sample had inappropriate eating behaviors. Being female implied in a greater risk of
having inadequate eating behaviors (odds ratio = 1.54; 95% confidence interval = 1.16 – 2.05).
According to the Bulimic Inventory Test Edinburgh, 1.1% of the sample had a possible diagnosis of
bulimia nervosa. Another Brazilian study assessed the prevalence of abnormal eating behaviors among
513 young women (aged 12 to 29 years) randomly selected (Nunes et al., 2003). Combining scores
obtained in the Eating Attitudes Test and in the Bulimic Inventory Test Edinburgh, it was observed that
10.9% of the sample presented abnormal eating behaviors, while 23.8% had unusual eating patterns.
Other striking findings were found by Nappo et al. (2002). Investigating a sample of 2,370 Brazilian
subjects about the methods used by them in order to lose weight, the authors observed that 72.4% of the
sample had been submitted to some treatment to lose weight, and 79.2% of these had consumed
amphetamine-like anorectic drugs. The most interesting fact was that among these consumers, 60% had
a Body Mass Index below 29.9 kg/m2, which shows that they did not need these drugs and that probably
they were consuming them motivated by physical appearance aspects. Taken together, this data shows
that is necessary to study, prevent and treat eating disorders in Brazil.
Effects of Multiprofessional Treatment on Clinical Symptoms... 3
Eating disorders have been treated in Brazil since 1992 with the creation of the ED Unit of Clinics
Hospital of the University of São Paulo, which is a public service (visit http://www.ambulim.org.br for
more information about this service). Together with the unit of ED in children and adolescents and the
binge eating disorder (accompanied by obesity) unit, these services has treated 1,794 patients, mainly
females (88.3%), white, reasonable educated (36.4% completed junior high or high school and 27% had
studied for more than high school) and aged between 21 and 40 years (58.1%). Nowadays some
Brazilian groups work with ED, offering some public assistance (Fontenelle et al., 2003; Negrão and
Cordás, 1996) and doing researches (Borges et al., 2002; Nunes et al, 2003; Vilela et al, 2004). It is
important to remind that there are only ten of these centers in Brazil, which certainly is too little for such
populous country (total population: 182 million people – for more information visit
http://www.ibge.gov.br).
The Brazilian studies that focused in nutritional aspects of ED started to be conducted in 1994 as
graduate researches of the dietitians that belonged to the Nutrition in Eating Disorders Study Group
(visit http://www.genta.com.br for more information about this group) (Alvarenga et al., 2003; Dunker
and Philippi, 2003; Scagliusi et al., 2005a). Our current researches focus mainly in bulimia nervosa
(BN).
The interest for this area of research came from the observation that the majority of patients who
looked for treatment in our unit had BN and this is an eating disorder marked not only by binge eating
and compensatory practices, but also by an extremely affected eating behavior (ADA, 2001; APA,
1994). Distorted cognitions about nutrition and feelings of repugnance, hate and incompetence in
dealing with food are also features of this disease (Sunday et al., 1992).
Nutritional rehabilitation has a key and primary role with regards to treatment objectives, which
should be performed by a multiprofessional staff aiming to end bulimic behaviors and to alter the
patient’s relationship towards food and weight (ADA, 2001; APA, 1994; Eiger et al., 1996).
The first studies regarding nutritional aspects of BN were conducted between 1980 and 1990,
essentially in developed countries (Hadigan et al., 1989; Kissileff et al., 1986; Mitchell and Laine, 1985;
Walsh et al., 1989). Researches describes that a chaotic eating pattern is present in BN, oscillating
between severe dietary restraint and episodes in which the energy intake is extremely high (Wallin et al.,
1995). The “diet – binge – purge” cycle illustrates the eating pattern of bulimic patients. They constantly
start a new diet, which makes them eat a very limited amount of food and avoid those foods considered
by them caloric or “fattening” (the named “forbidden foods”). This restraint leads to a binge eating
episode, where the energy consumption can be very high (Reiff, 1992). The items more consumed in
these binge episodes are those most avoided by the patients due to their fear of gaining weight (for
example, cookies, chocolates, candies, etc) (Alvarenga et al., 2003; Wallin et al., 1994; Walsh et al.,
1989).
Some authors argue that the disturbed eating pattern is a general feature of BN and not only a
characteristic of their restrictive diets and binge episodes, which explain the difficulties faced in order to
normalize their intake (Hetherington et al., 1993; Sunday and, Halmi, 1996). Besides their unhealthy
food consumption, its is known that these patients have other disturbed eating behaviors, as difficulties
regarding food choice, abnormal patterns of hungry and satiety, food aversion, fears, taboos and
prejudices regarding food and weight control (Elmore and Castro, 1991; Hetherington et al., 1993;
Sunday and Halmi, 1996).
The studies conducted in laboratories, metabolic units or hospitals (with inpatients) observed in the
binges episodes an energy intake varying from 1,436 to 8,585 kcal, which was generally followed by
vomits. These episodes usually lasted 59 minutes and they were composed by 59% of carbohydrates,
43% of lipids and 8% of proteins. Without the binges patients had a wide range of energy consumption,
varying from 69 to 10,620 kcal (Hadigan et al., 1989; Hetherington et al., 1994; Kissileff et al., 1986;
Mitchell and Laine, 1985; Sunday and, Halmi, 1996; Walsh et al., 1989). The artificial settings and the
low ecological validity of these studies may have limited their findings, but the ample difference
between the minimal and maximal values shows that there is a great variability in food intake data of
bulimic patients.
This scenario shows that it is hard to study nutritional aspects of BN, especially if one considers that
the term “nutritional aspects” embodies several different variables. In our studies we divided this term in
the following components: food intake (foods that are eaten and their energy and nutrient content);
eating pattern (general characteristics of the intake, as number, types and schedules of the meals) and
eating attitudes (relationship with food, feelings and beliefs related to food). Among these aspects, we
are most interest in eating attitudes, not only because of the scarce number of studies concerning it but
also because it seems that it is one of the most disturbed characteristics of BN. Due to our interest, we
created a more specific definition of eating attitudes, based on the statements of Garcia (1999) and
Johnson (1985): what, how, with what, with whom, where, and when we eat, why we eat that, in which
situation we eat, what we think and feel towards food. It is also important to ask in what are food choices
based on, and where there is difficulty, lack of control, aversion, and what are the feelings related to
food.
Although follow-up studies of bulimic patients are commonly carried out in developed countries
(Collings and King, 1994; Fahy and Russell, 1993; Keel et al., 1999; Keel and Mitchell, 1997; Leung et
al., 2000; Maddocks et al., 1992), outcome measurements and follow-up studies are not conducted
systematically in Brazil.
Studies to measure outcome are hard to be conducted because of methodological difficulties, which
include the definition of a recovery criteria and follow-up methods. The definition of recovery varies in
each study: some considered recovery as those patient that presented bulimic episodes and purging
episodes once a month (Pyle et al., 1990) whereas others consider it as just those that did not present any
episode (Herzog et al., 1996; Keller et al., 1992; Maddocks and Kaplan, 1991).
To assess the effects of BN treatment, most studies compare the frequency of pre and post treatment
bulimic behavior (vomiting episodes, for example) (Herzog et al., 1996). In addition to analyzing the
frequency of binge eating and purging episodes, many follow-up studies utilized recovery predictors and
indicated that the frequency of bulimic behavior at baseline was not associated to the outcome (Abraham
et al., 1983; Fairburn et al., 1986; Hsu and Holder, 1986). Nevertheless, several factors are used as
prognostic predictors: age at the beginning of the disorder, presence of comorbidities, psychosocial
aspects, weight at the start of the treatment, eating behavior and methods used to lose weight (Herzog et
al., 1996).
Also, there are some standardized tests used to screen patients with eating disorders, such as Eating
Attitudes Test - EAT-26 (Garner et al., 1982), Bulimic Inventory Test Edinburgh - BITE (Henderson
and Freeman, 1987), and Eating Disorder Inventory - EDI (Garner et al, 1983), among others. The
results of some of these tests are analyzed in studies on recovery predictors, in which Olmested et al.
(1994) found a high score in the subscale of bulimia of EAT-26 (Garner and Garfinkel, 1979) and high
score in the interpersonal distrust subscale of the Eating Disorder Inventory-EDI (Garner et al., 1983)
among the recurrence predictors. According to Steinhausen and Seidel (1993), self-applied scales should
be used in prognostic studies. Although there are many studies using screening tests in several
populations (Adami et al., 1997; Beals, 2002; Bhugra et al., 2003; Ghazal et al., 2001; Lee et al., 2002;
Nobakht and Dezhkam, 2000), even to compare results of healthy individuals to those from ED patients
(Behar et al., 2003; Nakazato et al., 2003), few studies assessed the scores of individuals with ED post-
treatment (Brambilla et al., 1995; Fernandéz et al., 1998; Steinhausen and Seidel, 1993). The uncertainty
remains as to whether the scores attained on these tests return to normal patterns after the remission of
ED symptoms.
Even in developed countries, few studies have assessed the nutritional progress of bulimic patients
and no study has evaluated the effect of a multiprofessional intervention with regards to important BN
aspects: relationship and behavior towards food. Also, as far as we are concerned the food intake of
bulimic patients was analyzed only in cross-sectional studies, so it is not know if the treatment improves
the food consumption of these patients. Therefore, this issue requires further study (Whisenant and
Smith, 1995).
The few studies that have assessed the effect of treatment on eating behavior used tools such as food
diaries and standardized tests such as the Eating Disorder Inventory (Garner et al., 1993). Although we
presented above these tests as interesting measurement tools, one must remember that these instruments
do not encompass the wide concept of food behavior and are frequently limited to the analysis of dietary
restraint (Herman and Mack, 1975). Because of that, researchers with interest in nutritional aspects of
BN have to use other instruments able to approach these aspects in a more comprehensive manner.
Whisennat and Smith (1995) interviewed dietitians who worked with ED and stressed the
importance of more objective evaluations of the nutritional treatment. This idea is supported by
Eckstein-Harmon (1993) who attested the importance of the outcome measurements of nutritional
education and rehabilitation in eating disordered outpatients and inpatients.
So we conducted an follow-up study to assess the effect of multiprofessional intervention on bulimic
symptoms, food intake, eating patterns, eating behavior and body image in bulimic patients treated at a
center considered to be one of reference in Brazil: the ED Unit of Clinics Hospital of the University of
São Paulo.
Methods
Thirty-nine female patients with BN treated at the Eating Disorders Unit of the University of São
Paulo (in Brazil) were followed-up. Subjects were evaluated by a psychiatrist, and BN was diagnosed by
means of a semi-structured clinical interview, according to the criteria of the Diagnostic and Statistical
Manual of Mental Disorders - DSM-IV (APA, 1994). The descriptive data of the patients were collected
in this interview. Patients had their weights and heights measured, and this data was used to calculate
Body Mass Index (BMI – weight in kg/height2 in meters).
Patients gave informed consent before participation. They were also informed that the goal of the
study was to evaluate the outcome of the treatment. The study was approved by the Committee of Ethics
of the Clinics Hospital of the College of Medicine of the University of São Paulo.
Measurements were performed at baseline (Phase 1), immediately after treatment (Phase 2) and
three months after treatment (Phase 3). All measures were compared between these phases.
Bulimia nervosa should be treated by a multiprofessional staff working to end bulimic behaviors and
to change patients’ relationship towards food and weight (Gannon and Mitchell, 1986; ADA, 1988;
APA, 1994). Cognitive Behavioral Therapy (CBT) is considered the best technique to treat BN (Agras et
al., 2000; Leung et al., 2000). Because of that, treatment consisted of 12 weeks of cognitive behavioral
therapy (CBT) – with one weekly consultation with the psychiatrist, the psychology and the nutrition
education teams. At the end of treatment, the unit provided 3 more months of care, but in an
unstructured form.
The number of weeks of treatment was defined arbitrary, but its structure and content followed the
models proposed by Fairburn (1981), Johnson et al. (1986), Lacey (1985), Nutzunger and Zwann (1990)
and Vanderlinden et al. (1989), which described cognitive-behavioral techniques and provided
guidelines for nutritional counseling, even suggesting some educative materials.
The goals of the nutritional treatment were to: a) decrease the binge and purging episodes; b)
minimize dietary restraint; c) establish a regular meal pattern; d) increase food variety; e) correct
nutritional deficiencies and f) implant a healthy food intake and behavior (ADA, 1994; ADA, 2001;
Latner and Wilson, 2001). The approach can be divided in some key points: a) education about the
disease and its implications; b) education about food and nutrition; c) reduction of weight concerns; d)
self-monitoring of the food intake by means of a food record and e) implementation of a healthy eating
pattern (Story, 1986).
Weekly nutritional treatment consisted of one hour of nutrition education and 30 minutes of
individual counseling based on the food record. The topics addressed during the nutrition education
program were: role of nutrients; energy and nutrient requirements; food pyramid; ineffectiveness of
dietary restraint and of restrictive diets; definitions of hunger and satiety; healthy weight and build;
guidance for buying food and how to eat at restaurants and social events. After the 12 weeks, the topics
discussed were chosen by patients and/or the professional team such as issues from lay magazines about
body and nutrition, the social and emotional meanings of foods and exchange of ideas about methods
and tips to handle difficult situations regarding food.
Patients received one hour and half of psychology consultation, in which the following issues were
addressed, according to the models of Villapiano and Goodman (2001a; 2001b) and those described
above: a) the kinds of hunger (physical, emotional and social); b) the beliefs involved in the diet-binge-
purge cycle; c) the personal meaning of BN; d) body image dysfunctions; e) mechanisms used in order
to copy with the emotions; and f) barriers for change.
The dietitians instructed the patients to register all food consumed, the amount eaten, and the
schedule and duration of their meals in a food diary (ADA, 1988; Story, 1986). They were also asked to
mark if they considered the meal a binge eating episode and if any purging method had been used to
compensate it. If the answer was yes, they had to specify which ones. Weekly frequencies of binges,
vomits and use of laxatives, diuretics and diet pills were obtained through this diary.
The food records were also used to obtain patients’ energy and nutrient intakes, number and type of
meals consumed. To do so, diaries filled at weeks 2, 12 and 24 were analyzed. We chose to use the diary
from the second week as a baseline measurement because the record from the first week was used by the
dietitians to check if the patients were registering their intake and bulimic behaviors in a proper manner.
If one patient did not fill her record in one of these weeks, the prior or the next week diary was utilized.
Only the days that were completely recorded were analyzed. For example, if the patient did not describe
correctly one meal, this day was excluded from analysis.
The food intake was converted into energy and nutrient intake by means of the software Virtual
Nutri (Version 1.0) (Philippi et al., 1996), which contains data regarding nutritional composition and
serving sizes consumed in Brazil. When a patient registered that a meal was followed by vomits, this
meal was separated from the others. We calculated the energy and macronutrient intake from the meals
not followed by vomits (named VET) and from those meals followed by vomits (named VOM). This
differentiation (meals followed by vomiting or not) was made because it was impossible to take into
account the energy of foods eaten in a meal followed by vomiting, insofar as the amount effectively
absorbed is not known (Alvarenga et al., 2003; Gendall et al., 1997; Kaye et al., 1993) and would
require a very complex physiological study. Energy consumption ranges for VOM and VET were
defined, in which the values for energy were classified as hypoenergetic, normoenergetic, and
hyperenergetic.
Reference values used were:
VOM: hypoenergetic < 600Kcal; normoenergetic 600–1,000 Kcal; and hyperenergetic > 1,001Kcal
VET: hypoenergetic < 1,199 Kcal; normoenergetic 1,200–2,200 Kcal; and hyperenergetic > 2201
Kcal
These VET values were defined according to the mean energy recommendation for young women
(+/- 2,200Kcal) (NRC, 1989; Trumbo et al., 2002); and the VOM values were based on studies of the
energy content of binges (Elmore and Castro, 1991; Woell et al., 1989).
Also, the intake of the following minerals and vitamins were analyzed (using only the meals not
followed by vomits): sodium, potassium, magnesium, calcium, iron and vitamins A, B1, B6, C, D and E.
The values obtained were compared to the Dietary Reference Intakes – DRI’s (Institute of Medicine,
1997; 1998; 2000).
Patients filled in a questionnaire about their eating attitudes and relationship with food specially
developed for this population. The scale contained 24 questions about feelings and beliefs regarding
food, behavior during meals, and others. These subjects were derived from our clinical experience (for
example, based on the myths and misconceptions about nutrition that our patients usually declare) and
from other questionnaires that in a certain manner approach eating behavior and EDs, such as Eating
Disorder Inventory (Garner et al., 1983), Restraint Scale (Herman and Mack, 1975), Three-Factor Eating
Questionnaire (Stunkard and Messick, 1975) and the Dutch Eating Behavior Questionnaire (van Strien
et al., 1986). The instrument had been applied in a previous sample of patients in order to verify if it was
clear and easily understandable.
They also answered the Eating Attitudes Test - EAT-26 (Garner et al., 1982), translated to
Portuguese by Nunes et al. (1994), which measures concern over diet, certain types of food consumed
and body image; the Bulimic Inventory Test Edinburgh - BITE (Henderson and Freeman, 1987),
translated to Portuguese by Cordás and Hochgraf (1993), which measures the symptoms and the severity
of BN; and the Body Shape Questionnaire - BSQ (Cooper et al., 1987), translated to Portuguese by
Cordás and Castilho (1994), which measures concern over body image, shape and size.
Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) software
for Windows v. 6.0. Data is presented by phase, as percent frequencies or as mean, standard deviation,
median, and minimum and maximum values. Significance level adopted was p ≤ 0.05.
Friedman´s test was used to compare the frequency of bulimic behaviors, the energy and nutrient
intakes and the EAT, BITE and BSQ scores throughout the phases. When significant results were found,
the Bonferroni test was used to assess which phase would differ from the other.
The chi-square test was performed to see if there was any difference between the proportion of
individuals in each classification of VET and VOM energy intakes (hypoenergetic, normoenergetic and
hyperenergetic), among the phases. The Wilcoxon Matched-Pairs Signed-Ranks test was used to check
if the macronutrient profile differed between meals not followed by vomits (VET intake) and meals
followed by vomits (VOM intake).
In order to analyze the evolution of eating behaviors and relationship toward food throughout the
phases, the following approach was adopted. For the questions regarding eating attitudes and beliefs, the
frequency of affirmative or negative responses was calculated. A chi-square test compared the ratio of
affirmative responses for these questions between the phases. For the questions regarding the relation
with food, the first three options of answers (always, very often, often) were grouped as “frequent
thought or feeling”, and the last three (sometimes, rarely, and never) as “infrequent thought or feeling”.
Chi-square test was also performed to compare the ratio of frequent and infrequent answers for the
questions of relationship towards food between the phases.
The Spearman correlation coefficient was used to determine the existence of correlations between
these variables: frequencies of vomiting and binges, BMI and EAT, BITE and BSQ scores. Kruskal-
Wallis ANOVA was used to determine if the frequency of bulimic behavior and EAT, BITE and BSQ
scores varied according to the energy intake range (for VET and VOM consumption), and the Mann-
Whitney test was used when the independent variable had only two categories.
Findings and Discussion
Thirty-nine patients started the study (Phase 1); at the end of 3 months (Phase 2), 20 were still
undergoing treatment; at the end of 6 months (Phase 3), there were only 15 patients – for a 48.7%
dropout rate during treatment and 61.5% dropout rate during the entire follow-up. This high rate may
have limited our results, but other outcomes studies also found an elevated dropout rate (Bacaltchuk and
Hay, 1999; Elmore and Castro, 1991). For example, Agras et al. (2000) found that 26% of the patients
abandoned the treatment after approximately five weeks.
The diaries returned at each phase, the responses to the tests, and the n of each parameter varied.
The data for the 19 patients that quit follow-up from Phase 1 to Phase 2 were not used for analysis, but
merely to describe the group profile.
Most patients belonged to the BN bulimic subtype (90%); the length of the disorder varied from 1 to
20 years; 3 patients (15%) had a previous history of anorexia nervosa; 70% did not have a partner; 65%
had at least started college; 25% had professions or activities that demanded a lean body (dietitian,
physical education teacher, nutrition student, dancer, and actress); and 70% were taking antidepressants
according to psychiatric evaluation. Table 1 shows other descriptive data.
The patients presented a profile similar to those described in the literature as characteristic of
bulimic patients: young women, unmarried, with a high level of education and with a greater prevalence
of the purging subtype (Dolan et al., 1990; Fitcher et al., 1992; Gendall et al., 1997; Hetherington et al.,
1994).
Table 1- Patients descriptive data at the beginning of treatment (phase 1)
Characteristics Mean + Standard Deviation
Age (years) 27.7 + 6.3
Age when dieting started (years) 17.3 + 4.6
Age when binges started (years) 18.7 + 4.2
Age when vomiting started (years) 20.5 + 6.1
Weight (pounds) 135.9 + 23.7
Body Mass Index (kg/m2) 22.9 + 3.9
Desirable weight (pounds) 120.0 + 14.0
Weight variation throughout adulthood (pounds) 33.3 + 17.5
Although the patients were still young (median age was 25 years), they were slightly older than the
bulimic patients from developed countries – whose age varies between 16 and 20 years (Joergensen,
1992). This may be due to the long time of the disease and also to the long time that the patients took to
seek treatment, probably because they felt ashamed of their behaviors or because the lack of awareness
about the disorder (Becker et al., 1999). These findings are corroborated by other studies of bulimic
patients, which also found a higher mean age and a long time of disease (Hadigan et al., 1989;
Hetherington et al., 1993; Kissileff et al., 1986; Leung et al., 2000; Wallin et al., 1994; Woell et al.,
1989).
Nevertheless, this difference between Brazilian results and the literature may be due to our health
care system. In this study the sample were patients of the Eating Disorder Unit, at Institute and
Department of Psychiatry (a public institution), University of São Paulo. This was the first center in
Brazil to treat eating disorders and it is still the most known and important center. People from all over
the country come to be treated in this unit, which makes our sample very representative of eating
disorders cases in Brazil. In the other hand, the vacancies are not much and the wait-list is long, which
may explain the higher mean age of our sample. Finally, in Brazil there are no primary care services
preventing and detecting eating disorders, so the diagnosis of the disorders happens too late, usually
when the disease is very severe.
Regarding the anthropometrical data, the initial BMI was normal as appointed by other authors
(Gendall et al., 1997; Wallin et al., 1994). The mean desirable weight was 15.9 pounds lower than the
mean current weight, evidencing the persistent desire to loose weight that is characteristic of BN. The
mean weight’s oscillation in the adulthood was also high (33.3 pounds), which illustrated the weight
cycling derived from the many times the patients tried to loose weight, following the
restraint/binge/purge cycle of BN (Reiff, 1992). Kell et al. found (1999) a mean weight’s oscillation of
35.2 pounds in the historic of bulimic patients, while Sunday and Halmi (1996) affirmed that the bulimic
recruited in their study had been heavier in the past.
Table 2 shows the progress of binge eating and purging behaviors in the 3 different phases. There
was a significant statistical difference between Phases 1 and 3, and between 2 and 3, regarding the
frequency of binge eating episodes per week. However up until Phase 2, the mean number of binge
eating episodes per week met the DSM-IV criteria for bulimic frequency (minimum of twice a week for
at least three months); in Phase 3, the mean number of binge eating episodes per week was below the
minimum frequency established by the DSM-IV (APA, 1994).
Table 2 - Measures of bulimic behaviors along the follow-up (data presented as mean + standard deviation (median; minimal-maximal))
Phases Weekly frequency Weekly frequency Weekly use Weekly use Weekly use of
of binges of vomits of laxatives of diuretics diet pills
1 – Before treatment 9.5 + 8.5* (7; 0-29) 4.2 + 6.6 (1.5; 0-28) 1 + 1.6 (0; 0-6) 1.4 + 3.6 (0; 0-13) 0.55 + 2.5 (0; 0-11)
2 – Immediately after treatment 4.2 + 4.7* (3.5; 0-20) 2.4 + 3.4 (0; 0-11) 0.9 + 2.3 (0; 0-9) 0.65 + 1.9 (0; 0-8) 0
3 – Three months after treatment 1.6 + 2.3 (0.5; 0-7) 0.4 + 0.9 (0; 0-3) 0.08 + 0.3 (0; 0-1) 0.92 + 3.2 (0; 0-11) 0
*: significantly different from results obtained three months after treatment

There was no significant statistical difference between the phases, regarding the number of vomiting
episodes per week. Even though, the median of vomiting episodes was zero in Phase 2 and at Phase 3
the mean value was below the minimum frequency demanded by DSM-IV.
There was no significant statistical difference between the phases regarding use of laxatives,
diuretics and diet pills. This type of compensatory method was less utilized than vomiting, and the
medians were zero in all phases.
Regarding percentage of improvement in the bulimic behaviors assessed, there was clear
improvement in the binge eating and purging symptoms at the end of the six-month follow-up: 75% of
the patients had a frequency of binge eating bellow that one that fulfill diagnostic criteria, and 91.7%
had this result in regard to vomiting episodes. Other purging behavior, such as the use of laxatives,
diuretics, and appetite moderators, was shown in 100% of the responses below the diagnostic criteria.
The frequency of other compensatory methods (fasting, dieting, physical activity) could not be estimated
and compared to the DSM-IV criteria (APA, 1994).
The percentages found are somewhat compatible with the data described in literature. Lacey (1983)
observed that 80% of these patients completely ended their binge eating and vomiting episodes at the
end of 10 sessions of CBT; actually, in this study, it took more than 12 sessions for patients to
significantly cease these behavioral patterns. The major difference was that in Lacey’s study patients
spent half a day, once a week, being treated, whereas they stayed 3 hours per week at our center.
Mitchell et al. (1988) found that 75% of patients had improved their eating behavior (without
defining what kind of changes had taken place) and that 60% did not show bulimic behavior after
treatment. Collings and King (1994) found that 52% of patients fully recovered, 39% experienced some
symptoms, and 9% still suffered from this disease after treatment. Leung et al. (2000) found an over 50%
decrease in bulimic symptoms after 12 CBT sessions. This data can be compared to the findings for this
study: 60% did not meet the diagnostic criteria for BN according to the frequency of vomiting after 12
weeks, and 45% did not meet the diagnostic criteria for BN according to the frequency of binge eating
episodes after 12 weeks.
After six months, 8.3% vomited more than twice a week. This finding is very important. According
to Olmested et al. (1994), the frequency of vomiting episodes, even if at low levels, seems to be a poor
prognostic indicator and can be considered one of the best parameters for residual symptoms in these
patients.
It can be seen, as stated by Keel et al. (1999), that a longer period of treatment and follow-up (at
least six months) yields better results. Nevertheless, the length of follow-up was short and patients may
have had relapse episodes after this period of time. Regarding recovery after six months, based on the
definition by Pyle et al. (1990), of maximum of two episodes of binge eating and purging episodes in the
last two weeks of treatment, these patients should be considered already under recovery. According to
the criteria adopted by Maddocks and Kaplan (1991) (less than one episode of binge eating or purging in
the last 4 weeks), these patients presented a "moderate" response. One needs to consider that BN is
known for being a disorder with poor prognostics because most patients remain with symptoms at the
end of treatment (Garner, 1987). According to Becker et al. (1999), half of the patients attain full
recovery, about 30% attain partial recovery, and 20% do not present significant symptom improvement.
The criterion proposed by Keel et al. (1999) is much more severe: "absence of changed behavior for
at least six months, and the weight and shape cannot influence how the subject felt." From this point, we
cannot assess patients from this study, who would require a longer follow-up to verify a six-month
abstinence. Perhaps it would be very difficult to consider them recovered based on the criteria of non-
influence of weight and body shape. As stated by Herzog et al. (1996), in their review, a comparison of
results between studies is very difficult because of the variability of how improvement, diagnostic
criteria, duration of intervals and evaluation methods are defined.
Table 3 presents the number of meals consumed in one week among the treatment phases. We
observed that after six months the median number of lunches was 7 (significantly different from Phase
1), which means having lunch everyday. There were no significant differences regarding the number of
the other meals. Even so, at the end of the following the median number of the breakfasts was 7, and the
median number of the afternoon snacks, dinners and evening snacks were slightly higher than at
baseline.
Tables 4 and 5 show the energy and nutrient consumption along the treatment phases, in the VET
intake (meals not followed by vomits) and in the VOM intake (meals followed by vomits), respectively.
The results showed that the mean intake of energy in the meals not followed by vomits (VET intake)
was much lower than the energy consumption recommendation to young women (+/- 2,200 kcal) (NRC,
1989; Trumbo et al., 2002). Wallin et al. (1994) and Gendall et al. (1997) found similar results and
attested that these patients use the binges episodes to regularize their limited intake. It seems like that the
patients usually eat less energy than necessary, which leads to a binge episode in order to compensate
this deficit.
The studies regarding eating pattern and nutrient intakes of bulimic patients are diverse. According
to Gendall et al. (1997), empirical studies noticed a variation of 605-4,800 kcal in the energy intake,
while the macronutrient consumption seems to follow the American diet pattern. Woell et al. (1989)
found a mean energy intake of 3,100 kcal per day, including the binges episodes. On the other hand,
Wallin et al. (1995) observed a mean intake of 762 + 560 kcal/day. Sunday and Halmi (1996) observed
that bulimic patients ate less energy than anorexic patients in a weight maintenance phase.
These great variability among studies was expected, since it is known that bulimic patients tend to
have an atypical and chaotic food intake which varies between the restrictive and the compensatory
phases or between the “regular” meals and the binge episodes (Gayle, 1998; Gendall et al., 1997;
Hetherington et al., 1994; Wallin et al., 1994; Wallin et al., 1995; Walsh et al., 1989). According to
Gayle (1998), these extreme fluctuations in energy intake disconcert the appetite regulation and other
physiological functions. The author affirms that the low energy intake leads to a loss of control, in spite
of the great amount of energy consumed subsequently. Due to that it is recommended to include as one
of goals of the treatment the regularization of the eating pattern, in order to prevent fluctuations of the
bulimic behaviors.
Regarding the energy consumed in the meals followed by vomits (VOM intake), we found a range
of 460-2,690 kcal. This data shows that the energy intake of these meals was not so high, which is
surprising considering that these meals were more likely to be binge episodes. Woell et al. (1989) found
that one third of the bulimic patients declared as compulsive episodes with less than 500 kcal (Rosen et
al., 1986, obtained a very similar finding) and that this judgment depends not only of the amount of food
or energy consumed but also of the type of food and the psychological state of the patient. Other studies
found a great variability in the energy content of the binges. Mitchell et al. (1981) observed a mean
intake of 3,415 kcal (range: 1,200-11,500 kcal), while Mitchell and Laine (1985) obtained a mean
consumption of 4,394 kcal (range: 1,436 – 8,585 kcal). Elmore and Castro (1991) affirmed that the
greater binges are more likely to be purged and that patients with longer time of disease had even greater
binges. Gendall et al. (1997) declared that the binges that happen more frequently have greater energy
content and also that although compulsive meals have more energetic value than the non-compulsive
ones they do not have different macronutrient composition.
The median macronutrient profile of the VOM intake was similar to those observed by Woell et al.
(1989) in binges (42% of carbohydrates, 12% of proteins and 43% of lipids). We also observed that the
macronutrient profile of the VOM intake did not differ much from the macronutrient profile of the VET
intake, except for the lipid consumption (in percent contribution to total energy intake), which was
higher in the VOM intake, but only at baseline (VET intake = 32.1 + 7%; VOM intake = 35.3 + 4%, p =
0.03).
Table 3 – Weekly number of meals along the follow-up (data presented as mean + standard deviation (median; minimal-maximal))
Phases Total meals Breakfast Morning snack Lunch Afternoon snack Dinner Evening snack
1 – Before treatment 25.8 + 10 4.1 + 2 2.9 + 2 4.3 + 2 3.4 + 2 4.5 + 1 2.3 + 2

(23; 5-50) (4; 0-6) (3; 0-6) (5; 0-7)* (4; 0-6) (4; 2-7) (3; 0-6)
2 – Immediately after 25.4 + 7 4.7 + 2 2.3 + 2 5.2 + 1 4.0 + 2 3.7 + 1 3.1 + 2
treatment (23; 18-40) (5; 0-7) (2; 0-7) (6; 3-7)* (4; 1-6) (4; 1-7) (3; 0-7)
3 – Three months after 31 + 13 6.3 + 2 2.3 + 2 6.5 + 2 4.7 + 3 5.1 + 2 3.0 + 2
treatment (27; 11-65) (7; 3-8) (2; 0-7) (7; 1-8) (5; 0-9) (6; 0-9) (3; 0-6)
*: significantly different from Phase 3.
Table 4 – Energy and macronutrient content (as percentage contribution to total energy intake) of the meals not followed by vomits, along the
follow-up (data presented as mean + standard deviation (median; minimal-maximal))
Phases Energy intake (kcal) Protein intake (%) Carbohydrate intake (%) Lipid intake (%)
1 – Before treatment 1,529 + 945 14.6 + 3 53.5 + 8 32.1 + 7

(1,197; 337- 4,094) (14; 10-21)* (51; 44-72) (32; 19-43)
2 – Immediately after 1,475 + 771 15.8 + 3 50.8 + 6 32.6 + 5

treatment (1,277; 577-3,853) (15; 12-21) (49; 44-65) (32; 24-40)
3 – Three months after 1,337 + 519 17.6 + 3 50.4 + 6 31.6 + 6

treatment (1,393; 641-2,131) (18; 13-21) (50; 40-60) (31; 22-42)
*: significantly different from Phase 3.

Table 5 – Energy and macronutrient content (as percentage contribution to total energy intake) of the meals followed by vomits, along the
follow-up (data presented as mean + standard deviation (median; minimal-maximal))
Phases Energy intake (kcal) Protein intake (%) Carbohydrate intake (%) Lipid intake (%)
1 – Before treatment 1,310 + 686 17.5 + 7 47.4 + 6 35.3 + 4
(1,274; 460-2,689) (14; 7-32) (49; 37-55) (36; 26-41)
2 – Immediately after 1,402 + 707 17.2 + 7 45.9 + 15 34.2 + 7

treatment (1,320; 584-2,664) (16; 10-33) (44; 21-69) (35; 21-43)
3 – Three months after 1,211 + 226 10.1 + 5 60.7 + 3 28.1 + 3

treatment (1,238; 927-1,440) (9; 6-17) (60; 57-65) (28; 24-31)
In every phase, the percentage contribution of each macronutrient to the VET intake was similar to
those recommended in Reference Dietary Allowances (NRC, 1989; Trumbo et al., 2002). The values
were also similar to those obtained in a prior cross-sectional study conducted with Brazilian bulimic
patients (Alvarenga et al., 2003). In that study, the mean carbohydrate intake contributed with 50.8% of
the total intake, while the mean lipid consumption contributed with 32.3% and the mean protein intake
with 17.9%. In this chapter, we observed that along the phases, only protein intake significantly changed
(the baseline intake was lower than the intake presented at Phase 3).
Table 6 shows the distribution of patients in each energy intake range, considering the meals not
followed by vomits (VET) and the meals followed by vomits (VOM).
Table 6 - Proportion of subjects classified in each category of energy intake, within the phases of
the follow-up
Energy intake Phase 1 – Before Phase 2 – Immediately Phase 3 – Three months after
treatment after treatment treatment
Meals not followed by vomits

Hypoenergetic intakea 52.6% 47.0% 50.0%
Normoenergetic intakeb 31.6% 41.2% 50.0%
Hyperenergetic intakec 15.8% 11.8% 0%
Meals followed by vomits*

Hypoenergetic intaked 21.0% 11.8% 25.0%
Normoenergetic intakee 47.4% 70.6% 75.0%
Hyperenergetic intakef 31.6% 17.6% 0%
*: χ2 (2) = 21.32; p < 0.005.

Meals not followed by vomits:
a
: Hypoenergetic = Intake < 1,199 kcal.
b
: Normoenergetic = Intake between 1,200 e 2,200 kcal.
c
: Hyperenergetic = Intake > 2,201 kcal.
Meals followed by vomits:
d
: Hypoenergetic = Intake < 600 kcal.
e
: Normoenergetic = Intake between 600 e 1,000 kcal.
f
The results indicated that there was no significant change in the number of patients in each
category in regard to energy intake of meals not followed by vomiting (VET). Only a non-significant
increase in normoenergetic intake, and a non-significant reduction in hypereneregetic intake were
observed.
In relation to the meals followed by vomiting (VOM), the number of patients that presented
episodes with an intake less than or equal to 600 Kcal decreased by half after 12 weeks of treatment
and then increased after six months. Regarding meals of 601-1,000 Kcal, the number of patients
increased after 12 weeks and after six months, and meals with over 1,001 Kcal decreased after 12
weeks and fell to zero after six months. It was concluded that there was a trend of decrease for
hyperenergetic meals followed by vomiting throughout the phases.
As for the nomenclature used to describe the energy intake of these patients, the terms hypo, normo,
hyper for VET applied, respectively, to eating less energy than one should, eating the right amount of
energy, and eating more energy than one should. The same terms were used for VOM, meaning meals
with a low intake of energy, with an intermediate intake of energy and with high intake of energy;
therefore, hypo VOM does not mean that the patient ate less energy than he should at that moment.
These categories were based on the energy content of binges, supposing that meals followed by vomiting
are more likely to be binge eating episodes. Even though, one must also consider that not only binges are
followed by vomiting (since regular meals also can be followed by vomiting) and not all binge episodes
are followed by vomiting.
Elmore and Castro (1991) stated that greater binge eating episodes are more likely to be purged, and
that, as the length of the disorder progresses, the size of these binge eating episodes also increases. This
paper shows that throughout the follow-up stage patients decreased the size of their meals followed by
vomits, however these are patients undergoing treatment. Most probably, patients without treatment will
present binge eating episodes with higher energetic content.
The intake of vitamins and minerals along the phases, as well their adequacies in relation to the
recommended intakes, can be seen in Table 7.
Table 7 – Micronutrient intake and adequacy, obtained in the meals not followed by vomits,
along the treatment phases
Recommended
Nutrient Phase Amount consumeda Adequacyc (%)
intakeb
1d 710 + 377 (680; 27 – 1,632) 89
Vitamin A (mcg) e 800
2 774 + 337 (765; 219 – 1,612) 97
f
3 1117 + 460 (990; 656 – 2,050) 140
d
1 88 + 74 (69; 1 - 258) 118
Vitamin C (mg) e 75
2 84 + 44 (85; 16 - 186) 112
3f 217 + 259 (124; 60 - 992) 289
1d 1 + 0.7 (0.7; 0.4 – 3.2) 95
Thiamin (mg) 2 e
1 + 0.6 (0.8; 0.3 – 2.7) 1.1 91
3f 0.9 + 0.4 (0.7; 0.5 – 1.5) 81
1d 0.8 + 0.4 (0.7; 0.1 – 1.4) 58
Vitamin B6 (mg) 2e 0.9 + 0.4 (0.8; 0.4 – 2.0) 1.3 68
3f 0.9 + 0.4 (0.8; 0.5 – 1.7) 72
1d 18 + 29 (0.8; 0 – 95) 351
Vitamin D (mcg) 2e 10 + 15 (1; 0 – 55) 5 199
3f 8 + 20 (0.6; 0 – 68) 166
1d 7 + 5 (6; 0 – 22) 49
Vitamin E (mg) 2e 9 + 7 (7; 2 – 25) 15 57
3f 7 + 5 (5; 3 – 16) 49
1d 1,551 + 1,156 (1,236; 68 – 4,406) 65
Sodium (mg) 2e 1,604 + 1,125 (1,123; 598 – 4,917) 2,400 67
3f 1,397 + 669 (1,427; 483 – 2,652) 58
1d 552 + 289 (481; 99 – 1,081) 55
Calcium (mg) 2e 855 + 960 (569; 196 – 4,178) 1,000 86
3 f
632 + 288 (578; 344 – 1,414) 63
1 d
113 + 54 (119; 19 – 241) 37
Magnesium (mg) 2e 132 + 79 (116; 43 – 356) 310 43
3f 132 + 39 (133; 73 – 199) 42
1d 1,195 + 539 (1,128; 211 – 2,433) 34
Potassium (mg) 2e 1,265 + 513 (1,061; 508 – 2,625) 3,500 36
3f 1,493 + 382 (1,390; 1,015 – 2,150) 43
1d 6 + 4 (5; 0.4 – 15) 34
Iron (mg) 2e 7 + 3 (6; 2 – 15) 18 37
3f 6 + 3 (5; 3 – 12) 35
a
: mean + standard deviation (median; minimal-maximal).
b: Recommended intake to young women, according to the Dietary Reference Intakes (Institute of Medicine, 1997;
1998; 2000).
c: Percent adequacy of the mean intake, when compared to the recommended intake.
d: Phase 1 – before treatment.
e: Phase 2 – immediately after treatment.
f: Phase 3 – three months after treatment.
In a broad manner, intake of micronutrients was below the recommendations of the Dietary
Reference Intakes (Institute of Medicine, 1997; 1998; 2000). Intake of vitamins A and C was closer to
the recommendations, while the most inadequate intakes were found to sodium, calcium, magnesium,
potassium and iron It is not possible to affirm that this unhealthy intake is characteristic of bulimic
patients, because since we did not have a control group we could not know if the intake of healthy young
women is so inadequate as the patients’ intake. The fact that the sodium and potassium intake was so
low is very preoccupant because, when combined with compensatory behaviors as vomiting and use of
laxatives and diuretics, this may cause a hydroeletrolitic disturbance (Greenfeld et al., 1995; Lasater and
Mehler, 2001).
This inappropriate pattern of intake did not change throughout the phases. This result suggests that
the nutritional treatment was not able to correct this unhealthy eating pattern. It is necessary to evaluate
why this happened and what could be done to improve the micronutrient intake of these patients.
Chart 1 shows the results of frequency of affirmative responses for questions about eating behavior
and beliefs. The reduction of guilt declarations when patients ate foods whose consumption they
restricted demonstrates greater permissiveness towards these foods. There was a gradual reduction in
statements regarding behavior change after eating sweets, fast food, and “different” foods; however, less
than half of the patients changed. It is remarkable that, even with significant changes, most of them were
still feeling guilty and having difficulties in eating the foods regarded as “dangerous”, behavior also
described by Keller et al. (1992).
More than half of the patients were still practicing some kind of restraint on their diet at the end of
the following. This ratifies that diet restraint is a symptom much more common among BN patients and
that it is difficult to eliminate (Keller et al., 1992).
Chart 1 - Frequency of affirmative answers to the questions regarding eating attitudes and beliefs towards food, between the treatment phases.
Questions Phase 1 – Phase 2 –Immediately Phase 3- Three months after treatment
Before treatment after treatment
Do you make any restrictions in your regular diet? 94% 75% 57%
Do you feel guilty whenever you eat one of the foods 70% 65% 60%
that you try to cut from your diet?*
Do you feel pleasure when you eat? 75% 71% 76%
Do you like cooking? 70% 65% 59%
Do you usually eat the meals that you prepare? 74% 76% 82%
When you eat sweets, fast-foods, pizza, or when you go to a 95% 76% 53%
party, do you eat in a different manner?**
Does it bother you to eat in the presence of other people?a 60% 29% 29%
Do you believe that there is a combination of food that 74% 59% 59%
is dangerously “fattening”?
Do you believe that there is a food or some thing that “melts” 35% 29% 6%
fat? a
Do you believe that overeating in one meal or in special 90% 41% 29%
occasion automatically makes you put on weight?***
Do you believe that not eating for one day or eating a liquid 65% 41% 35%
diet can make you lose weight?
*: p ≤ 0.05; **: p ≤ 0.01; ***: p ≤ 0.001; a: p = 0.09

Regarding the feeling of nuisance while eating in the presence of others, positive answers were less
than half after 12 weeks of CBT and they maintained the same pattern along the following, almost
reaching significance. It showed that the treatment provided a more adequate eating pattern for this
issue, probably decreasing the episodes of “hidden eating” and making possible for the patients the
opportunity of sharing the meals with other people. Even so, at the end of the following approximately
one third of the patients still felt bothered while eating in the presence of the others, which was also
observed by Keller et al. (1992).
No important shifts were found in the statements regarding eating with pleasure. We believe that
treatment does not alter feelings as much as behavior regarding food; and that it is harder to change the
relationship with food than to change behavior. Patients seem to associate food preparation with the
possibility of loosing control and eventually dislike the activity, as indicated by the gradual reduction of
affirmative answers with regards to the enjoyment of cooking.
One question asked if they ate the food that they prepare. This question was based on the
observation that anorexics usually cook for their relatives, but do not eat the food prepared (Reiff and
Reiff, 1992). The high frequency of affirmative answers, even at baseline, showed that this disturbed
behavior (not eating what they prepare) was not common among bulimics.
Among the misconceptions about diet, significant reductions were observed just in the proportion of
patients who thought they would gain weight immediately after eating and who believed that something
could melt fat (here, p value was close to significance). Part of the sample still believed that some food
combinations were especially “fattening” and that fasting for one day would make them thinner, which
suggests that in spite of all the information provided, fear and suspicion in relation to food were not
eliminated.
Chart 2 shows the responses for questions about the relationship with food. At the end of follow-up,
most of them no longer worried about food all the time. We think that the establishment of a regular diet
pattern decreases obsessive thinking about food since the relationship between obsessive dieting and
extreme concern in relation to food is a well-known fact (Polivy, 1996). There was also a significant
reduction in concern with body weight and in feeling fat regardless of what they ate, which could
suggest that the treatment was able to address some body image issues, as extolled in the literature
(Garfinkel et al., 1992). However, many patients remained with such perceptions and feelings, which is
corroborated by the observation of Swift et al. (1987) that, regardless of the result of the treatment,
weight fluctuations and body dissatisfaction remain. Even though, it is known that many healthy women,
without EDs, feel fat and overestimate their body sizes, so these features are not exclusively of bulimic
patients (Cash and Henry, 1995; Rodin et al., 1984; Strigel-Moore et al., 1986).
Almost one third of patients declared that they dream of a pill that would replace food at the end of
the following. Such an impossible and surreal desire clearly indicates an inadequate and pathological
relationship toward food that could not be altered for some patients, which is very preoccupant.
The results appointed that most of the patients started the treatment already believing that they could
achieve a regular intake and a regular weight, which is very important since motivational aspects are
considered predictors of improvement (Herzog et al., 1996; Rorty et al., 1993). Even though, the
answers’ pattern to this question did not change along the following, suggesting that the treatment did
not increase motivation of those patients who were not motivated at baseline. This feature should be
carefully observed during treatment, and the professionals should try to have a better understanding of
the reasons for such lack of motivation, in order to provide an adequate treatment for all patients.
Chart 2 - Frequency of ‘frequent’ or ‘not frequent’ answers to the questions regarding relationship towards food, between the treatment
phases
Questions Phase 1 – Before Phase 2 – Immediately after treatment Phase 3 – Three months
treatment after treatment
Frequently Infrequently Frequently Infrequently Frequently Infrequently
I worry all the time about what I am going to eat** 95% 5% 71% 29% 44% 56%
I worry all the time with my weight** 100% 0% 94% 6% 56% 44%
I feel fat despite what I eat** 95% 5% 82% 18% 56% 44%
I hate feeling hungry 50% 50% 59% 42% 38% 63%
It is hard for me to choose what to eat 60% 40% 41% 59% 38% 63%
I wish I did not have the need to eat 60% 40% 53% 47% 36% 63%
I dream of a pill that would replace food 42% 58% 35% 65% 31% 69%
I don’t believe I’ll ever be able to follow a regular 44% 56% 35% 65% 19% 81%
intake and achieve a regular weight
In a situation in which there is much food, such as 63% 37% 53% 47% 25% 75%
parties and buffets, I get nervous and/or lose control*
Whenever I have a problem, I look for food 65% 35% 47% 53% 46% 56%
My eating habits have a great 89% 11% 59% 41% 40% 60%
interference in my life as a whole**

*: p ≤ 0.05; ** p ≤ 0.01
Regarding the question of feeling nervous or loosing control in situations with abundant food, the
most important reduction took place only at the end of the six months, indicating that longer treatment is
needed for patients to gain confidence and ease to eat in any situation. The analysis of the question about
“the way you eat” interfering greatly in their lives as a whole demonstrated a significant change,
although 40% of the patients were still answering positively after six months, indicating that to a
subgroup, BN represented the complex role of food in human life. There were no significant shifts in the
question related to looking for food whenever they have a problem. This suggests that food still
performed many different roles in the lives of these patients, as an expression of feelings and impulses
and “a means of external adaptation and an attempt at internal control” (Johnson and Maddi, 1988).
Thus, faced with many possibilities, ED patients choose weight control and, therefore food control, as a
way of life. Changing this behavior pattern seems to demand much more than 12 weeks of CBT and
nutritional education. No significant alterations were observed in the answers about “being angry when
feeling hungry”, “having difficulty in choosing foods” and “I wish I did not have to eat”. These data
reflect the inadequate relationship with food, with the denial of the physiological and emotional needs
for food, probably due to their feeling of incompetence towards it (Keller et al., 1992).
Figures 1 and 2 shows the percent distribution of affirmative answers regarding the way they behave
during the meals and the feelings experienced while they ate outside home, along the phases. The
number of patients who ate their meals sitting at a table increased significantly over the phase periods,
just as those who had their meals with a companion. These changes were important, because eating
quickly while standing, often in front of the refrigerator, may be associated with bulimic behavior. CBT
seemed to be also effective in reducing the discomfort of eating in the presence of other people, as there
was a falling trend in the frequency of answers to this question. One of the most difficult behaviors to
change seems to be that of reading while eating, or eating in front of the TV. However, it is well known
that today, many people eat alone and entertain themselves in this manner, and this is not a
distinguishing feature of EDs. Patients started to feel more at ease and less anxious when eating out. The
feeling of irritation was the one that showed the smallest reduction in affirmative answers, still indicating
difficulty in the relationship with food.
One should also note that the nutritional approach of the treatment was based on more elementary
subjects of nutritional education and that there was no specific approach to address the relationship of
patients with food. Some authors (Rosen et al., 1995; Wolff and Clark, 2001) say that traditional CBT is
not enough to change body image issues in EDs, and that specific interventions are needed for that
purpose. We can infer that the same is true for eating attitudes and relationship towards food.
Table 8 shows the test scores throughout the follow-up. There was significant statistical difference
for EAT from one phase to another, showing continuous improvement provided by treatment. However,
diet behavior was still significant at the end of the 12 weeks of CBT. The symptoms started to disappear
only six months after the beginning of the follow-up, showing that more time is necessary for the
patients to stop presenting the symptoms, according to data from the EAT questionnaire. The scores
from this study could not be compared to those found in literature, because most of the studies used
EAT-40 and those which utilized EAT-26 had a study design very different from ours, not allowing a
comparison.
Significant statistical difference was observed in the BITE (symptom subscale) from Phase 1 to
Phase 2. The initial mean value (23.6) found was similar to that observed in the study conducted by Fahy
and Russell (1993) of 26.3, and lower than that found by Thiels et al. (2003) of 31.2 and by
Hetherington et al. (1993) of 48.7. Thiels et al. (2003) did a reevaluation after 16 weeks of CBT,
obtaining a score of 16.2, and another reevaluation after 6 months, with score of 17.2. Fahy and Russell
(1993) reassessed the patients after 1 year, and observed a mean score of 16.9. The scores observed by
Thiels et al. (2003) after 6 months, and by Fahy and Russel (1993) after 1 year were higher than the
mean found after the 6-month follow-up of this study (15.8). Regarding the progress of BITE-symptom,
data showed that a significant difference in bulimic symptoms occurred after 12 weeks of CBT.
Actually, the guidelines for this approach aim at reducing bulimic symptoms, so this change was
expected. The scores of the BITE-symptom showed just a "sub-clinical" group after six months of
follow-up, showing positive evolution of these patients.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
ing
ng
V
e
g
t*
g*
on
din
dy
tio
gT
uie
lki
ttin
ad
Al
en
bo
an
Ta
Q
hin
Re
Si
att
me
St
atc
ith
so
W
ith
Phase 1 Phase 2 Phase 3

W
Figure 1 – Percent distribution of the affirmative answers to the question “How do you usually eat your meals?”
*: p < 0.05
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
At ease* Anxious* Irritated Fearful Nervous
Phase 1 Phase 2 Phase 3
Figure 2 – Percent distribution of the affirmative answers to the question “How do you feel when you go to a restaurant,
coffee shop or a bar?”
*: p < 0.05
Table 8 - Scores obtained in the scales (EAT, BITE and BSQ), along the follow-up (data presented as mean + standard deviation (median;
minimal-maximal))
Phases EATa BITE symptomsb BITE severityc BSQd

1 – Before treatment 38.6 + 10 (40; 15-53)†* 23.6 + 5 (25; 11-29)†* 15.3 + 5 (14; 3-25) 145.2 + 28 (142; 99-190)*
2 – Immediately after 25.5 + 14 (28; 6-49)* 19.8 + 8 (23; 1-28) 10.1 + 6 (8; 2-23) 132.6 + 40 (149; 48-189)*
treatment
3 – Three months after 17.0 + 11 (16.5; 2-42) 15.8 + 8 (17.5; 1-28) 7.6 + 6 (5.5; 2-24) 109.2 + 44 (103.5; 47-189)
treatment
† significantly different from the scores obtained immediately after treatment
*: significantly different from results obtained three months after treatment.

There was no significant statistical difference between the phases in regard to the BITE
severity scale. The mean score after six months showed a "clinically significant" group. This
result is similar to that found in the Fahy and Russell (1993) follow-up in which the mean
initial score was 14.1, and after one year, 6.1, showing a still "clinically significant" group.
BSQ showed significant statistical difference between Phases 1 and 3, and between 2
and 3, thereby indicating a continuous improvement. The BSQ initial mean score (145.2)
was lower than the 156 described by Hetherington et al. (1993). No study showed the
evolution of BSQ scores throughout follow-up. Results show that concern over body image
takes more than 12 weeks of CBT to present significant changes. These results are consistent
with those found by Swift et al. (1987), in which weight variations and body dissatisfaction
remained present even among asymptomatic patients. Some authors (Ramirez and Rosen,
2001; Wolff and Clark, 2001) declare that traditional CBT is not enough to improve body
image in EDs, and that specific intervention is required to this end, so the improvement
found in the classification regarding concern over body image through BSQ was surprising.
Although we found this improvement in body image issues at the end of the follow-up, one
might argue that the BSQ along did not provide much information about what changes did
occur in relation to body image. Using this scale, it is not possible to know if whether
overestimation of body size or body dissatisfaction or body disparagement decreased. For
this reason, nowadays it is recommend the use of tests more specifics to the body image
aspect that is intended to be measured (Thompson, 2004).
A series of studies used the Eating Disorders Inventory (EDI) to measure outcome
(Brambilla et al., 1995; Fernandéz et al., 1998; Hedges et al., 2003; Steinhausen and Seidel,
1993), but the EDI test has not yet been translated to Portuguese. When this study was
carried out, BITE, EAT, and BSQ were the only tests that had been translated to Portuguese
and that were available to assess BN. Currently, there are other tests that have been
translated, which measure the chronic practice of restrictive diets (Restraint Scale –
Scagliusi et al., 2005-a), body attitudes (Body Attitudes Questionnaire – Scagliusi et al.,
2005-c), perception and satisfaction with body size and shape (Stunkard’s Figure Rating
Scale – Scagliusi et al., 2006), nutritional knowledge (Scagliusi et al., 2005-b), among
others.
Therefore, an analysis of the evolution of classification based on test scores showed
good results, but not as good as the findings for binge eating and purging behavior.
Notwithstanding, these tests do not diagnose ED, they just address some issues and suggest a
classification.
Table 9 shows the correlations between BITE, EAT, BSQ, BMI, number of vomiting
episodes per week and number of binge eating episodes per week, found in each phase. EAT
and BSQ presented a positive correlation in the 3 phases of the program, showing that for
these bulimic patients, the higher their EAT score, the greater their concern over body image,
regardless of the timeframe. It is known that these two responses, greater dissatisfaction with
body image after treatment and higher EAT scores, are related to a poor outcome or a
complication of the disease during follow-up (Agras et al., 2000; Freeman et al., 1985;
Olmested et al., 1994).
The number of binge eating episodes and BITE-symptom presented a positive correlation
just at the beginning of the treatment, showing that, at that point, the more severe the level of
BN symptoms, the greater the number of binge eating episodes per week presented by the
patient. The severity of BN symptoms at the beginning of treatment was considered a
predictor of recurrence by Fahy and Russell (1993). This correlation was no longer true in the
following phases, and it seemed that, after treatment and follow-up, the bulimic symptoms
had somehow changed and no longer had any correlation to the frequency of binge eating
episodes. It seemed that, despite the bulimic symptoms, the number of binge eating episodes
had decreased.
Positive correlations between BMI and BITE-symptom inventory test and between BMI
and number of binge eating episodes per week were found just at the beginning of treatment.
This shows that to patients not being treated, the higher the BMI, the more severe the levels
of BN symptoms, and the greater the number of binge eating episodes. According to
Maddocks and Kaplan (1991) patients who have been heavier in the past had more chances of
presenting worse treatment outcome. After treatment, it was concluded that patients with a
higher BMI no longer presented the more severe levels of BN symptoms nor presented higher
frequency of binge eating episodes, that is, the symptoms originated from the
psychopathology of the disorder and not from inadequate body weight.
After 12 weeks of treatment, and also after six months of follow-up, EAT and BITE-
symptom inventory test presented a positive correlation. Bite-severity inventory test and EAT
presented a positive correlation only during Phase 2. These correlations were not present at
the beginning. This result shows that after being treated, the stronger the concern of the
patient over diet, foods eaten, and body image, the more severe the patient’s symptoms and
BN itself. The study also suggests that the severity of BN was not related to the level of
concern over food and body at the beginning and after 6 months of treatment. This data
suggests that these patients (more concerned over food and their body, even after treatment)
are highly prone to experiencing recurrence, as described by Freeman et al. (1985) and by
Fahy and Russell (1993).
It could be thought that the frequency of binge eating and the frequency of vomiting
episodes would present a correlation during all phases, but this became true only after 12
weeks of treatment, suggesting that only at this moment did a greater number of binge eating
episodes result in more vomiting episodes. In fact, the presence of binge eating and vomiting
episodes did not present such a correlation at the beginning of treatment and after six months.
This finding is supported by Olmested et al. (1994) who said that vomiting can be used to
control weight, stress and affection, among others factors, and not only to compensate binge
eating.
BMI and BSQ presented a positive correlation after 12 weeks of treatment showing that,
at this phase, the higher the BMI, the greater the concern over body image. This finding
supports the fact that individuals with ED are overly concerned about body image regardless
of their weight (Dowson and Henderson, 2001), insofar as it is the pathological condition that
causes this concern. When patients are treated, their concern for the body is the same as what
is presented by the overall population: the heavier they are, the more concerned they are (Hill
and Williams, 1998; Scagliusi et al., 2006). This finding also shows that treatment can
minimize weight-related concerns in individuals who are not overweight.
Table 9 - Spearman correlation coefficients between scales scores, bulimic behaviors

and body mass index, along the follow-up
Scales and EAT BITE BITE Frequency Frequency BodyMass

measures severity symptoms of binges of vomits Index
Phase 1 – Before treatment
BSQ 0.59* 0.28 0.44 0.38 -0.20 0.06
EAT - 0.40 0.06 0.22 0.10 -0.13
BITE severity - - 0.44 0.38 -0.13 0.19
BITE symptoms - - - 0.44* -0.11 0.45*
Frequency of binges - - - - 0.20 0.57*
Phase 2 – Immediately after treatment
BSQ 0.80* 0.45 0.48 -0.01 -0.05 0.50*
EAT - 0.63* 0.75* 0.13 -0.19 0.36*
BITE severity - - 0.61 0.22 0.21 0.02
BITE symptoms - - - 0.40 0.36 0.39
Frequency of binges - - - - 0.48* 0.09
Phase 3 – Three months after treatment

BSQ 0.78* -0.04 0.73 0.15 -0.08 0.10
EAT - 0.21 0.81* 0.30 0.03 0.01
BITE severity - - 0.28 0.62* 0.68* -0.40
BITE symptoms - - - 0.47 0.28 0.13
Frequency of binges - - - - 0.49 -0.18
*: p ≤ 0.05; a: bulimic behaviors are expressed as weekly frequencies.
BITE-symptom inventory test and BSQ presented positive correlation only after the six-
month follow-up, showing that the greater the number of symptoms of BN presented at the
end of this period, the greater the concern of the patient over body image. This result was not
observed at the beginning or after 12 weeks. It seems that BN symptoms are significantly
affected by body image only if the patient still remains highly concerned about his image after
six months of treatment. As shown by Freeman et al. (1985), Fahy and Russell (1993) e Agras
et al. (2000), patients with more BN symptoms and more concern about their bodies at the
end of the treatment present a higher risk of recurrence.
Only after six months of follow-up was any positive correlation found between BITE-
severity scale and the number of vomiting episodes per week and between this scale and
weekly frequency of binges, showing that the more vomiting and binge episodes after this
length of treatment, the more severe the BN. It can be said that a patient that still presents a
significant number of vomiting and binge episodes after six months of treatment has more
severe and more treatment-resistant bulimia, supporting the presence of vomiting and binge
episodes as an indicator of poor prognosis (Olmested et al., 1994; Herzog et al., 1996).
Actually, severity measurement by BITE scale considers the frequency of binge eating
and vomiting episodes, among others (use of drugs and fasting). Since the number of binge
eating and vomiting episodes presented positive correlation with the BITE-severity score only
after six months, it seems that the severity of bulimia at the beginning of treatment and after
12 weeks was related to other factors of this test, such as the use of drugs and the practice of
fasting.
Tables 10 and 11 show BITE-symptom and severity, BSQ, EAT scores, and the number
of binge eating and vomiting episodes per week according to the energetic intake ranges for
VOM and VET in each of the 3 phases. The goal was to assess these different response
variables between patients that had hypoenergetic, normoenergetic or hyperenergetic intake.
Findings show that the scores of BITE-severity were significantly higher in patients with
hypoenergetic VET in Phase 3. Therefore, the patient that ate less in Phase 3 presented a
more severe case of BN; that is, the more restrictive a patient is, the more severe is her
disorder.
In regard to the BITE-symptom, Phase 1 results presented a mean rank very similar to the
scores for hypo and normoenergetic VET, but very different from the hyperenergetic
category, showing that patients with hyperenergetic intake presented more symptoms of BN.
As for the number of vomiting episodes per week, it was significantly higher for those
with hypoenergetic VET intake in Phases 1 and 2 (p = 0.07 in Phase 2). This shows that the
greater the food restriction, the greater the vomiting episodes, even without more binge eating
episodes. Again, this shows that vomiting is used for several reasons not related to the
purging of excessive food intake (Olmested et al., 1994). Gendall et al. (1997) found the same
result, and according to them, the less a patient eats, the more often the purgation occurs.
In regard to the number of binge eating episodes per week, the result was significantly
higher for patients with hypoenergetic VET intake in Phase 3, which proves, once again, that
food restriction leads to binge eating episodes (Reiff, 1992).
In regard to meals followed by vomiting and BITE-symptom, it was observed that: those
with hypoenergetic intake presented a lower score, that is, patients with low energy
consumption (in the VOM intake) presented less symptoms; however, this difference was
observed only in Phase 1, indicating that, after treatment, the level of energy intake of meals
followed by vomiting did not determine BN symptoms.
Table 10 – Mean ranks of the scores and bulimic behaviors, within each interval of
energy intake in meals not followed by vomits, along the follow-up
Energy intake in meals BSQ BITE BITE EAT Weekly Weekly

not followed by vomits severity symptoms frequency of frequency of
vomits binges
Hypoenergetic intakea 7.9 10.0 8.6* 10.8 13.4* 11.2
b
Normoenergetic intake 9.8 10.0 8.7 8.8 6.8 6.0
c
Hyperenergetic intake 13.7 10.0 17.3 6.3 5.0 14.0
Hypoenergetic intakea 5.6 6.6 6.5 5.2 11.6d 10.6
b
c e e
Hyperenergetic intake 12.0 9.0 5.5 11.0
Hypoenergetic intakea 5.7 9.3* 7.2 6.5 8.0* 8.4*

b
*: significantly different from the others energy categories, within the same phase.
a
: Hypoenergetic = Intake < 1,199 kcal.
b
: Normoenergetic = Intake between 1,200 e 2,200 kcal.
c
d
: p = 0.07 between the energy categories, within phase 2.
e
: missing value (no subject from this category filled this questionnaire).
Phase 2 showed that BSQ scores were lower in patients with hypoenergetic VOM. It can
be concluded that if the patient worried less about her body, she would eat less energy during
her meals followed by vomiting.
Gendall et al. (1997) also compared energy intake and clinical variables, and they also
found that, the less the patient ate (apart from binge eating episodes), the more often he
purged. They also found that patients that presented more binge eating episodes had a higher
energy intake during these episodes, and that body dissatisfaction scores were higher among
those consuming meals with less energy intake – indicating severe food restriction. This data
was not followed up in this paper. However, the study by Gendall et al. was a cross-sectional,
and not a follow-up study.
Table 11 – Mean ranks of the scores and bulimic behaviors, within each interval of
energy intake in meals followed by vomits, along the follow-up
Energy intake in meals BSQ BITE BITE EAT Weekly Weekly

followed by vomits severity symptoms frequency of frequency
vomits of binges
Hypoenergetic intakea 9.6 9.4 5.5* 11.5 11.0 8.9
b
c
Hypoenergetic intakea 2.0d 4.0 3.0 4.5 5.5 10.0
b
c
Hypoenergetic intakea 7.3 8.8 8.0 9.0 6.8 6.7

b
*: significantly different from the others energy categories, within the same phase.
a
: Hypoenergetic = Intake < 600 kcal.
b
: Normoenergetic = Intake between 600 and 1,000 kcal.
c
d
: p = 0.06 between the energy categories, within phase 2.
Some considerations should be made about this study: firstly, the number of patients was
relatively small, and it became smaller because of the high rate of treatment dropout.
However, it is believed that the number of patients followed up until the end of the process
was sufficient, considering that there are few studies on ED in Brazil, particularly follow-up
studies of bulimic patients and nutritional issues. The number of patients that filled in the tests
and food diaries in Phases 2 and 3 of the follow-up was also low because of dropouts, and
eventually led to missing values, which may have affected the analysis.
It is important to note that the method of dietary assessment – food record – has
limitations and it is subject to bias. Even so, Gayle (1998) affirmed that this method is the
only one able to assess energy intake and to identify binges in free-living bulimic subjects.
We are aware that subjects who fill a food record may change their intake, motivated by
feelings of guilty and shame. Besides that, one still has to consider that the process of coding
the food consumption may have mistakes and that the software used to convert food intake
into nutrient intake may not have values for all foods consumed, for example (Livingstone
and Black, 2003).
Few studies tested strategies to improve the self-report of food intake, especially by
means of not changing the intake during the recording period. Goris and Westerterp (2000)
observed that confronting subjects with implausible results from a prior diary decreases the
errors. In Brazil, Scagliusi et al. (2003) verified that confronting the subjects and conducting
an intensive training on how to record the intake attenuate the error, although it remains high.
In the present research, some procedures were used in order to improve the record.
Patients were told to register their intakes soon after them and instructed on how to describe
the foods consumed and to estimate portion sizes. Every week, a dietitian reviewed the diaries
when the patients returned them, probing the patients and instructing them one more time
when necessary. Moreover, all the records were coded and analyzed by only one researcher,
who was previously trained. We believe that these procedures should have decreased the
errors associated to dietary assessment. As stated by Woell et al. (1989) even with this bias it
is possible to analyze food intake by means of a food diary. Other authors used this method to
assess food intake of bulimic patients and considered it a valid instrument (Elmore and
Castro, 1991; Gendall et al., 1997; Woell et al., 1989).
The instrument used to assess aspects of eating attitudes and relationship with food was
developed for this research based on clinical practice. Many studies confuse the term eating
behavior with food intake, so that the questionnaires that claim to measure behavior, in fact
only assess if some groups of foods are bought and eaten (Kubik et al., 2002; Townsend et
al., 2003). In other researches, food behavior is cited but is not defined, as for example in the
study of Mitchell et al. (1988) which showed that bulimics with poorer prognostic had more
abnormal eating behaviors, without specification of what these behaviors would be. Some
studies focus on behaviors that are important to EDs, but their interrogations only cover the
classical symptoms of BN, like for example vomiting frequency (Martín et al., 1999). There
are some widely used scales in ED research, like the Restraint Scale (Herman and Mack,
1975), which measures chronic dieting or the switch between periods of restraint and lapses,
the Three-Factor Eating Questionnaire (Stunkard and Messick, 1985), a measure of
disinhibition, restraint and subjective assessment of hunger, and the Dutch Eating Behavior
Questionnaire (van Strien et al., 1986), which also measures restraint. Although these scales
are useful and well developed psychometrically, they are limited in scope, and assess mainly
dietary restraint. These factors are associated to BN, but they do not encompass the wide
range of dysfunctional eating attitudes that this disease implies. In this manner, using only
these questionnaires supplies a lot of relevant data, but also ignores other pieces of
information, such as beliefs and perceptions about food, the pleasure of eating, hidden eating,
difficulty in handling with hunger, social events, food choice, and feelings towards food. We
believe it is relevant to research these aspects, as we could note, with the data of this study,
that even the patients whose clinical status becomes normal may still have a complicated
relationship with eating and their bodies. This may, in turn, cause psychological distress and
lead to recurrence. In this manner, the questions utilized in this research served as a starting
point for the development of a specific tool to measure eating attitudes in patients with EDs.
Today, based on these results an instrument is being adapted and validated.
Moreover, the results of specific nutritional interventions for the treatment of BN could
not be separately tested in controlled studies, because they are a part of a total treatment
program (Rock and Curran-Celentano, 1996). Using just the nutritional intervention, without
the due clinical, psychiatric and therapeutic follow-ups would be unethical. Also, due to
ethical considerations, control groups, to which only one of the treatment components is
provided, are not recommended.
Conclusion
In summary, some positive changes were observed after 12 weeks of CBT: a significant
change in the EAT and the BITE-symptom scores, and zero median for laxative, diuretic and
appetite moderator drug use. After six months follow-up, the positive changes found were:
the patients did not meet the diagnostic criteria for BN, taking into consideration the means
and medians of binge eating and vomiting episodes; EAT and BITE-symptom scores showed
a non-symptomatic group; and there was significant difference in the BSQ score.
Regarding eating behaviors and relationship toward foods the following improves were
observed: guilty after eating ‘forbidden foods’ decreased (as well as the behavior while and
after eating these foods improved), some misconceptions about food were reverted (as
thinking that eating a little more automatically causes weight gain), some negative feelings
involving food were reduced (as anxiety, lack of control and nervousness) while the feeling of
tranquility has increased. The obsession with food has also decreased, resulting in a smaller
interference of food in patients’ life. Nevertheless, it is remarkable that many disturbed
attitudes did not change, especially those related to feelings, reflected by the lack of pleasure
with food and the difficulties in dealing with hunger.
On the other hand, we did not find changes in food intake. This result is preoccupant and
should be carefully monitored by dietitians while they treat bulimic patients. Treatment
should encourage a regular meal pattern, composed by frequent meals rich in nutrient-dense
foods.
The assessment of these patients, based on standardized tests, showed positive progress,
as shown by the progress of bulimic symptoms. The use of standardized score tests and data
regarding bulimic behavior and energy intake allowed for a clearer understanding of the
pattern of the disease and its prognosis. It was possible to confirm an important fact, namely
that energy restriction is related to higher frequency of binge eating and purging.
It is believed that standardized tests are an effective strategy to assess follow-up of
bulimic patients, since measuring the treatment outcome just by verifying changes in the
frequency of bulimic symptoms cannot cover the complexity of ED. Furthermore, it is
relevant to include measurements of nutritional consumption, such as energy intake in eating
episodes, whether followed by vomiting or not. Because it is known that BN is a chronic
disorder, with a high chance of recurrence, it is necessary to think about recovery in a broader
manner, aiming to improve the relation towards body, weight and food in addition to other
positive psychological changes.
The main objective of the traditional nutritional approach for BN is to establish a normal
eating pattern and to cease the purging practices. Further nutritional treatment, based specially
on counseling, should aim to help the patient to distinguish behavior related to food and
weight from feelings and psychological issues, and to promote improvements in eating
attitudes (ADA, 2001). New techniques and interventions are required to treat and to alter the
relation established by the patient towards food.
In-depth knowledge about eating attitudes is necessary to design a nutritional intervention
able to improve the quality of the diet of these patients and also to promote behavioral
changes (Hetherington et al., 1993; Sunday and Halmi, 1996). Researchers and practitioners
need to understand and treat all the disordered eating aspects presented by patients with BN
and not only the bulimic episodes that define this syndrome (Hetherington et al., 1993).
Therefore, other measures – such as relationship and attitudes towards food – should be
investigated and assessed after the intervention. We believe that this kind of comprehensive
treatment is necessarily long and can be conducted only if the professionals involved have a
broad understanding of all meanings that food (and also the disease) has. As stated by Levine
(1994), “people with eating disorders are people struggling with fantasies, motives, anxieties,
and coping mechanisms that are established and vigorously reinforced by our culture. They
are not ‘ics’ – anorexics or bulimics”. So dietitians that work with ED should strive to better
understand these topics and to seek training in counseling, cognitive techniques and
motivational interviewing to improve the treatment of all features of the eating attitudes of
these patients.
Based on the results presented in this chapter, our program of nutritional treatment was
improved. Its duration was increased to 18 weeks, and the individual counseling has been
receiving more attention and time. We are also developing a new treatment program, whose
aim will be the improvement of eating attitudes and relationship with the body and food. This
new program will be provided to patients after completion of the 18-weeks program. We
believe that the first treatment goal is to end bulimic behavior and establish a healthier intake,
but if we do not provide a deeper understanding of all food and body issues that the patient
presents it is very likely to have a relapse. Also, by providing a more comprehensive care we
can be sure that we are treating a person and not a disease.
It is also relevant to note that in order to meet this goal, tools for measuring eating
attitudes, especially those focused on feelings, beliefs and attitudes towards food, should be
developed and validated. Our research group is now working with the instrument tested in
this study. Considering the findings of this research, this eating attitudes questionnaire is
being adapted and will be psychometrically tested.
Finally, our data showed that eating disorders are also a reason for concern in an
undeveloped country as Brazil. Our health system needs to be more prepared to deal with this
problem, since there are too few centers that treat these diseases in Brazil. Perhaps it is even
more necessary to discuss prevention of eating disorders, especially because they afflict
mainly young women. In Brazil, young women live in a difficult scenario, already marked by
a poor health status, which could be more aggravate with the presence of an eating disorder.
It is also relevant to attest that in order to prevent eating disorders specific interventions
should be provided to a wide range of people, specially young girls and women, with focus in
nutrition education, body image improvement, size acceptance and with strategies to improve
relationship towards food. As a research group on nutrition and eating disorders, we believe
that improvement of eating attitudes and relationship towards food is necessary not only for
treatment of eating disorders, but also for its prevention.
References
Abraham, SF; Mira, M; Llewellyn-Jones, D. Bulimia: a study of outcome. Int J Eat Disord,
1983, 2, 175-80.
Adami, G; Bauer, B; Gandolfo, P; Scopinaro, N. Body image in early-onset obese patients.
Eat Weight Disord, 1997, 2, 87-93.
Agras, WS; Crow, SJ; Halmi, KA; Mitchell, JE; Wilson, GT; Kraemer, HC. Outcome
predictors for cognitive behavior treatment of bulimia nervosa: data from a multisite
study. Am J Psychiatry, 2000, 157, 1302-08.
Alvarenga, MS; Philippi, ST; Negrão, AB. Nutritional aspects of eating episodes followed by
vomiting in Brazilian patients with bulimia nervosa. Eat Weight Disord, 2003, 8, 150-56.
American Dietetic Association (ADA). Position of the American Dietetic Association:
nutritional intervention in the treatment of anorexia nervosa and bulimia nervosa –
technical support paper. J Am Diet Assoc, 1988, 88, 69-71.
nutritional intervention in the treatment of anorexia nervosa, bulimia nervosa and binge
eating. J Am Diet Assoc, 1994, 94, 902-7.
nutritional intervention in the treatment of anorexia nervosa, bulimia nervosa, and eating
disorders not otherwise specified (EDNOS). J Am Diet Assoc, 2001, 101, 810-19.
American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental
Disorders (4th ed.), Washington DC: American Psychiatric Association; 1994.
Bacaltchuk, J; Hay, P. Treatment of bulimia nervosa: a synthesis of evidence. Rev Bras Psiq,
1999, 21, 1-8.
Beals, KA. Eating behaviors, nutritional status, and menstrual function in elite female
adolescent volleyball players. J Am Diet Assoc, 2002,102,1293-96.
Becker, AE; Grinspoon, SK; Klibanski, A; Herzog, DB. Eating disorders – current concepts.
New Engl J Med, 1999, 8, 1092-98.
Behar, R; de la Barrera, M; Michelotti, J. Clinical characteristics and gender identity among
eating disordered patients subtypes. Rev Med Chil, 2003, 131,748-58.
Bhugra, D; Mastrogianni, A; Maharajh, H; Harvey, S. Prevalence of bulimic behaviours and
eating attitudes in schoolgirls from Trinidad and Barbados. Transcult Psychiatry, 2003,
40, 409-28.
Borges, MB; Jorge, MR; Morgan, CM; Da Silveira, DX; Custodio, O. Binge-eating disorder
in Brazilian women on a weight-loss program. Obes Res, 2002, 10, 1127-34.
Brambilla, F; Draisci, A; Peirone, A; Brunetta, M. Combined cognitive-behavioral,
psychopharmacological and nutritional therapy in bulimia nervosa. Neuropsychobiology,
1995, 32, 68-71.
Cash, TF; Henry, PE. Women’s body images. The results of a national survey in the USA.
Sex Roles, 1995, 33, 19.
Collings, S; King, M. Ten-year follow-up of 50 patients with bulimia nervosa. Br J Psych,
1994, 164, 80-7.
Cooper, PJ; Taylor, M; Cooper, Z; Fairburn, CG. The development and validation of the
Body Shape Questionnaire. Int J Eat Disord, 1987, 6, 485-94.
Cordás, TA; Castilho, S. Body image in eating disorders - Assessment instrument: "Body
Shape Questionnaire". Psiq Biol, 1994, 2, 17-21.
Cordás, TA; Hochgraf, PB. The BITE: instrument for bulimia nervosa assessment. J Bras
Psiq, 1993, 42, 141-4.
Dolan, JB; Lacey, H; Evans, C. Eating behavior and attitudes to weight and shape in British
women from three ethnic groups. Br J Psych, 1990, 157, 523-28.
Dowson, J; Henderson, L. The validity of a short version of the Body
Shape Questionnaire. Psychiatry Research, 2001, 102, 263-71.
Dunker, KLL; Philippi, ST. Food habits and behavior in adolescents with symptoms of
anorexia nervosa. Rev Nutrição Puccamp, 2003, 16, 51-60.
Eckstein-Harman, M. Eating disorders: the changing role of nutrition intervention with
anorexic and bulimic patients during psychiatric hospitalization. J Am Diet Assoc, 1993,
93, 1039-40.
Eiger, MR; Christie, BW; Sucher, KP. Change in eating attitudes: An outcome measure of
patients with eating disorders. J Am Diet Assoc, 1996, 96, 62-4.
Elmore, DK; Castro, JM. Meal patterns of normal, untreated bulimia nervosa and recovered
bulimic women. Psychol Behav, 1991, 49, 99-105.
Fahy, TA; Russell, GFM. Outcome and prognostic variables in bulimia nervosa. Int J Eat
Disord, 1993,14, 135-45.
Fairburn, CG. A cognitive behavioral approach to the treatment of bulimia. Psychol Med,
1981, 11, 707-11.
Fairburn, CG; Kirk, J; O´Connor, M; Cooper, PJ. A comparison of two psychological
treatments for bulimia nervosa. Behav Res Therapy, 1986, 24, 629-43.
Fernández, F; Sánchez, I; Turón, JV; Jiménez, S; Alonso, P; Vallejo, J. Psychoeducative
ambulatory group in bulimia nervosa. Evaluation of a short-term approach. Actas Luso
Esp Neurol Psiquiatr Cienc Afines, 1998, 26, 23-8.
Fitcher, MM; Quadflieg, N; Rief, W. The German longitudinal bulimia nervosa study. In:
Herzog, W; Deter, HC; Vanderycken, W. (Eds.), The course of eating disorders: long
term follow-up studies of anorexia and bulimia nervosa. New York: Springer-Verlag;
1992; pp.133-49.
Fontenelle, L; Mendlowicz, M; Menezes, GB; Papelbaum, M; Freitas, S; Godoymatos, A;
Coutinho, W; Appolinario, JC. Psychiatric comorbidity in a Brazilian sample of patients
with binge-eating disorder. Psychiatry Research, 2003, 119,189-94.
Freeman, RJ; Beach, B; Davis, R; Solyom, L. The prediction of relapse in bulimia nervosa. J
Psych Res, 1985, 9, 349-53.
Gannon, MA; Mitchell, JE. Subjective evaluation of treatment methods by patients treated for
bulimia. J Am Diet Assoc, 1986, 86, 520-21.
Garcia, RWD. The food, the diet, the taste. Changes in the Urban Food Culture.
[dissertation]. São Paulo (SP): University of São Paulo; 1999.
Garfinkel, PE; Goldbloom, D; Davis, R; Olmested, MP; Garner, DK; Halmi KA. Body
dissatisfaction in bulimia nervosa: relationship to weight and shape concerns and
psychological functioning. Int J Eat Disord. 1992, 11, 151-61.
Garner, DM. Psychotherapy outcome research with bulimia nervosa. Psychoth Psychos,
1987, 48, 129-40.
Garner, DM; Garfinkel, PE. The eating attitudes test: an index of the symptom of anorexia
nervosa. Psychol Med, 1979, 9, 273-9.
Garner, DM; Olmested, MP; Bohr, Y; Garfinkel, PE. The eating attitude test: psychometric
features and clinical correlates. Psychol Med, 1982, 12, 871-79.
Garner, DM; Olmested, MP; Polivy, J. Development and validation of a multidimensional
eating disorder inventory for anorexia nervosa and bulimia. Int J Eat Disord, 1983, 2, 15-
34.
Gayle, MT. Caloric intake patterns of nonpurge binge-eating women. West J Nurs Res, 1998,
20, 103-18.
Gendall, KA; Sullivan, PE; Joyce, PR; Carter, FA; Bulik, CM. The nutrient intake of women
with bulimia nervosa. Int J Eat Disord, 1997, 21, 115-27.
Ghazal, N; Agoub, M; Moussaoui, D; Battas, O. Prevalence of bulimia among secondary
school students in Casablanca. L´Encephale, 2001, 27, 338-42.
Goris, AHC; Westerterp, KR. Improved reporting of habitual food intake after confrontation
with earlier results on food reporting. Brit J Nutr, 2000, 83, 363-9.
Greenfeld, D; Mickley, D; Quinlan, DM; Roloff, P. Hypocalemia in outpatients with eating
disorders. Am J Psychiatry, 1995, 152, 60-3.
Hadigan, CM; Kissileff, HR; Walsh, BT. Patterns of food selection during meals in women
with bulimia. Am J Clin Nutr, 1989, 50, 759-66.
Hay, PJ. Epidemiology of eating disorders: current status and future developments. Rev Bras
Psiquiatr, 2002, 24, 13-7.
Hedges, DW; Reimherr, FW; Hoopes, SP; Rosenthal, NR; Kamin, M; Karim, R; Capece, J.
Treatment of bulimia nervosa with topiramate in a randomized, double-blind, placebo-
controlled trial, part 2: improvement in psychiatric measures. J Clin Psychiatry, 2003,
64,1449-54.
Henderson, M; Freeman, A. A self-rating scale for bulimia: the BITE. Brit J Psych, 1987,
150, 18-24.
Herman, CP; Mack, D. Restrained and unrestrained eating. J Pers, 1975, 43, 647-60.
Herzog, DB; Nussbaum, KM; Marmor, AK. Comorbidity and outcome in eating disorders.
Psych Clin North Am,1996, 9, 843-59.
Hetherington, MM; Altemus, M; Nelson, ML; Bernat, AS; Gold, PW. Eating behavior in
bulimia nervosa: multiple meal analyses. Am J Clin Nutr, 1994, 60, 864-73.
Hetherington, MM; Spalter, AR; Bernat, AS; Nelson, ML; Gold, PW. Eating pathology in
bulimia nervosa. Int J Eat Disord, 1993, 13, 13-24.
Hill, AJ; Williams, J. Psychological health in a non-clinical sample of obese women. Int J
Obes, 1998, 22, 578-83.
Hsu, LKG; Holder, D. Bulimia nervosa: treatment and short-term outcome. Psychol Med,
1986, 16, 65-70.
Institute of Medicine. Dietary Reference Intakes: for Calcium, Phosphorus, Magnesium,
Vitamin D, and Fluoride. Food and Nutrition Board. Washington, D.C.:
National Academy Press; 1997.
Institute of Medicine. Dietary Reference Intakes: for Riboflavin, Niacin, Vitamin B6, Folate,
Vitamin B12, Pantothenic Acid, Biotin, and Choline. Food and Nutrition Board.
Washington, D.C.: National Academy Press; 1998.
Institute of Medicine. Dietary Reference Intakes: for Vitamin C, Vitamin E, Selenium and
Carotenoids. Food and Nutrition Board. Washington, D.C.: National Academy Press;
2000.
Joergensen, J. The epidemiology of eating disorders in Fyn County, Denmark, 1977-1986.
Acta Psych Scand, 1992, 85, 30-4.
Johnson, C. Initial consultation for patients with bulimia and anorexia nervosa In: Garner,
DM; Garfinkel PE. (Eds). Handbook of psychotherapy for anorexia nervosa and
bulimia. New York: Guilford Press; 1985; 19-51.
Johnson, C; Maddi, K. Etiologia de la bulimia: perspectivas biopsicosociales In: Feinstein,
SC; Sorosky, AD. (Eds). Transtornos en la alimentación. Buenos Aires: Ediciones
Nueva Vision; 1988; 53-80.
Johnson, WG; Shlundt, DG; Jarrell, MP. Exposure with response prevention, training in
energy balance and problem/solving therapy for bulimia nervosa. Int J Eat Disord, 1986,
5, 35-46.
Kaye, WH; Weltzin, TE; Hsu, LKG; McConaha, CW; Bolton, B. Amount of calories retained
after binge eating and vomiting. Am J Psychiatry, 1993,150, 969-71.
Keel, PK; Mitchell, JE. Outcome in bulimia nervosa. Am J Psychiatry, 1997,154, 313-21.
Keel, PK; MitchelI, JE; Miller, KB; Davis, TL; Crow, SJ. Long-term outcome of bulimia
nervosa. Arch Gen Psych, 1999,56, 63-9.
Keller, MB; Herzog, DB; Lavori, PW; Bradburn, IS; Mahoney, EM. The naturalistic history
of bulimia nervosa: extraordinary high rates of chronicity, relapse, recurrence, and
psychosocial morbidity. Int J Eat Disord, 1992, 12, 1-9.
Kissileff, HR; Walsh, BT; Kral, JG; Cassidy, SM. Laboratory studies of eating behavior in
women with bulimia. Physiol Behav, 1986, 38, 563-70.
Kubik MY; Lytle, LA; Hannan, PJ; Story, M; Perry, CL. Food-related beliefs, eating
behavior, and classroom food practices of middle school teachers. J Sch Health, 2002,
72, 339-345.
Lacey, JH. Bulimia nervosa, binge eating, and psychogenic vomiting: a controlled treatment
study and long term outcome. Brit Med J, 1983, 286, 1609-13.
Lacey, JH. Time limited individual and group treatment for bulimia. In: Garner, M; Garfinkel,
PE. (Eds). Handbook of Psychotherapy for anorexia nervosa and bulimia. New York:
Guilford Press; 1985; p. 431-57.
Lasater, LM; Mehler, PS. Medical complications of bulimia nervosa. Eat Behav, 2001, 2,
279-92.
Latner, JD; Wilson, T. Cognitive-behavioral therapy and nutritional counseling in the
treatment of bulimia nervosa and binge eating. Eat Behav, 2000, 1, 3-21.
Lee, S; Kwok, K; Liau, C; Leung, T. Screening Chinese patients with eating disorders using
the Eating Attitudes Test in Hong Kong. Int J Eat Disord, 2002, 32, 91-7.
Leung, N; Waller, G; Thomas, G. Outcome of group cognitive-behavior therapy for bulimia
nervosa: the role of score beliefs. Behav Res Ther, 2000, 38, 145-56.
Levine, M. Some basic principles for understanding, referring, and preventing eating
disorders. [Presented at the 13th National NEDO Conference, Columbus, Ohio, October
3, 1994.]
Livingstone, MBE; Black, AE. Markers of the validity of reported energy intake. J Nutr,
2003, 133, 895S-920S.
Maddocks, SE, Kaplan, AS. The prediction of treatment response in bulimia nervosa - A
study of patient variables. Brit J Psych, 1991, 159, 846-9.
Maddocks, SE; Kaplan, AS; Woodside, DB; Langdon, L; Piran, N. Two year follow-up of
bulimia nervosa: the importance of abstinence as the criterion of outcome. Int J Eat
Disord, 1992, 12, 133-41.
Martín, AR; Nieto, JMM; Jiménez, MAR; Ruiz, JPN; Vasquez, MCD; Fernández, YC;
Gómez, MAR; Fernández, CC. Unhealthy eating behaviour in adolescents. Eur J
Epidemiol. 1999, 15, 643-8.
Mitchell, JE; Laine, DC. Monitored binge-eating behavior in patients with bulimia. Int J Eat
Disord, 1985, 4, 177-83.
Mitchell, JE; Pyle, RL; Eckert, ED. Frequency and duration of binge-eating episodes in
patients with bulimia. Am J Psychiatry, 1981, 138, 835-6.
Mitchell, JE; Pyle, RL; Hatsukami, D; Goff, G; Glotter, D; Harper, J. A 2-5 year follow-up
study of patients treated for bulimia. Int J Eat Disord, 1988, 8, 157-65.
Monteiro, CA; Conde, WL; Popkin, BM. Is obesity replacing or adding to undernutrition?
Evidence from different social classes in Brazil. Public Health Nutr, 2002, 5, 105-12.
Monteiro, CA; Conde, WL; Popkin, BM. The burden of disease from undernutrition and
overnutrition in countries undergoing rapid nutrition transition: a view from Brazil. Am J
Public Heath, 2004, 94, 433-4.
Nakazato, M; Hashimoto, K; Shimizu, E; Kumakiri, C; Koizumi, H; Okamura, N; Mitsumori,
M; Komatsu, N; Iyo, M. Decreased levels of serum brain-derived neurotrophic factor in
female patients with eating disorders. Biol Psychiatry, 2003,54, 485-90.
Nappo, SA; Tabach, R; Noto, AR; Galduróz, JCF; Carlini, EA. Use of anoretic amphetamine-
like drugs by Brazilian women. Eat Behav, 2002, 3, 153-65.
Nasser, M. Culture and weight consciousness. J Psychosom Res, 1988, 32, 573-7.
Nasser, M; Katzman, MA; Gordon, RA. Eating disorders and cultures in transition. New
York: Taylor and Francis; 2001.
National Research Council (NRC). Recommended Dietary Allowances (RDA). 10.ed.
Washington, D.C.: National Academy Press; 1989.
Negrão, AB; Cordás, TA. Clinical characteristics and course of anorexia nervosa in Latin
America, a Brazilian sample. Psychiatry Res, 1996, 62,17-21.
Nobakht, M; Dezhkam, M. An epidemiological study of eating disorders in Iran. Int J Eat
Disord , 2000, 28, 265-71.
Nunes, MA; Bagatini, LF; Abuchaim, AL; Kunz, A; Ramos, D; Silva, A; Somenzi, L;
Pinheiro, A. Eating disorders: considerations about The Eating Attitudes Test (EAT). R
ABP-APAL, 1994, 16, 7-10.
Nunes, MA; Barros, FC; Anselmo Olinto, MT; Camey, S; Mari, JDJ. Prevalence of abnormal
eating behaviours and inappropriate methods of weight control in Young women from
Brazil: a population-based study. Eat Weight Disord, 2003, 8, 100-06.
Nutzinger, DO; Zwann, M. Behavioral treatment of bulimia nervosa. In: Fitcher, MF. (Ed.).
Bulimia nervosa: basic research, diagnosis and therapy. Chischester: John Willey and
Sons; 1990; p.292
Olmested, MP; Kaplan, AS; Rockert, W. Rate and prediction of relapse in bulimia nervosa.
Am J Psychiatry, 1994, 151, 738-43.
Philippi, ST; Szarfarc, SC; Latterza, AR. Virtual Nutri (Version 1.0 for Windows).
[Computer software]. São Paulo, SP: Department of Nutrition, School of Public Health,
University of São Paulo; 1996.
Polivy, J. Psychological consequences of food restriction. J Am Diet Assoc, 1996, 96, 589-92.
Popkin, BM. Nutritional patterns and transitions. Pop Devel Res, 1993, 19, 138-57.
Pyle, RL; Mitchell, JE; Eckert ED; Hatsukami, D; Pomeroy, C; Zimmerman, R. Maintenance
treatment and 6 month outcome for bulimic patients who respond to initial treatment. Am
J Psychiatry, 1990, 147, 871-75.
Ramirez, EM; Rosen, JC. A comparison of weight control and weight control plus body
image therapy for obese men and women. J Consult Clin Psychol, 2001, 69, 440-46.
Reiff, DW. Behavior change: bulimia nervosa. In: Reiff, DW; Reiff, KKL. (Eds.). Eating
disorders – Nutrition therapy in the recovery process. Maryland: Aspen Publishers;
1992; p.360-4.
Reiff, DW; Reiff, KKL. Eating disorders – Nutrition therapy in the recovery process.
Maryland: Aspen Publishers; 1992.
Rock, CL; Curran-Celentano, J. Nutritional management of eating disorders. Psych Clin
North Am, 1996, 19, 701-13.
Rodin, J; Silberstein, L; Striegel-Moore, R. Women and weigh: a normative discontent. In:
Sonderegger, TB. (Ed.) Nebraska symposium on motivation: psychology and gender.
Lincoln: University of Nebraska Press; 1984; p.267.
Rorty, M; Yager, J; Rossoto, E. Why and how do women recover from bulimia nervosa? The
subjective appraisals of forty women recovered for a year or more. Int J Eat Disord,
1993, 14, 249.
Rosen, JC; Leitenberg, H; Fisher, C; Khazam, C. Binge-eating episodes in bulimia nervosa:
the amount and type of food consumed. Int J Eat Disord, 1986, 5, 255-67.
Rosen, JC; Reiter, J; Orosan, P. Cognitive-behavioral body image therapy for body
dysmorphic disorder. J Consult Clin Psychol, 1995, 63, 263-9. [Erratum in: J Consult
Clin Psychol, 1995, 63, 437.]
Scagliusi, FB; Polacow, VO; Artioli, GG; Benatti, FB; Lancha Jr, AH. Selective
underreporting of energy intake in women: magnitude, determinants, and effect of
training. J Am Diet Assoc, 2003, 103, 1306-13.
Scagliusi, FB; Polacow, VO; Cordás, TA; Coelho, D; Alvarenga, MS; Philippi, ST; Lancha
Jr, AH. Test-Retest Reliability and Discriminant Validity Of the Restraint Scale
Translated into Portuguese. Eat Behav, 2005a, 6, 85-93.
Scagliusi, FB; Polacow, VO; Cordás, TA; Coelho, D; Alvarenga, MS; Philippi, ST; Lancha Jr
AH. Translation, adaptation and psychometric evaluation of a nutrition knowledge scale.
Brazilian Journal of Nutrition, 2005-b. (in press)
Scagliusi, FB; Polacow, VO; Cordás, TA; Coelho, D; Alvarenga, MS; Philippi, ST; Lancha Jr
AH. Translation into Portuguese and validation of the Body Attitudes Questionnaire.
Percept Mot Skills. 2005-c, 100, 25-41.
Scagliusi, FB; Alvarenga, MS; Polacow, VO; Cordás, TA; Queiróz GKO; Coelho, D;
Philippi, ST; Lancha Jr AH. Concurrent and discriminant validity of the Stunkard’s
Figure Rating Scale adapted into Portuguese. Apettite, 2006. (in press)
Steinhausen, HC; Seidel, R. Correspondence between the clinical assessment of eating-
disordered patients and findings derived from questionnaires at follow-up. Int J Eat
Disord, 1993, 14, 367-74.
Story, M. Nutrition management and dietary treatment of bulimia. J Am Diet Assoc, 1986, 86,
517-19.
Stunkard, AJ; Messick, S. The three-factor eating questionnaire to measure dietary restraint,
disinhibition and hunger. J Psychosom Res. 1985, 29, 71-83.
Sunday, SR; Einhorn, A; Halmi, KA. Relashionship of perceived macronutrient and caloric
content to affective cognitions about food in eating-disordered, restrained, and
unrestrained subjects. Am J Clin Nutr, 1992, 55, 362-71.
Sunday, SR; Halmi, KA. Micro-and macroanalyses of patterns within a meal in anorexia and
bulimia nervosa. Appettite, 1996, 26, 21-36.
Strigel-Moore, RH; Silberstein, LR; Rodin, J. Toward an understanding of risk factors for
bulimia. Am Psychologist, 1986, 41, 246-63.
Swift, WJ; Ritholz, M; Kalin, NH; Kaslow, N. A follow-up study of thirty hospitalized
bulimics. Psychosom Med, 1987, 49, 45-55.
Thiels, C; Schmidt, U; Treasure, J; Garthe, R. Four-year follow-up of guided self-change for
bulimia nervosa. Eat Weight Disord, 2003, 8, 212-17.
Thompson, JK. The (mis)measurement of body image: ten strategies to improve assessment
for applied and research purposes. Body Image, 2004, 1, 7-14.
Townsend, MS; Kaiser, LL; Allen, LH; Joy, AB; Murphy, SP. Selecting items for a food
behavior checklist for a limited-resource audience. J Nutr Educ Behav, 2003, 35, 69-82.
Trumbo, P; Schlicker, S; Yates, AA; Poos, M. Dietary Reference Intakes for energy,
carbohydrate, fiber, fat, fatty acids, cholesterol, protein and amino acids. J Am Diet
Assoc, 2002, 102, 1621-30.
Vanderlinden, J; Norre, J; Vanderycken, W. A practical guide to the treatment of bulimia
nervosa. New York: Brunner/Mazel; 1989.
Van Strien, T; Frijters, JE; van Staveren, WA; Defares, PB; Deurenberg, P. The predictive
validity of the Dutch Restrained Eating Scale. Int J Eat Disord, 1986, 5, 747-55.
Villapiano, M; Goodman, LJ. Eating Disorders: Time for Change. Philadelphia: Taylor and
Francis; 2001a.
Villapiano, M; Goodman, LJ. Eating Disorders: The Journey to Recovery Workbook.
Philadelphia: Taylor and Francis; 2001b.
Vilela, JE; Lamounier, JA; Dellaretti Filho, MA; Barros Neto, JR; Horta, GM.
Eating disorders in school children. J Pediatr, 2004, 80, 49-54.
Wallin, G.van der Ster, Noring, C; Holmgren, S. Binge eating versus nonpurged eating in
bulimics: is there a carbohydrate craving after all? Acta Psych Scand, 1994, 89, 376-81.
Wallin, G van der Ster; Noring, C; Lennernas, MAC; Holmgren, S. Food selection in
anorectics and bulimics: food items, nutrient content and nutrient density. J Am Coll
Nutr, 1995, 4, 271-2.
Walsh, BT; Kissileff, HR; Cassidy, SM; Dantzic, S. Eating behavior of women with bulimia.
Arch Gen Psych, 1989, 46, 54-8.
Whisenant, SL; Smith, BA. Eating disorders: current nutrition therapy and perceived needs in
dietetics education and research. J Am Diet Assoc, 1995, 95,1109-12.
Woell, C; Ficther, MM; Pirke, KM; Wolfram, G. Eating behavior of patients with bulimia
nervosa. Int J Eat Disord, 1989, 8, 557-68.
Wolff, GE; Clark, MM. Changes in eating self-efficacy and body image following cognitive-
behavioral group therapy for binge eating disorder: a clinical study. Eat Behav, 2001, 2,
97-104.
Yager, J. Weighty perspectives: contemporary challenges in obesity and eating disorders. Am
J Psychiatry, 2000, 157, 851-3.

Cap Nova Publishers

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Cap Nova Publishers

Uploaded by

Copyright:

Available Formats

Effects of Multiprofessional Treatment on

Clinical Symptoms, Food Intake, Eating

Marle dos Santos Alvarenga(1), Fernanda Baeza Scagliusi(2) and Sonia

Just as in other developing countries, Brazil is undergoing a nutritional transition. Nutritional

Findings and Discussion

Table 1- Patients descriptive data at the beginning of treatment (phase 1)

Characteristics Mean + Standard Deviation

Age (years) 27.7 + 6.3

Age when dieting started (years) 17.3 + 4.6

Age when binges started (years) 18.7 + 4.2

Age when vomiting started (years) 20.5 + 6.1

Weight (pounds) 135.9 + 23.7

Body Mass Index (kg/m2) 22.9 + 3.9

Desirable weight (pounds) 120.0 + 14.0

Weight variation throughout adulthood (pounds) 33.3 + 17.5

*: significantly different from results obtained three months after treatment

1 – Before treatment 25.8 + 10 4.1 + 2 2.9 + 2 4.3 + 2 3.4 + 2 4.5 + 1 2.3 + 2

*: significantly different from Phase 3.

1 – Before treatment 1,529 + 945 14.6 + 3 53.5 + 8 32.1 + 7

2 – Immediately after 1,475 + 771 15.8 + 3 50.8 + 6 32.6 + 5

3 – Three months after 1,337 + 519 17.6 + 3 50.4 + 6 31.6 + 6

*: significantly different from Phase 3.

2 – Immediately after 1,402 + 707 17.2 + 7 45.9 + 15 34.2 + 7

3 – Three months after 1,211 + 226 10.1 + 5 60.7 + 3 28.1 + 3

treatment after treatment treatment

Meals not followed by vomits

Normoenergetic intakeb 31.6% 41.2% 50.0%

Hyperenergetic intakec 15.8% 11.8% 0%

Meals followed by vomits*

Normoenergetic intakee 47.4% 70.6% 75.0%

Hyperenergetic intakef 31.6% 17.6% 0%

*: χ2 (2) = 21.32; p < 0.005.

3f 0.9 + 0.4 (0.7; 0.5 – 1.5) 81

1d 0.8 + 0.4 (0.7; 0.1 – 1.4) 58

Vitamin B6 (mg) 2e 0.9 + 0.4 (0.8; 0.4 – 2.0) 1.3 68

3f 0.9 + 0.4 (0.8; 0.5 – 1.7) 72

1d 18 + 29 (0.8; 0 – 95) 351

Vitamin D (mcg) 2e 10 + 15 (1; 0 – 55) 5 199

3f 8 + 20 (0.6; 0 – 68) 166

Vitamin E (mg) 2e 9 + 7 (7; 2 – 25) 15 57

1d 1,551 + 1,156 (1,236; 68 – 4,406) 65

Sodium (mg) 2e 1,604 + 1,125 (1,123; 598 – 4,917) 2,400 67

3f 1,397 + 669 (1,427; 483 – 2,652) 58

1d 552 + 289 (481; 99 – 1,081) 55

Calcium (mg) 2e 855 + 960 (569; 196 – 4,178) 1,000 86

Magnesium (mg) 2e 132 + 79 (116; 43 – 356) 310 43

3f 132 + 39 (133; 73 – 199) 42

1d 1,195 + 539 (1,128; 211 – 2,433) 34

Potassium (mg) 2e 1,265 + 513 (1,061; 508 – 2,625) 3,500 36

3f 1,493 + 382 (1,390; 1,015 – 2,150) 43

1d 6 + 4 (5; 0.4 – 15) 34

Iron (mg) 2e 7 + 3 (6; 2 – 15) 18 37

Questions Phase 1 – Phase 2 –Immediately Phase 3- Three months after treatment

Before treatment after treatment

that you try to cut from your diet?*

Do you feel pleasure when you eat? 75% 71% 76%

Do you like cooking? 70% 65% 59%

party, do you eat in a different manner?**

occasion automatically makes you put on weight?***

diet can make you lose weight?

*: p ≤ 0.05; **: p ≤ 0.01; ***: p ≤ 0.001; a: p = 0.09

treatment after treatment

Frequently Infrequently Frequently Infrequently Frequently Infrequently

: p ≤ 0.05; : p ≤ 0.01; : p ≤ 0.001; a: p = 0.09