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The Role of Nutrition
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The Role of Nutrition

What do food and nutrition have to do with eating disorder recovery? What can parents do when it comes to what, when, and how much to eat?


There are two important things for parents to know: Food is medicine for an eating disorder patient, and it is appropriate for parents to be involved when a patient is unable to self-regulate. Restoring and stabilizing food intake and correcting malnutrition is a foundation of effective, evidence- based eating disorder treatment.


Food is Medicine

The first task of eating disorder recovery is repairing lost weight and health, and normalizing food intake and behaviors. The longer eating disordered behaviors persist, the harder they are to get rid of which is why early diagnosis and prompt increases in food intake are associated with better prognosis.  With anorexia, not eating dulls the senses. With bulimia, not eating leads to bingeing and then purging to relieve the distress - followed by more restriction of food. Some people are particularly vulnerable to these self-perpetuating cycles, especially at certain developmental stages. This paradoxical reaction to malnutrition appears to be largely genetic; 50-80% of the risk of developing an eating disorder appears to be genetic. 

Increasingly, the symptoms associated with eating disorders - and once believed to cause them - are understood to be consequences of malnutrition. In the most dramatic illustration of this, the Minnesota Semi-Starvation study in the 1940s documented a group of formerly healthy young men who were observed under caloric restriction to display these familiar symptoms: social withdrawal, hoarding of food and food-related items, strange ritualized eating, irritability, bingeing, and paranoia.

Brain function and chemistry are changed by even small deficiencies in diet, especially during adolescence. 

Recovery of brain and other medical systems requires balanced nutrition, often at higher calorie levels than usual. Fats, calorie and nutrient-dense foods, often avoided by recovering patients, are essential. Surprisingly, the foods needed during recovery can temporarily increase, not decrease, the anxiety associated with recovery, which makes re-feeding difficult but absolutely essential. Dramatic reversal of eating disorder symptoms and personality changes are generally seen once weight is restored to an appropriate level and maintained there for several months.

Nutrition intervention and weight restoration need to occur prior to or alongside other therapeutic interventions. Psychotherapy is ineffective, even counterproductive, without full nutrition. As painful as it is, restoring full nutrition and healthy body weight are necessary to recovery. Although it is often necessary to address other issues, like anxiety and life circumstances, a patient must first restore medical health.It is also important that recovery of healthy body composition and brain function must be to optimal, not minimum levels. In other words, settling for the lowest target weight is associated with poor recovery. 

Parents and Food

Despite the clear goal of nutritional restoration, parents struggle to understand what role is appropriate for them to play. It is far easier to say “food is medicine” than to overcome the resistance of our loved one to normal eating. Parents are often told to leave the issue of eating and food to the patient, or to put the responsibility into the hands of the therapists, nutritionists and doctors. Alternately, parents are sometimes told the food problems are theirs and theirs alone to solve. 

Under normal circumstances, parents do not expect to be very involved in monitoring food intake after early childhood. It may seem unnatural - even unhealthy - to step back into the role of nurturer around food for an older teen or adult. Parents sometimes resist, on a loved one's behalf, treatment options where sufficient nutrition is enforced and weight gain is required. But food is absolutely an issue parents can and often should be very involved in.

Keep in mind that an eating disorder causes a temporary regression both emotionally and functionally. Someone who is chronologically a 16-year old may only be able to handle the kind of responsibilities of a pre-teen during recovery. Adult patients may need to leave all decisions to other adults or hospital staff during recovery. This is not a reflection of the patient's maturity or dignity: the illness often temporarily robs the person of the ability to make rational choices.

Whether the treatment is outpatient or inpatient, self-directed or family-based, parents should support or insist on full nutrition first. Parents can keep in mind that control is not being taken from the loved one, but from the controlling hands of the potentially disabling or fatal illness. Parents should not aid or enable a loved one in suffering from malnutrition or the ravages of bingeing and purging without intervention. 

It is not unusual, in fact it is usually the case, that eating disorder patients resist treatment and are unable to see caregivers as helpful. This is a symptom of the illness, and not a reason to stand aside. Malnutrition causes lack of rational thought.

It is just as appropriate for others to take over responsibility for food for a patient ill with an eating disorder as it is for caregivers to administer pharmaceutical medicines prescribed by the doctor. Where this happens is less important than that the nutrition be adequate for full recovery (not just stabilization), and that it continue consistently until the patient is able to resume normal behaviors around food and activity.

At present, research indicates that the most effective way to achieve full nutritional recovery for children and adolescents living at home is the Family-Based Maudsley Approach, which involves outpatient family therapy where the parents are put in charge, temporarily, of what, when, and how much is eaten. Later in the process, the therapy focusses on restoring responsibility to the patient and getting back to age-appropriate development and relationships.

Full recovery means a patient is physically healthy, self-regulating in food and activity levels, emotionally stable and has insight into his or her behaviors. This cannot be done without full nutritional rehabilitation.

The Food Police

The term "food police" was popular in the era when parents were seen as part of the problem that caused the eating disorder. Parents were once believed to be overstepping boundaries and making things worse by insisting on full nutrition. The term is still used, pejoratively, by those who doubt the importance of nutrition for recovery, and those who remain wary of parent involvement during treatment. Those who tell parents or loved ones not to be the "Food Police" may not be familiar with current thinking on the role of nutrition in eating disorders or fully aware of the overwhelming cognitive effects of malnutrition. 

Nutrition resources

The nutritional needs of a recovering eating disorder patient are very different from other people. In addition, the needs of early recovery are not the same as that needed later in recovery. In general, patients recovering from restrictive eating disorders will initially have slow metabolisms that will increase dramatically during early recovery. Patients who have been bingeing and purging will often need to eat more dense, varied, and closely spaced meals during recovery. It is useful to have the help of an experienced clinician who understands how to calculate a target weight and can recommend calorie levels that are appropriate and foods that are calorically and nutritionally dense.

Related Links: Nutritional Interventions

By special permission, 

Practice Paper of the American Dietetic Association: Nutrition Intervention in the Treatment of Eating Disorders

Why is Food Medicine? The Functional Role of Nutrition

Article by Dr. Sarah Ravin for F.E.A.S.T.

They Starved So That Others Be Better Fed: Remembering Ancel Keys and the Minnesota Experiment

By Leah M. Kalm and Richard D. Semba, The Johns Hopkins School of Medicine, Baltimore, MD

Wikipedia: Minnesota Semi-Starvation study

Refeeding syndrome – awareness, prevention and management

Full text article from Head & Neck Oncology 2009; 1: 4. Published online 2009 January 26.

"Dietary energy density and diet variety as predictors of outcome in anorexia nervosa,"

by Janet E Schebendach, Laurel ES Mayer, Michael J Devlin, Evelyn Attia, Isobel R Contento, Randi L Wolf, and
B Timothy Walsh. Conclusion: "...the results of the present study suggest that the intake of energy-dense foods and a greater variety of foods may be crucial to relapse prevention."


Related Links: Target Weights and Outcomes

Determining Target Weight Ranges and Ideal Body Weight

The slippery slope: prediction of successful weight maintenance in anorexia nervosa

Abnormal distribution normalizes within a 1-y period of weight maintenance

American Journal of Clinical Nutrition, November 2009 AJCN.27820 Conclusions: "In adult women with AN, normalization of weight in the short term is associated with a distribution of adipose tissue that is consistent with a central adiposity phenotype. This abnormal distribution appears to normalize within a 1-y period of weight maintenance."

"Does Percent Body Fat Predict Outcome in Anorexia Nervosa"

Am J Psychiatry 2007;164:970-972.doi:10.1176/appi.ajp.164.6.970 Results: "In a binary logistic regression model examining the effect of percent body fat, body mass index, anorexia nervosa subtype, waist-to-hip ratio, and serum cortisol and leptin levels on treatment outcome, only percent body fat was significantly associated with outcome."

Conclusions: "In recently weight-restored women with anorexia nervosa, lower percent body fat was associated with poor long-term outcome."

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