Nutritional Therapy for Anorexia Nervosa
Written by ‘Ai Pono Hawaii Staff Writer
Nutritional therapy for anorexia nervosa (AN) and other eating disorders is considered an integral component of a successful treatment program. In fact, the American Dietetic Association states that nutrition intervention (which includes nutritional counseling) delivered by a registered dietitian (RD) is crucial in healing AN, bulimia nervosa, and other types of eating disorders (ED) during the assessment stage and throughout the treatment process.
Treating an eating disorder demands joint effort from a team of specialists in medicine, psychology, and nutrition. The specialized knowledge of RDs who have experience in treating anorexia nervosa and other eating disorders through nutritional therapy is essential in addressing the medical and nutritional challenges that come with these disorders.
The expertise and knowledge of RDs include not only nutrition but also physiology and skills for promoting changes in behavior that are related to the psycho-socio-cultural factors involved in eating.
What is Nutritional Therapy for Anorexia Nervosa?
Medical nutrition therapy is an essential element in the process of recovering from an eating disorder. It may come in one of two forms: traditional nutrition therapy and medical nutrition therapy (MNT).
MNT is a specific evidence-based treatment that’s used in clinical settings for managing diseases associated with EDs. MNT is more intensive than conventional nutrition therapy and requires a referral from a medical doctor.
MNT shares a number of similarities with nutrition therapy, such as creating a nutritional plan, goal-setting, and offering assistance to the patient with ED. However, MNT is the recommended nutritional therapy for patients with complex nutritional requirements that result from an eating disorder or a disease like diabetes. MNT is also preferred for patients who need medical intervention to stabilize their health and monitor their status, whether in a hospital or in an outpatient setting.
Medical interventions like MNT usually involve intravenous or tube feeding, along with regular monitoring of vital signs to prevent or treat health complications. Psychiatric treatment is also simultaneously provided to the patient in order to address disordered eating patterns and the other psychological conditions that tend to be present (i.e., comorbid) along with an eating disorder.
Medical Nutrition Therapy for Anorexia Nervosa
MNT is valuable for people suffering from eating disorders like anorexia, as it helps them recognize the connection between nutrition, diet, and overall health from a medical standpoint. It also teaches how inadequate nourishment can lead to severe, life-threatening outcomes.
The main objective of MNT is to modify the unhealthy eating habits of people with anorexia or other EDs in the long run in order to enhance their well-being. To achieve this, MNT involves evaluating patients’ nutritional needs, diagnosing existing conditions (if any), implementing suitable interventions, and regularly tracking and evaluating patients’ progress.
MNT involves more than just a dietary plan. When used in treating an eating disorder like anorexia, MNT targets the patient’s unique eating behaviors in order to uncover the real reasons behind the patient’s unhealthy eating habits or irrational food avoidance. With the guidance of an experienced dietitian, a care plan can be designed to help the patient struggling with an eating disorder to develop new and healthier eating patterns.
Who Provides Nutritional Therapy for Anorexia Nervosa?
Due to the intricate nature of eating disorders, a collaborative team approach involving various professionals is often necessary for successful recovery. This team typically includes psychiatrists, therapists, general practitioners, and registered dietitians.
In this team, the RD plays a vital role in providing medical nutrition therapy to restore good nutritional status and rebuild healthy eating habits. An RD works with patients struggling with eating disorders in building a better relationship with food.
It’s important to know that even if many RDs also refer to themselves as "nutritionists'', these two professions are different. RDs are required to complete a rigorous education and training program, which includes a bachelor's or master's degree as well as national medical accreditation. On the other hand, nutritionists may only need to finish a single course to earn their title. Simply put, RDs have more extensive education and training in a medical setting compared to nutritionists.
RDs identify clinical symptoms associated with eating disorders, offer expert nutritional guidance, and support medical monitoring. At the same time, they remain mindful of the indispensable roles of psychotherapy and pharmacotherapy in treatment.
Risks and Possible Complications of Binge Eating Disorder
In addition to the red flags that were discussed above, BED can lead to weight gain, hypertension, high cholesterol levels, heart disease, joint pain, sleep apnea, vitamin deficiencies and other medical symptoms. It may also lead to severe and life-threatening dehydration, which can cause heart problems, seizures, kidney failure, and even death.
People who are struggling with BED also have a higher risk of experiencing comorbid conditions, including anxiety disorders, substance use disorders, mood disorders, and impulse control disorders.
They may also have suicidal thoughts and harm themselves. In severe cases or when left untreated, some may even attempt suicide. Thus, it is critical to seek treatment as soon as possible to avoid (or promptly treat) complications that are due to this eating disorder.
What Are the Goals of Nutritional Therapy in Anorexia Nervosa?
Nutritional therapy aims to achieve several important objectives in the treatment of anorexia nervosa, such as:
Restoring and maintaining a healthy body weight
Fostering a neutral attitude towards food by re-establishing intuitive understandings of hunger, fullness, and satiety
Maintaining appropriate levels of phosphate in the blood
Addressing health complications (if any) that result from malnutrition
Educating patients on healthy nutrition and eating habits
Correcting distorted thoughts, attitudes, and feelings towards their eating disorder
Increasing motivation towards normalization of one’s eating habits and participation in treatment
These objectives are usually achieved through an individualized program for each patient with AN, which involves gradually increasing the patient’s food intake over time.
RDs will usually focus on different things when treating different types of eating disorders. For instance, when treating a patient with anorexia, an RD may teach the patient which foods are best eaten to maintain strong bones or energize certain parts of the body. The RD would also likely discuss the negative effects of inadequate nutrition on one’s health.
On the other hand, for patients suffering from avoidant restrictive food intake disorder (ARFID), the RD would likely explain the health benefits of the foods that they’re avoiding or restricting and why their body needs those for peak performance. Meanwhile, patients with binge eating disorder (BED) will likely be taught by the RD about the process in which the hormones in their body and the neurotransmitters in their brain are affected by food restriction and how limiting intake of certain foods can lead to biological processes in their body that result in their urge to binge.
As patients who struggle with anorexia start gaining weight, many of the mental and behavioral issues that result from malnutrition—such as depression and food anxiety—will also likely improve (or even completely disappear). In turn, this can enhance the effectiveness of other treatments, such as psychotherapy and medication.
The specific approach that will be used in nutritional rehabilitation depends on each patient's situation and what level of care will be given: outpatient, day hospital, inpatient, and so on. Refeeding is typically performed in phases and agreed upon with the patient. Extreme caution will be done by the treatment team to avoid refeeding syndrome. Refeeding syndrome refers to a potentially deadly condition that occurs when someone who has been malnourished begins feeding again. When food is introduced too quickly, serious complications may result due to the changes that have occurred in the body that’s been deprived of nutrients.
Weight gains during hospitalization and weight upon discharge are determined accordingly. Treatment will usually take months or even longer, with repeated hospitalizations and care provided across different settings whenever needed until the patient reaches a healthy weight.
For children and adolescents, the criteria are that they already attained normal growth and development, since this stage is critical in achieving normal adult size and reproductive capacity through growth and development. Keeping in mind that the onset of AN is normally in the teenage years, proper nutrition is particularly crucial during this period. Adolescents need to have the right caloric intake, as well as the healthy balance of carbohydrates, proteins, and fats throughout this developmental stage. They also need the right dietary intake of essential nutrients such as iron, calcium, and folic acid.
Based on The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (or DSM-5), patients with AN can be classified based on the severity of their malnutrition:
mild (those with a BMI equal to or higher than 17.0 kg/m2)
moderate (BMI of 16.0–16.99 kg/m2)
severe (BMI of 15.0–15.99 kg/m2)
and extreme (BMI < 15.0 kg/m2)
Addressing micronutrient deficiencies is an important part of nutritional therapy for anorexia, since this is common among patients with AN because of their low food intake. Micronutrient deficiencies may even be greater in patients who purge, or when they’re in the refeeding process.
A systematic review found that zinc is the mineral that AN patients lack the most (64.3%), followed by vitamin D (54.2%), copper (37.1%), selenium (20.5%), vitamin B1 (15%), vitamin B12 (4.7%), and vitamin B9 (8.9%). All of these vitamins and minerals play an important role in health, but the two most frequently lacking ones (zinc and vitamin D) are particularly important for immune system function. Thus, it’s important to ensure that levels of these are normalized as soon as possible in order to prevent a host of diseases—particularly infections—in the patient.
What Nutritional Therapy for Anorexia Nervosa Involves
Medical nutrition therapy is available to patients who are diagnosed with an eating disorder through recovery centers, hospitals, or outpatient clinics. In order to effectively treat anorexia or any other type of eating disorder, a patient-centered interdisciplinary approach is necessary, regardless of the level of care the patient is receiving.
The first step in nutritional therapy for anorexia is to assess the patient's nutritional status. Based on that, personalized meal plans will be designed for the patient, which promote variety while incorporating all macronutrients. The meal plans should be gradually increased once or twice a week as needed, while continuously checking the patient’s physical signs and symptoms and lab results to prevent refeeding syndrome.
Weight restoration education should be included in the process of restoring weight, along with proven therapies such as Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT).
For outpatient care, the goal in terms of weight gain is usually 1 to 2 pounds per week. On the other hand, for inpatient care, it’s usually 2 to 3 pounds per week. Many AN patients fear gaining fat during the weight restoration process, but the treatment team should assure the patient that gaining fat is just one aspect of the restoration process, and that muscle, organ tissue, bone mass, and water are all gained and reflect in their weight as well.
An important element of the MNT process is nutritional education, such as teaching how certain foods impact one’s body and help in reaching one’s health objectives. MNT involves not only teaching patients how to make better dietary choices but also guiding them in dismantling their existing destructive behaviors, establishing goals, and cultivating healthier eating habits.
To serve as a truly effective treatment for eating disorders like anorexia, MNT also incorporates an examination of the psychodynamics that underlie one’s eating disorder. People who struggle with eating disorders usually face certain psychological or emotional issues that influence their dysfunctional relationship with food. An RD collaborates with patients who suffer from anorexia in transforming the latter’s unhealthy food-related behaviors by first looking into the motives behind the patients’ behavior.
The RD conducts a thorough nutritional evaluation of the patient who was diagnosed with an eating disorder. During this assessment, the RD will examine the patient's unique eating patterns and behaviors. The RD will also uncover relevant personal factors like the patient’s view of their body, self-esteem, and issues concerning food. Based on all of the relevant information gathered, the RD will develop a care plan with well-defined objectives that the patient (supported and guided by his or her treatment team) will strive for.
Care plans are individualized for each patient and designed based on the eating disorder. For patients with anorexia, care plans usually prioritize taking steps for them to increase the calories they consume every day. Establishing a set meal schedule for each day is also a common element of such care plans. Their objectives usually include gradually raising their calorie consumption every week or reintroducing certain nutritious foods that they have avoided since the onset of their eating disorder. On the other hand, care plans for patients with BED may emphasize dividing their meal portions throughout the day to prevent overeating, promoting mindful eating, and possibly also establishing a specific number of meals to eat per day.
After knowing their care plan, patients are encouraged to continue working with the RD to track and assess their progress. Regular monitoring will allow the RD to confirm that the patient who has ED truly understands and abides with his or her care plan.
The RD will evaluate the patient based on the latter’s advancement toward his or her set objectives. This may involve tracking their weight increase, food intake, mood, and overall mental and physical well-being. As each patient’s eating behaviors are transformed, the RD will also update the care plan to incorporate new objectives as well as strategies to use for achieving those.
What Are the Benefits of Nutritional Therapy in Anorexia Nervosa?
MNT plays a crucial role in the treatment of eating disorders and is recommended throughout a patient's entire recovery journey. MNT can help ED patients develop a deeper appreciation and understanding of their body, their relationship with food, and the effects of various foods on their physical and mental well-being. Patients also learn concrete steps in developing and maintaining healthy eating habits.
Some of the physical and psychological benefits of nutritional therapy for patients with anorexia or other eating disorders are the following:
Greater knowledge about one’s body and nutrition
Medical nutritional therapy examines the vital relationship that exists between one’s body and one’s food choices. It gives patients an improved understanding of their body's nutritional requirements and the exact foods that can provide the necessary nutrients for optimal functioning of their body.
Personalization
MNT for patients with anorexia (or other EDs) is tailored to their unique dietary needs, instead of simply giving one-size-fits-all advice. It includes a personalized diet that suits each patient’s specific health needs.
Lessen or address health issues
MNT is helpful in reducing the likelihood of medical complications such as heart disease and diabetes (among others), which are associated with disordered eating. In addition, MNT can help in managing or even treating pre-existing health conditions that may have been exacerbated or caused by disordered eating behaviors.
The involvement of a registered dietitian as a member of a patient’s treatment team is a crucial element in the recovery journey of someone with an eating disorder. Dietitians have the relevant knowledge and specialized skills that are needed to stimulate changes in a patient’s eating patterns. Studies have shown that medical nutritional therapy that’s provided by registered dietitians can effectively promote behavioral changes in patients who are struggling with either anorexia and bulimia, who are receiving either inpatient or outpatient care.
Get Nutritional Therapy for Anorexia Nervosa and Other Eating Disorders
‘Ai Pono Hawaii is a trusted eating disorder recovery center that has been providing effective and holistic treatment for anorexia and other eating disorder patients for more than 35 years. Our tranquil recovery center is located in beautiful Maui and is home to a professional team of experienced specialists in the fields of medicine, psychology, nutrition, and more.
We offer nutrition therapy for eating disorders that takes into account various aspects of each patient, such as their nutritional status, body image, physical activity, mental health, and other important factors.
Your treatment team in ‘Ai Pono Hawaii will design and provide a personalized and holistic treatment program that will help you transform your disordered eating patterns into healthy and sustainable lifelong habits.