Featured article in the Summer 2016 Issue of Nutrition Close-Up; written by Kylie Thompson, RDN
As health professionals, we often idealize a nutrient-dense eating pattern as a tool to prevent disease. However, it is also important to recognize its role in the treatment of disease. This
article describes the role of nutrition in the treatment of eating disorders (ED), and more specifically, anorexia nervosa (AN).
EDs often develop from a perfect storm of genetics, neurobiology, temperament and environment, although common beliefs of etiology may be muddled by misinformation and social stigma.1 The physiologically normal and reward-motivated act of eating increasingly becomes associated with guilt and anxiety. This leads to the restriction of energy intake and over time, results in significantly low body weight, distorted body image, and extreme fear of gaining weight.1 The complexities of this illness require a multi-disciplinary treatment team consisting of a physician, mental health professional, and registered dietitian/nutritionist (RDN). Taking all three of these important roles into consideration, nutrition therapy delivered by a RDN is critical for recovery.
The inherent nature of AN often inhibits effective and sustainable treatment, even with increasing research and knowledge of its etiology. Too often patients relapse, however. It is well established that early intervention is the most effective treatment.2 Just as AN severity exists along a spectrum, so too does the required intervention.3 In patients requiring inpatient or residential treatment, a primary role of the RDN is to first restore nutrition and weight status for cognitive function and medical stability.3 This initial nutrition therapy is needed to ensure further progression in recovery.1 In patients requiring a lower level of care, the RDN partners with the patient to help mend the damaged relationship with food. Development of rapport allows the exchange of necessary information about normal eating patterns that will meet each patient’s energy and nutrient needs. It is worth noting that accomplishing this task requires effort and skills in behavioral therapy and personalized nutrition counseling, reinforced by frequent communication between the patient and all treatment team members.
Education about normal eating patterns encompasses assistance with meal planning. It is important that patients are involved in their own meal planning once it is considered appropriate by their treatment team. This skill should be practiced in a qualitative manner to reinforce the value of nutrition knowledge. Patients with AN often choose to eat the same food again and again, a tendency that has been shown to persist into recovery.3 Meal planning should emphasize a variety of foods along with a balance of macro- and micronutrients. A meal plan that achieves variety has been shown to be predictive of weight maintenance in AN.3 While some consideration may be given to macronutrient distribution, the primary goal is achieving adequate energy intake.3 Daily intake of foods containing protein of high biological value such as whey, casein and egg whites should be recommended. Consuming a small amount of these protein sources, coupled with foods that are perceived by ED patients as less challenging, can assist in efficient restoration of nutrition status.3 Achieving adequate fat intake is also critical, yet often more challenging, as AN patients tend to avoid fat consumption. For this reason, AN patients are often deficient in the essential fatty acids: alpha-linolenic acid, an omega-3, and linoleic acid, an omega-6.4 These fatty acids are essential because they are not produced by the body and must be acquired through the diet. Omega-3s have captured a lot of attention recently as they are needed for maintenance of cell membranes, regulation of gene expression, and cognitive function.4 The RDN is a critical member of the eating disorder treatment team and should be constantly on the lookout for tools to add to their toolbox. One go-to food for meal planning that should be in everyone’s toolbox is the egg. It contains protein of high biological value, omega-6 fatty acids, and some varieties of eggs can also be a source of omega-3 fatty acids. The egg can be prepared in a variety of ways to suit the tastes of most everyone. For instance, some ED patients will eat traditional scrambled eggs without reluctance. Others, however, who are resistant to a meal plan including eggs, may be more accepting of a breakfast such as oatmeal prepared with an egg. This not only increases the nutrient density and quality of the oatmeal, but adds variety to the diet without altering taste.
Kylie Thompson, RDN, is a Human Nutrition M.S. student at The Ohio State University. She is also working with retailers to assist in meeting FDA regulations for the upcoming menu nutrition guidelines. Her passion lies in working with eating disorders and staying current on recent literature in the field.