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Nutritional Aspects of Eating Disorders

 

Spring 2003, Volume 2, Issue 2

The Remuda Review presents practical guidelines for treating eating disorders according to a bio-psycho-social-spiritual model. This model is Biblically-based and scientifically-valid and was described in the first volume of The Remuda Review.


Following the bio-psycho-social-model, we recently began an exploration of the biological dimension of eating disorders. Our previous issue considered eating disorders’ psychiatric and medical aspects. The present issue continues with nutritional aspects and nutrition counseling methods.

Editorial Staff
Nutrition Philosophy
Janet K. Carr, MS, RD, Department of Nutrition Services
Marian C. Eberly, RN, MSW, CISW, DAPA, Division of Patient Care Services
Remuda Ranch at The Meadows Programs for Anorexia and Bulimia



Then Jesus said to his disciples: “Therefore I tell you, do not worry about your life, what you will eat; or about your body, what you will wear. Life is more than food, and the body more than clothes.” Luke 12:22-24

Americans worry a great deal about what they will eat and wear (Kilbourne, 1999). Our culture focuses prominently on the body and external appearances. A near-obsession with thinness drives the practice of cyclical dieting and a sizable interest in information related to nutrition and health. Contradictory nutrition messages from sources which vary in accuracy have promoted confusion over healthful eating. The treatment of eating disorders is therefore aided by a Biblically-based and scientifically-valid nutrition philosophy that patients can understand and adopt in place of the confusing messages they receive from other avenues. The treatment of eating disorders is also aided by Biblically-consistent and evidence-based methods for achieving proper nutrition, healthy weight, and working through eating disorder fears and behaviors.
Food Guide Pyramid

The first step in approaching food and meal planning is to establish a foundation for healthful food choices. The Food Guide Pyramid (FGP) is a practical, basic, and easily used eating model designed for the general public and disseminated by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services (1992). From a healthful eating perspective, it promotes the proper distribution of nutrients to meet the body’s needs efficiently. It also provides flexible guidelines to allow for food preferences while ensuring proper nourishment. The FGP is a scientifically-valid model; as was reasoned in an earlier issue of The Remuda Review, relying on scientifically-grounded knowledge is a Biblically-consistent practice (Wall & Eberly, 2002). “[E]very prudent man acts out of knowledge” Proverbs 13:16.

Throughout recent history, models for healthy eating have evolved as new research has emerged in the areas of nutrition and health. Research has likewise led to debate about the current model, the FGP, which is now 10 years old. Proposed changes, derived from research findings, may indeed lead to incremental modifications in the FGP, but not an overhaul as some have suggested.

Recommendations for modification to the FGP include an emphasis on consuming less saturated fat; moderate unsaturated fat; and more whole grains, legumes, fruits, and vegetables to ensure fiber intake. These changes would incorporate guidelines for eating that have already been established. The Dietary Guidelines for Healthy Americans and Healthy People 2010 (Food and Drug Administration and National Institutes of Health, 2003; U.S. Department of Agriculture and the U.S. Department of Health and Human Services, 2000) promote these aspects of healthful eating and have long been indicated as supplements to the FGP. The FGP remains an excellent one-page guide to eating; using the FGP with the accompanying guidelines for health offers a sound foundation for a nutritious eating plan.
All Foods Can Fit

A vital part of a healthful approach to eating and meal planning is the concept that “All foods can fit!” This motto is affirmed by the American Dietetic Association, and is critical in working through the distorted belief systems frequently accompanying eating disorders. In our society, it has become second nature to label foods as “good” and “bad”. This may be appropriate to express individual tastes and personal appeal, but confusion often results when these terms are used to define healthful eating. Individuals use different standards for judging the healthiness of food. Labeling foods as “good” and “bad” influences food intake. “Bad” foods are typically avoided, even though these foods may offer beneficial nourishment. Extreme elimination of foods labeled “bad” is a hallmark of anorexia, and clearly leads to serious malnourishment. Those with bulimia often label as “bad” those foods which they most enjoy; avoidance of these foods may lead to an experience of psychological deprivation, followed by food cravings and binge behaviors.

Another danger of labeling foods as “good” and “bad” is inappropriate moral judgment. For example, when a “bad” food is consumed, people may judge themselves “bad” based on their food intake. Statements such as, “I am going to be bad and have a piece of cheesecake” are part of our everyday American parlance. When eating is equated with morality, guilt may mount with each bite of a “bad” food. Likewise, when eating “good” foods, people may perceive themselves as virtuous. In eating disorders, these distorted correlations between food and personal morality/worth are frequent and often extreme. But the truth is simple: Individual foods are neutral and should be viewed as neither “good” nor “bad.” Scripture makes this plain when, in the New Testament, the distinction between “clean” and “unclean” foods is abolished (Matthew 15:11, Acts 10:15). Furthermore, it is evident from hundreds of Scriptures that food is a blessing and eating is intended to be one of humanity’s sources of joy (e.g., Esther 8:17 and 9:22, 1 Chronicles 12:40, Nehemiah 8:12). “So I commend the enjoyment of life, because nothing is better for a man under the sun than to eat and drink and be glad. Then joy will accompany him … all the days of the life God has given him…” Ecclesiastes 8:15.

Promoting the belief that all foods can fit into a healthful meal plan does not mean that all foods are equal. Some foods have greater nutritional benefits than others. For example, fruits are high in fiber and vitamins, and milk is rich in calcium; desserts, candy, and snack foods may offer less nutritional value. But this does not mean that the less nutritionally beneficial foods do not have a purpose and place in a healthful lifestyle and in celebrating and affirming life and God’s blessings.
Balance, Variety, and Moderation

How all foods can fit into healthful meal planning is very important to address with eating disorder patients. This occurs under the guidelines of balance, variety, and moderation.

* Balance equates to flexibility: adjusting to hunger, appetite, time, place, people, and food availability.
* Variety simply means eating different foods, consuming the various food groups, and having variety within each group.
* Moderation includes serving size and frequency of consumption. Moderation involves saying both “yes” and “no” to food, knowing one’s nutritional needs, listening to hunger and fullness, and taking personal responsibility and accountability for food choices.

Moderation is the guideline most frequently violated in the American diet. The question should not be whether a food is “good” or “bad”, but how much and how often it is consumed. “If you find honey, eat just enough--too much of it, and you will vomit” Proverbs 25:16.

Following the guidelines of balance, variety, and moderation will promote proper nourishment and proper distribution of calories from nutrients: 50-60% carbohydrate, 25-30% fat, and 15-20% protein. In treating eating disorders, using the FGP with the accompanying guidelines will nourish bodies successfully and facilitate therapeutic progress by effectively challenging food fears and misinformation.
Normal/Intuitive Eating

The ultimate goal for those with or without eating disorders may be referred to as Normal Eating (Satter, 1987) or Intuitive Eating (Tribole & Resch, 1995). A common theme of intuitive eating is “eat when you are hungry and stop when you are full.” Listening to the body’s cues regarding hunger and satiety is the general rule.

Normal eating includes three meals a day in general. But occasionally it may mean consuming a large, late breakfast or an early, substantial dinner. It may mean eating an extra cookie because they are freshly baked or saving the slice of cake for later because you are too full from dinner. It involves savoring the moment, noticing texture, tasting the food, and simply enjoying it. Normal eating may mean having a comforting bowl of ice cream when life’s trials lead to tears, but knowing when to put the spoon down to finish the day’s tasks or address the underlying issue. Allowing oneself the freedom to occasionally eat beyond the point of fullness because the food is tasty or the meal is part of a holiday celebration, or ending a meal prematurely when still hungry because you are late for an appointment—such things challenge the rigid, black-and-white thinking encountered so often in patients with anorexia and bulimia.

For those with eating disorders or issues, these skills must still be learned or developed. The normal/intuitive eating mindset leads to flexible, moderate eating behavior and directly confronts eating disorder thoughts. The end result is responsible freedom and autonomy in one’s eating practices and the ability to put food in proper perspective, knowing that “[l]ife is more than food…” Luke 12:23.
References

Kilbourne, J. (1999). Deadly persuasion: Why women and girls must fight the addictive power of advertising. New York: The Free Press.

Satter, E. (1987). How to get your kid to eat . . . but not too much. Palo Alto, CA: Bull Publishing Co.

Tribole, E.T. & Resch E. (1995). Intuitive eating. New York: St. Martin’s Press.

Wall, A.D. & Eberly, M. (2002). Five Biblical factors in eating disorder development. The Remuda Review, 1, 6-10.

U.S. Department of Agriculture and the U.S. Department of Health and Human Services (2000). Dietary guidelines for Americans. Retrieved from http://www.health.gov/dietaryguidelines/dga2000/document/summary/ default.htm

U.S. Department of Agriculture and the U.S. Department of Health and Human Services (1992). Food guide pyramid. Retrieved from http://www.nal.usda.gov/fnic/Fpyr/pyramid.html

Food and Drug Administration and National Institutes of Health (2003). Healthy people 2010: 19. Nutrition and weight. Retrieved from http://www.healthypeople.gov/document/HTML/Volume2/19Nutrition.html
Nutrition Foundations: The Basics of Assessment and Treatment
Janet K. Carr, MS, RD, Department of Nutrition Services
Marian C. Eberly, RN, MSW, CISW, DAPA, Division of Patient Care Services
Remuda Ranch at The Meadows Programs for Anorexia and Bulimia



Nourishing the body properly and achieving a healthy weight are essential for physical and psychological health. “For we are the temple of the living God” 2 Corinthians 6:16. Without appropriate nourishment, the brain does not function properly, and other forms of psychotherapy and counseling are less effective. Proper nourishment and weight are therefore the foundation of treatment with eating disorder patients. The time and course of these foundational interventions is highly individual, but some standard principles apply.
Assessment

The development of individual care plans rests on thorough assessment. This is axiomatic. During the assessment, it is important to establish:

* Recent daily intake (previous 1-6 weeks), including both food and fluid consumption
* Frequency of binge and/or purge behaviors
* If purging is present, the methods of purging
* Use of exercise
* Foods that are avoided—"fear foods”
* Weight history
* Lab values
* Medical and psychiatric comorbidities related to the eating disorder.

A weight history—including circumstances and behaviors associated with being at a particular weight, length of time at that weight, accompanying feelings and beliefs, and how much the patient currently desires to weigh—assists in determining not only a healthy weight but also what type and amount of support the patient may need during the weight goal progression time period.
Treatment

Nourishing the Body

Current daily intake should be used when establishing the initial meal plan. If the patient has been engaging in severe restriction (<800 cal./day) and/or excessive purging through self-induced vomiting, an initial calorie level between 800 and 1200 is appropriate. Serving foods such as soups, cheese and crackers, and juices helps promote fluid intake and restore electrolyte balance. With less severe restriction and purging, a calorie level between 1500 and 1800 may be initiated.

Calorie progression is tempered by the risk for refeeding complications. For those at risk, daily vital signs—morning weight, pulse, and orthostatic blood pressure readings—and frequent lab studies provide the careful monitoring necessary to identify initial signs of complications and to promote medical stability.

Although common and potentially fatal, refeeding syndrome is highly preventable. Refeeding syndrome refers to severe fluid and electrolyte shifts and associated medical complications that may occur when malnourished patients accept increased nutritional intake. To prevent refeeding syndrome, recommended calorie progression is 300-400 every four to five days (Mehler & Andersen, 1999). For the severely underweight patient, monitoring lab values for potassium (K), phosphorous (P), and magnesium (Mg) is critical to prevent refeeding syndrome. Oral supplementation for K, P, and/or Mg under the supervision of a primary care provider may be necessary.

Normal/intuitive eating (see accompanying article, Nutrition Philosophy, in this issue of The Remuda Review) is the standard for establishing a meal plan. Planning three meals a day with snacks, as appropriate, approximates normal eating. Teaching the patient to ask the following questions will also help the patient to understand and implement normal eating:

* What are my nutritional needs?
* Am I hungry?
* What am I in the mood for?
* What is available?
* What else am I eating today?
* Am I noticing what I am eating (smell, taste, texture)?
* When am I full?

It is also important to understand and discuss with the patient his/her psycho-physiological responses during refeeding. Although listening to hunger and satiety is a goal of intuitive eating, the body will not send appropriate messages during the refeeding process. For those with anorexia, hunger cues are typically absent and a false sense of fullness is continually present. It is important to explain to the underweight patient that hunger and satiety cues will most likely be inaccurate until a healthy weight is achieved, a maintenance meal plan is established for some time, and therapeutic issues are being addressed. For those with bulimia, hunger and satiety cues are unreliable and often dependent upon emotional stress and/or environmental triggers. The first step for those with bulimia is to normalize eating by consuming three meals a day and eliminating binges. Once a consistent meal pattern is established, body signals are more accurate and the patient may begin to practice intuitive eating. But if bingeing with or without a restricting prelude persists, hunger and satiety cues will remain inaccurate.

Several nourishment options should be considered when weight gain is needed. Separating maintenance and weight gain calories can be beneficial. Maintenance calories can be served through meals and snacks while weight gain calories may be served through supplemental options. Supplemental products provide more nutrients with lower food volume and may be given in the form of shakes, puddings, juices, or cookies. Practically, these are often consumed as snacks. Another option for the severely malnourished is nasogastric (NG) tube feeding. At Remuda, we have experienced positive results with NG tube feeding in anorexia. Providing weight gain nourishment through an NG tube allows meals and snacks to resemble a maintenance meal plan. NG tube feeding throughout the night distributes satiation levels and decreases gastro-intestinal discomfort during the daytime. Other advantages, including more rapid weight gain, accrue to the use of NG tubes (Zuercher, Cumella, Woods, Eberly, & Carr, 2003). See sidebar on NG Tube Feeding in Anorexia Nervosa.
Achieving a Healthy Weight

Achieving a healthy weight is a critical component of treating an eating disorder, not only in the professionals’ mind but also the patients’. Weight history, stage of physical development including adolescent growth charts, and anthropometric data including height and frame size should be obtained. Body Mass Index (BMI) is commonly used to indicate weight appropriateness. Although BMI is useful, some observers believe that it is of limited utility in the treatment of eating disorders because it takes into consideration only height and weight. At Remuda, we obtain body composition measurements, specifically body fat percentage (BF%) and mid-arm muscle circumference (MAMC) through skin-fold caliper methods (Frisancho, 1981; Heyward & Stolarczyk, 1996; Lohman, 1992). This provides a more comprehensive assessment of nutritional status and more thoroughly evaluates the body’s response to refeeding. Muscle mass, in particular, is a significant variable when determining a healthy weight. Although refined technical skill is necessary to conduct these measurements, we believe the ensuing weight range is more accurate and individualized. Sharing body composition data with patients can also be very effective in gaining their acceptance of a recommended weight range.

Due to normal weight fluctuation in the human body, establishing a weight range with a mid-point is more useful than focusing on a fixed weight or single number. A 10 lb. weight range is recommended for most women, and an 8 lb. range for those at or below 5 feet tall. Having the midpoint as the goal allows for normal, moderate fluctuation (due to temporary dehydration or edema, menstruation, etc.). Weight ranges may need to be re-assessed over time for adolescents, in cases of weight restoration after severe emaciation, and to promote continued muscle growth through weight bearing exercise.

The recommended rate of weight gain per week is approximately 1-3 lbs. for inpatients and 1 lb. for outpatients. Gaining at a rate much greater than this may indicate edema, constipation, and/or precipitate refeeding complications (Mehler & Andersen, 1999). In our experience, the body replenishes fat and muscle tissue more proportionately at the 2 lbs. per week rate. Average weekly weight gains much below the recommendations may indicate patient resistance and/or an inappropriate level of care. Energy levels to promote weight gain are typically 1000-3000 calories greater per day than Basal Energy Expenditure (BEE) with an activity factor of 1.25. Total caloric needs may be as high as 3500-4000 per day to promote necessary weight gain (Reiff & Reiff, 1997). This occurs because of the hyper-metabolic state needed to rebuild lost tissue and promote homeostasis. Using the calorie progression guidelines offered above in combination with monitoring patient weight progression should promote safe and adequate weight gain.

When weight loss is appropriate, an average of 0.5-2.0 lbs. per week is recommended. It is essential to establish and maintain the goals of focusing on the issues of the eating disorder, normalizing eating, eliminating binges, and letting the body heal, and not to concentrate on weight loss. In our experience, normalization of eating and cessation of bingeing promotes weight loss and/or decreases in BF% and increases in MAMC. In bulimia, the metabolism typically functions at a low to normal state. Remaining at or above 1500-1600 calories per day will prevent the reduction in metabolic rate associated with restriction and promote rejuvenation of the metabolism.

Achieving weight maintenance is one of the ultimate goals in recovery from an eating disorder. This includes remaining in a healthy weight range and acceptance of weight and appearance. However, as patients begin to eat regularly and to gain needed weight, food fears and related issues will likely arise. A companion article, Nutrition Counseling with Eating Disorder Patients, appears in this issue of The Remuda Review, and describes tools that may be used by dietitians in their efforts to help patients overcome the psychological barriers to nourishing the body and achieving a healthy weight.
References

Frisancho, A.R. (1981). New norms of upper limb fat and muscle areas for assessment of nutritional status. American Journal of Clinical Nutrition, 34, 2540.

Heyward, V.H. & Stolarczyk, L.M. (1996) Applied body composition assessment. Champaign, IL: Human Kinetics Publishers.

Lohman, T.G. (1992). Advances in body composition assessment. Champaign, IL: Human Kinetics Publishers.

Mehler, P.S. & Andersen, A.E. (1999). Eating disorders: A guide to medical care and complications. Baltimore, MD: John Hopkins University Press.

Reiff, D.W. & Reiff, K.K.L. (1997). Eating disorders: Nutrition therapy in the recovery process. Mercer Island, WA: Life Enterprises Publishers.

Zuercher, J.N., Cumella, E.J., Woods, B.K., Eberly, M., & Carr, J.K. (2003). Efficacy of voluntary nasogastric tube feeding in female inpatients with anorexia nervosa. Journal of Parenteral and Enteral Nutrition, in press.
Nutrition Counseling with Eating Disorder Patients
Juliet Zuercher, RD, & Shannon Heffern, RD
Department of Nutrition Services
Remuda Ranch at The Meadows Programs for Anorexia and Bulimia



The purposes of a man's heart are deep waters, but a man of understanding draws them out. Proverbs 20:5

At one level, eating disorders are self-evidently about food. At another, they are about much more—misinformation, myths, and self-deception; anxiety, fear, and avoidance of problems. Because nutrition counseling seeks to reduce the overt symptoms related to food, nutrition counseling directly challenges patients to face the issues that drive their eating disorder. Therefore, treatment providers must often use creative techniques to discover and address patients’ needs. This article describes tools that dietitians may use to accomplish this task, assisting patients to work through the myths and fears commonly associated with eating disorders.
Assessment

To begin this process, it is important to assess the patient’s level of motivation (Cockell, 2000). A useful way to accomplish this is to evaluate the patient’s recovery goals. This establishes the patient’s level of readiness to change eating disorder behaviors. If a patient presents with the desire to change but is unsure of how to do so, the dietitian can provide assurance that a primary purpose of nutrition counseling is to assist with this objective. When experiencing ambivalence toward recovery, the patient can prepare a list of the pros and cons of keeping the eating disorder. This list can help to re-establish the value of recovery. Finally, identifying family, social, and environmental influences can help indicate the types of nutrition education and experientials that the patient may need.
Treatment

Nutrition Education

For the patient who is motivated to change, a good starting place is to provide basic nutrition education. Defining nutrition basics such as the function of carbohydrate, protein, and fat in the body can dispel misconceptions and allay common fears, such as the notion that “eating fat makes you fat”. Explaining the Food Guide Pyramid teaches not only proper nourishment but also how to include balance, variety, and appropriate portioning in meal planning (see accompanying article, Nutrition Philosophy, in this issue of The Remuda Review). Initial education will also involve rejecting the diet mentality and making peace with food; food is not the enemy.

Providing appropriate exercise guidelines supports the importance of exercise and the dangers of over-exercising. It may be useful to educate the patient about the exercise guidelines offered by the American College of Sports Medicine (ACSM), which suggests that healthy exercise occurs:

* 3-5 times per week
* 30-60 minutes per session
* 1 session per day
* Includes aerobic, strength training, & flexibility exercises
* Is motivated by fun and enjoyment

Exploring Myths

Surely you desire truth in the inner parts… Psalm 51:6

Frequently, patients with eating disorders take one element of nutrition truth and hold to it as their golden rule, while other facts and accompanying guidelines are ignored. Out of context and with too much emphasis placed on it, this modicum of nutrition truth may transmogrify into a dangerous myth. Therefore, patients will often require nutrition re-education according to the sound nutrition philosophy presented in the companion article, Nutrition Philosophy. They may also benefit from experientials to help them work through the dieting myths and misinformation which they have absorbed or developed and which have been leading them to make unhealthful eating choices.

One such experiential tool involves an exploration of how eating disorder trends and myths develop. The dietitian can explore with patients various influences on their nutrition beliefs, such as the media, family, sports coaches and trainers, fitness instructors, and the medical community. Discuss if or how any of these influences have affected the patient’s thinking. Follow the discussion with a trip to a local bookstore. Visit the health/wellness section and review current books and magazines. Evaluate facts and fictions found in these resources. Offer healthy alternatives to the patient— magazines, books, and websites that counter the erroneous claims found in the popular culture. Ultimately, the practitioner should encourage patients to use awareness, discernment, and common sense in evaluating marketing claims. Reinforce healthy eating guidelines and flexibility in eating. This is the best way to maintain balance in the face of an ever-changing health and nutrition field.

Other field trips, such as a trip to a local health food store, can also prove effective in challenging myths about food. Prior to the field trip, discuss the definition of “normal eating”. Normal eating is summarized well in Ellyn Satter’s (1987) book, How to Get Your Kid To Eat...But Not Too Much. More details can also be found in Nutrition Foundations, the accompanying article in this issue of The Remuda Review. Providing information about normal eating in printed form, or referring patients to Satter’s book, are both useful avenues of education.

Once at the health food store, examine products and evaluate them for appropriateness. Does this item fit into the definition of normal eating? Why or why not? What health food items are acceptable in a balanced meal plan? Examine nutrition labels and evaluate the claims made by nutritional supplements. Is this accurate information? How do manufacturers sometimes take a kernel of truth and expand it in order to sell products? A critical analysis of several items in a health food store can be a powerful tool for the patient. Learning about health food products may not motivate patients to change behaviors immediately, but may initiate contemplation for change. Ask what the patient’s commitment is to changing unhealthy behaviors. Develop a plan together on how to take small steps toward recovery.

Fears and Behaviors: Exposure Therapy

It is essential for practitioners working with eating disorder patients to understand the role that anxiety often plays in the development of the disorder. Fear promotes self-protective behaviors that may be perceived by others as “controlling” behaviors. When people are fearful, they may take radical steps to manage their fears. Although the spectrum of fears and behaviors is vast, common themes emerge. Anxiety predominantly surrounds the fear of becoming physically fat. This typically results in a focus on dietary fat and/or calories but may generalize to other nutrients as well. Patients are often fearful of: places associated with food, such as grocery stores, restaurants, or kitchens; preparing food; and eating with others. These fears may manifest through a variety of behaviors intended to provide relief from the intense anxiety. Such behaviors include excessive avoidance of food; bingeing; purging; cooking without eating; repeated calorie and/or fat gram counting; frequent weighing; social isolation; excessive exercise; and food rituals. It is essential in treating eating disorders to address the actual fears and behaviors related to eating. In conjunction with a multi-disciplinary treatment team, dietitians may address these fears over time through the types of nutrition education described above, through skill enhancement and exposure therapy.

Psalm 23:3-4 reminds us that: “He leads me in paths of righteousness for his name’s sake. Even though I walk through the valley of the shadow of death, I will fear no evil, for you are with me.” The Lord leads us in paths of righteousness, and sometimes these paths—by his design— journey through terrain of which we are afraid. Yet we may confront what we are afraid of and with God’s guidance overcome the fear. As the Psalm suggests, fear of anything but God is, in truth, a shadow, a myth, and a falsehood from which little good may come. “The LORD is my light and my salvation—whom shall I fear?” Psalm 27:1. “Do not let your hearts be troubled and do not be afraid” John 14:27.

For those with eating disorders, overcoming anxiety and fear and learning to make healthful food choices is a process accomplished over time, not overnight. The Lord walks us through the valley. This process involves re-education, exposure with response prevention, and opportunities to practice newly developed skills to reduce the anxiety associated with food and eating. With the guidance of a professional, eating disorder patients may experience their food and eating-related fears and finish the journey less afraid.

Exposure to Fear Foods. This exercise may occur individually or in a group. Assemble a variety of foods in the center of a large table. Include many flavors, textures, and colors, such as candy, peanut butter, crackers, frosting, marshmallows/ marshmallow cream, and chocolate syrup. For patients with bulimia, these may be foods used in binges. Sitting for several minutes while smelling and touching the food but without bingeing is not only great exposure but also a significant accomplishment. In anorexia, these foods may have become fearful because the patients have not allowed themselves to eat these foods. Patients are often terrified of what will happen if these foods are consumed.

Begin by asking each patient to describe why these foods might be considered “fearful”. After listening, direct the patient to use the food to create something that represents the eating disorder. Encourage participants to use all five senses. Ask each patient to describe what his/her creation represents and what s/he has learned during the experience.

A significant goal with this exposure exercise is for the patient to use appropriate coping skills to endure the anxiety until it subsides naturally. Doing this typically lessens the intensity and duration of the anxiety the next time these foods are encountered. Consequently, the need to act on unhealthy eating disorder urges is decreased (Landau- West, 1999).

Restaurant Experientials. Restaurant settings provide another beneficial venue for patients to face and overcome fears. Restaurants present a challenge for patients for a variety of reasons, including patients’ feeling self-conscious while eating in public, not knowing what to order or how much to eat, and not trusting how the food was prepared. Scheduling time to eat with patients in a public setting can provide many clues about the nature of their struggles. Preparation for the restaurant experiential is the key to success. Below we describe some practical tools to aid the practitioner in conducting this experiential.

Create the plan together. Involving the patient in as many aspects of this experiential as possible enhances the chances for success. First, select a restaurant well in advance. This may range from a few days to a few weeks ahead, depending on the patient’s anxiety level. Next, establish goals with the patient. For a patient with bulimia, the goals should include: 1) listening to hunger and satiety cues, while 2) eating an appropriate amount, and 3) leaving some food on the plate. For a patient with restricting anorexia, the goals should involve: 1) ordering a fear food as is from the menu, and 2) eating at least half the entrée.

Advise the patient to use the restaurant experience as a challenge to make choices different from those made during the eating disorder. This may mean ordering a food with cream sauce or French fries, or ordering one entrée instead of two or three. Set three to five reasonable goals together prior to the event and discuss the skills that the patient may use to accomplish these goals. Ask what they may need from you to help them succeed. Will you play the role of “food police” at the table, or carry on pleasant conversation as a means of distraction? Establish ground rules before the meal concerning redirection and discussion of ineffective behaviors. The patient may prefer to receive this during the meal or to discuss problem behaviors afterward. Learn how the patient best receives this information. Humor, matter-of-fact confrontation, “code” signals, or a combination of these may be most effective for a particular patient.

Ideally, a counseling session should immediately follow the restaurant outing to provide the patient with support and accountability. Did the patient meet his/her goals? If yes, how was this accomplished? Could the challenge transfer to other areas of recovery or life? If goals were not met, what might have been done differently? When will they have an opportunity to practice again? A restaurant challenge can be an exciting step forward for the patient since this is likely a regular part of life that has been avoided for some time. Affirm the progress made and challenge the behaviors still needing change.

These tools constitute a small sampling of creative interventions used at Remuda Treatment Centers. Additional tools are described in Reiff & Reiff (1997) and Hayes, King, & Kratina (1996).

Eating disorder recovery is gradual; gains are typically made in small steps. Victory occurs with each positive choice that patients make instead of repeating old behaviors. Celebrate these victories and continue to challenge patients toward additional progress.
References

Cockell, S.J. (2000). A decisional balance measure of readiness for change in anorexia nervosa. Dissertation Abstracts International. (UMI No. NQ56661).

Hayes, D., King, N., & Kratina, K. (1996). Moving away from diets. Lake Dallas: Helm Seminars Publishing.

Landau-West, D. (1999). Food as communication: Breaking through with experiential therapies. In L. Cohn & R. Lemberg (Eds.), Eating disorders: A reference sourcebook (pp. 167-169). Phoenix, AZ: Oryx Press.

Reiff, D.W. & Reiff, K.K.L. (1997). Eating disorders: Nutrition therapy in the recovery process. Mercer Island, WA: Life Enterprises Publishers.

Satter, E. (1987). How to get your kid to eat . . . but not too much. Palo Alto, CA: Bull Publishing Co.
Nasogastric Tube Feeding in Anorexia Nervosa
A Scientific Investigation

Background: Remuda staff recently completed a scientific investigation of nasogastric (NG) tube feeding in anorexia. The study will be published in the July 2003 issue of the Journal of Parenteral and Enteral Nutrition. The study includes detailed instructions on the use of NG tubes with patients who have anorexia. Copies of the study may be obtained from Remuda Ranch at The Meadows by calling 1-800-445-1900, ext. 4501.

The study included 381 female inpatients with a DSM-IV diagnosis of anorexia nervosa, both subtypes. 155 patients received tube feeding and oral refeeding; 226 received oral refeeding alone. Recovery from the psychological aspects of anorexia was measured by change in Eating Disorder Inventory-2 scores between admission and discharge. Patient satisfaction with treatment was measured using a Patient Satisfaction Questionnaire completed at discharge. Repeated measures and multivariate analyses were performed.

Results: Controlling for severity-of-illness and caloric intake differences between patients with and without tube feeding, patients who received tube feeding gained significantly more weight per treatment week than those who received oral calories alone. Patients who received tube feeding for at least half their length of stay gained 1 kg. (2.2 lbs.) per week versus 0.77 kg. (1.7 lbs.) per week for patients receiving oral refeeding alone. Tube fed patients evidenced no differences in recovery from anorexia’s psychological aspects, satisfaction with treatment, or medical complication frequency—suggesting that tube feeding does not have negative psychological or medical consequences for patients.

Conclusions: In residential psychiatric treatment settings where intensive therapeutic interventions and appropriate medical monitoring can manage potential psychological and medical risks, tube feeding’s weight gain benefits may be a viable and safe option in treating anorexia.


Next Issue: Psychological Dimension of Eating Disorders

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