EATING DISORDER
Anorexia Nervosa
General information:
Anorexia Nervosa (AN) is an eating disorder that is classified under the DSM-IV criteria. This eating disorder is characterized by being underweight and having an intense fear of gaining weight or becoming fat. The person’s self-perception of body weight, size or shape (self image) is distorted. Amenorrhea can also be present. A differentiation is made between the restricting type (consuming no food or little food) and the purging type (eating binges and otherwise eating very little, vomiting, using laxatives or diuretics). Compulsive exercise may occur in either type. If the eating disorder does not meet all the DSM criteria of Anorexia Nervosa or Bulimia Nervosa, then it is referred to as Eating Disorder NOS (not otherwise specified).
It is important for the doctor to refer the patient to a dietitian specialized in the treatment of eating disorders.
Patients are often ambivalent towards treatment. They often deny that they have eating problems. They come to the doctor with other symptoms. The general practitioner can consider the diagnosis of an eating disorder when someone in the risk group for eating disorders comes to the practice consult with psychological symptoms, gastrointestinal symptoms or menstrual symptoms. The doctor can then ask specifically about eating problems.
Best time to refer to the dietician:
Diagnosis
- when BMI < 18.5 kg/m2 or in children a standard deviation score (SDS) of < -1 and suspicion of anorexia nervosa
- when there is insufficient clarity around food consumption, eating patterns, attitudes to food, weight- and food-related subjects, and suspicion of anorexia nervosa
- when there is a negative self-image.
Treatment
- once the diagnosis has been made
Relevant information for the dietician:
- Diagnosis: (suspicion of) anorexia nervosa, any comorbid conditions
- Laboratory tests: if applicable
- Medication: laxatives, diuretics, psychopharmaceuticals, weight-loss drugs (stackers)
- Other: height, (changes in) weight, understanding of the disease, purging behavior, activity pattern, treatment history, other caregivers or health care providers.
Aims of the diet (determined individually in consultation with caregivers and other health care providers):
- in the stage at which weight gain is the goal: aim for 0.3-1 kg per week
- then maintain healthy weight
- achieve a (healthy) complete food intake and establish adequate eating behavior
- change irrational thought patterns about food and weight through psychoeducation
- prevent relapse
Characteristics of the treatment:
- Be attentive to the possibility of refeeding syndrome.
- If there has been laxative abuse, prescribe a diet rich in dietary fiber, if necessary.
- Motivate patient to undergo treatment and behavioral modification.
- psychoeducation with regard to:
- providing insight into nutrition and food-related topics
- effects of fasting and/or purging behavior
- effects of malnutrition
- hunger and satisfaction
- digestion
- Behavior modification through:
- normalizing dietary pattern
- providing insight into and changing irrational thoughts
Treatment time:
- Care level 6, see “Dietician’s working methods.”
Specific remarks:
- Young women of 15-25 years of age make up 95% of all eating disorder patients. (World-class) athletes whose weight plays a role in participating in the sport are a risk group for developing eating disorders. Models and ballerinas are in the risk group. They often come to their doctor with complaints of psychological problems, gastrointestinal complaints and/or menstrual problems.
- The treatment should involve a multidisciplinary approach. The dietician must cooperate with a psychologist or psychiatrist (with regular mutual coordination of tasks and agreements).
- In specialized treatment centers, the dietitian should be involved in the treatment immediately once the patient is enrolled.
- Early diagnosis is important for initiating the correct treatment, to increase the chance of recovery.
- If treatment stagnates, or if ambulatory treatment is unsuccessful, consider admission or part-time treatment in a specialized clinic.
- Somatic treatment is indicated in the case of terminal malnutrition, hypokalemia and hypoglycemia.
- Eating disorders increase mortality and increase the risk of suicide.
References:
Bleifeld EI, Wagner S, Halmi KA. Cognitive-behavioral treatment of anorexia nervosa. Psychiatric Clinics of North America 1996;19:715–37
Bloks JA, Furth EF van, Hoek HW. Behandelstrategieën bij Anorexia Nervosa. Houten/Diegem: Elsevier; 1999
Carbajal A, Moreiras O, Nunes C. Guidelines for the dietetic treatment of patients with anorexia nervosa based on an assessment of their nutrition status. Rev Clin Esp 1995 apr;195(4); 226-32
CBO/Trimbos instituut. Multidisciplinaire Richtlijn Eetstoornissen. Richtlijn voor de diagnostiek en behandeling van eetstoornissen. Utrecht: 2006
Crow SJ, Peterson CB et al. Increased Mortality in Bulimia Nervosa and Other Eating Disorders. Am J Psychiatry. 2009 Oct 15
Vandereycken W, Noordenbos G. Handboek eetstoornissen. Utrecht: De Tijdstroom; 2002
Anorexia Nervosa was updated by Tiny Geerets, dietician at Voedingsdviesgroep Utrecht, Esther Miltenburg, dietician at Praktijk Eeten Gewichtsproblematiek, Nienke Jager, dietician at Altrecht, and Sjerty Peeters, dietician at Universitair Medisch Centrum Maastricht (UMCM+), writing also on behalf of the Voedings Interventie Eetstoornissen (VIE) network.
Binge Eating Disorder
General information:
Binge Eating Disorder can be defined as Bulimia nervosa without compensatory behavior. This eating disorder is a new category in DSM-IV (APA) and has been introduced only as a “provisional diagnosis.”
Further research is still required before this eating disorder is officially included in the DSM. Though there is still considerable debate in the scientific literature, it appears that in practice binge eating disorder has been accepted as a disease. Formally, it is classified under Eating Disorder NOS (not otherwise specified). Patients usually come to the doctor seeking treatment for being overweight. Extensive interviewing provides more information about the type of overeating. About one third of all patients who seek professional help to lose weight also have an eating disorder. Typical of the binge eating disorder is that patients experience a sense of losing control during their eating fits. Afterwards they feel disgusted with themselves, grim or ashamed. The eating disorder is often accompanied by tension around overeating and low self-esteem.
Best time to refer to the dietician:
Diagnosis
- binging (usually with overweight or obesity), accompanied by dark mood, shame and/or disgust with oneself
- strong preoccupation with weight, figure and eating behavior
- low self esteem
- connecting self-esteem to weight.
Treatment
- after diagnosis
Relevant information for the dietician:
- Diagnosis: (suspected) binge eating disorder, any comorbid conditions
- Medications: psychopharmaceuticals, diuretics, laxatives, weight loss drugs, medication associated with obesity as a comorbidity
- Other: height, (changes in) weight, perception of illness, previous treatment history, other health care providers.
Aims of the diet:
- normalize eating habits, aiming for a complete nutritional diet, a regular meal schedule and structure.
- reduce the eating binges
- stabilize weight: in the longer term (moderate) weight loss
- modify irrational thought patterns about food and weight, through psychoeducation
- prevent relapse
Characteristics of the treatment:
- psychoeducation with regard to:
- providing insight into nutrition, food related topics and weight
- effects of eating patterns (physical, psychological and social)
- behavioral modification through:
- learning how to manage food cravings through self-control techniques and development of alternative behavior
- learning how to manage food cravings through insight into and changing irrational thoughts
- for weight loss: energy-restricted diet
Treatment time:
- Care level 6, see “Dietician’s working methods.”
Specific remarks:
- Treatment should involve a multidisciplinary approach. The dietician must cooperate with a psychologist, psychiatrist/doctor (with regular mutual coordination of tasks and agreements).
- It is important to first establish normal, structured eating habits before starting a weight loss program.
References:
CBO/Trimbos instituut. Multidisciplinaire Richtlijn Eetstoornissen. Richtlijn voor de diagnostiek en behandeling van eetstoornissen. Utrecht: 2006
Dingemans A. Eetbuien of controle? Onderzoek naar de validiteit, behandeling en onderliggende mechanismen van de Eetbuistoornis. Proefschrift Universiteit Leiden: 2009
National Institute of Diabetes and Digestive and Kidney Disease. Binge Eating Disorders. Bethesda, USA: 2001
NICE-clinical guideline. Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. London, National Institute for Clinical Excellence: 2004
Vandereycken, W, Noordenbos G. Handboek eetstoornissen. Utrecht: De Tijdstroom; 2002
Binge Eating Disorder was updated by Tiny Geerets, dietician at Voedingsadviesgroep Utrecht, Esther Miltenburg, dietician at Praktijk Eet- en Gewichtsproblematiek, Nienke Jager, dietician at Altrecht and Sjerty Peeters, dietician at Universitair Medisch Centrum Maastricht
(UMCM+), writing also on behalf of the Voedings Interventie Eetstoornissen (VIE) network.
Bulimia Nervosa
General information:
Bulimia Nervosa (BN) is an eating disorder described in the DSM-IV criteria. This eating disorder is characterized by binge eating (consumption of large quantities of food in a limited period of time, during which the person experiences a lack of control). In order to prevent weight gain, compensatory behaviors emerge in the form of vomiting, abuse of laxatives, diuretics or enemas, excessive exercising or extreme dieting. Body weight is usually normal. Body weight and figure heavily influence self-esteem. The disorder is classified into a restrictive type (consuming little or no food, and excessive exercising) and the purging type (inducing vomiting or using laxatives, diuretics or enemas). If the eating disorder does not meet all the DSM criteria of Anorexia Nervosa or Bulimia Nervosa, then it is referred to as Eating Disorder NOS (not otherwise specified).
It is important for the doctor to refer the patient to a dietitian specialized in the treatment of eating disorders.
Best time to refer to the dietician:
Diagnosis
- when there is a preoccupation with food consumption, eating pattern, or attitudes to food, weight and food-related topics.
Treatment
- once the diagnosis has been made
Relevant information for the dietician:
- Diagnosis: (suspected) bulimia nervosa, any comorbid conditions
- Laboratory tests: if applicable
- Medications: laxatives, diuretics, psychopharmaceuticals, weight loss drugs (stackers)
- Other: height, (changes in) weight, perception of illness, purging behavior, activity patterns, previous treatment history, other health care providers
Aims of the diet:
- achieve a (healthy) complete diet and adequate eating habits
- modify irrational thought patterns about food and weight, through psychoeducation
- prevent relapse
- maintain a healthy weight
Treatment characteristics:
- motivating the patient to be in treatment is an important part of the treatment
- in the case of laxative abuse: a diet high in dietary fiber, if necessary
- psychoeducation with regard to:
- providing insight into nutrition and food-related topics
- effects of fasting and/or purging behavior
- effects of malnutrition
- hunger and satiation
- digestion
- behavior modification through:
- restoring normal eating habits
- providing awareness of and changing irrational thought patterns
Treatment time:
- Care level 6, see “Dietician’s working methods.”
Specific remarks:
- Young women 15 to 25 years of age make up 95% of all eating disorder patients. (World class) athletes whose weight plays a role in practicing their sport constitute a risk group for developing eating disorders. They often come to the doctor with psychological symptoms, gastrointestinal symptoms and/or menstrual symptoms.
- Ambivalence towards the treatment due to shame is very common.
- The treatment should be a multidisciplinary approach. The dietician must cooperate with a psychologist or psychiatrist (with regular mutual coordination of tasks and agreements).
- In specialized treatment centers, the dietitian should be involved in the treatment as soon as the patient is enrolled.
- Early diagnosis is important for initiating the correct treatment, to increase the chance of recovery.
- If treatment stagnates, or if ambulatory treatment is unsuccessful, consider admission or part-time treatment in a specialized clinic.
- Somatic treatment is indicated in the case of severe hypokalemia.
- Eating disorders increase mortality and increase the risk of suicide.
References:
American Psychiatric Association. Beknopte handleiding bij de Diagnostische Criteria van de DSM-IV. Lisse: Swets & Zeitlinger: 1995
CBO/Trimbos instituut. Multidisciplinaire Richtlijn Eetstoornissen. Richtlijn voor de diagnostiek en behandeling van eetstoornissen. Utrecht: 2006
Crow SJ, Peterson CB et al. Increased Mortality in Bulimia Nervosa and Other Eating Disorders. Am J Psychiatry. 2009
NICE-clinical guideline. Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. London, National Institute for Clinical Excellence: 2004
Vandereycken W, Noordenbos G. Handboek eetstoornissen. Utrecht: De Tijdstroom; 2002
Bulimia Nervosa was updated by Tiny Geerets, dietician at Voedingsadviesgroep Utrecht, Esther Miltenburg, dietician at Praktijk Eet- en Gewichtsproblematiek and Sjerty Peeters, dietician at Universitair Medisch Centrum Maastricht (UMCM+), writing also on behalf of the
Voedings Interventie Eetstoornissen (VIE) network.