Anorexia's Multiple Distortions: It Takes A Village

Overview

Affecting 6 to 15% of the US population, and more common in boys than girls, Anorexia nervosa is an eating disorder where the individual suffers a distorted body image, refuses to maintain a normal weight,¹ and  intentionally avoids the intake of food.²  While anorexia can occur at any age, peaks are seen from 13 to 14 and 19 to 20 years old.²  There may be a genetic component that could potentially increase susceptibility to developing anorexia.²  Behaviors modeled from parents and peer groups and social media can also be a powerful influence.  There is a psychological prevalence with the disorder, but it is generally due to a distorted perception of the body composition.^1,2

The disorder causes extreme weight loss, low metabolism and fatigue,² as well as amenorrhea.¹  Severe long term cases can lead to osteopenia, Cushing disease and cardiac arrhythmias if left untreated.²

Biochemically, we might see low levels of potassium and chloride, low to normal thyroid hormones T3 and T4, anemic tendencies and low glucose.¹  Nutritional deficiencies across the board are evidenced as the main problem is the severe rejection of food.²  As the disorder persists, changes in metabolism, hormone control, and multiple conditions of malnourishment.²

 

Therapeutic Foods

Assuming an individual is ready to seek help, a nutritional rehabilitation program in order to restore weight and nutrition status is an appropriate dietary approach to anorexia and can be utilized on both an inpatient and an outpatient basis.³ Because those with anorexia avoid ingestion of food and therefore have an extremely low intake of calories, the initial goal is to begin with 30-40kcal per kg of weight per day.³  Rehydration is usually necessary initially along with a slow correction of malnutrition to prevent “refeeding”, a syndrome.²  A healthy balanced diet used in nutrition rehabilitation doesn’t suggest restrictions, but puts the focus on balance of foods offered across the spectrum.  Nutrition includes a nutrient dense focus on quality meats and proteins, fruits, vegetables, nuts, seeds, beans, green leafy vegetables, legumes and healthy fats.  It is also important to note that, as noted in the REAL food pyramid shown below, complete avoidance of “social foods” is not suggested.⁴

Evidence backed studies on effectiveness of any nutritional therapy in anorexia are varied and limited, as the methods of collecting data in such a study is difficult.  Considering the relapse rate in the disorder, no one specialized treatment protocol has been shown to be favorited,⁵ and nutritional studies seem to focus on refeeding and renourishing rather than long-term correction.

Medications used for anorexia are typically antipsychotics or anti-depressants, which can reduce the anxiety and d depression often associated with or from which the condition stems, can often cause constipation.²  For this, a nutritional rehabilitation program that includes fiber, fruit and vegetables is important.

A potential difficulty with a food plan such as this is that those with anorexia limit, restrict and avoid food.  A food plan of any kind can be difficult since avoiding food is the very nature of the illness.  Overcoming this would include a professional as a part of the intervention team that can assist with the often deep-rooted reasons behind the choices that led to anorexia to address the limiting beliefs and change the concepts surrounding calories, fats, and the necessity of diet.

 

Photo credit: S. Hart, C. Marnane, C McMaster, A. Thomas, original work 2018 Development of the "Recovery from Eating Disorders for Life" Food Guide (REAL Food Guide) - a food pyramid for adults with an eating disorder - PubMed (nih.gov) Creative license available at http://creativecommons.org/publicdomain/zero/1.0/ No changes made.

As the first goal is to restore weight, nutritious but calorie dense foods are suggested.³  Complex carbohydrates from breads, rice, and potatoes, as well as fruits, fruit juices and vegetables be offered.³  Whole grain toast is one option that meets these standards, offering fiber, folate, B vitamins important to a healthy complete diet. One study showed that 2 servings or more of white bread per day was statistically associated with the risk of overweight/obesity, whereas whole grain bread was not.⁶

A macro/micronutrient medical food powder can be an often well-tolerated addition when a client has difficulty in consuming quantities of food, and particularly to avoid the discomforts of refeeding.³  While there are not yet enough evidenced studies to support claims, medical foods are a way to gently refeed protein and micronutrients in a nourishing but not heavy way.

Supplements to Consider

Vitamin D – Vitamin D is typically insufficient in anorexia as with most other nutrients.  Adequate calcium and vitamin D is imperative to maintain bone mineral density.⁷,¹  1200 mg of calcium and 600-800IU of vitamin D is recommended in anorexia nervosa, with frequent serum monitoring.⁷

Multi vitamin/mineral – While there have not been clinical trials to demonstrate the effectiveness of a multivitamin/mineral intervention in anorexia, the fact that malnourishment is the key feature,¹ a quality supplement can begin to address all of the potentially dangerous effects malnourishment can bring and would possibly be a ore accepted way to begin re-nourishment on the part of the patient. Additional supplements supporting the systems and organs in which the malnourishment mostly affects the individual would be advantageous as well.

 

People To Add to Your Team

Anorexia is a complex condition that requires a solid team working together to deal with the many components.⁸  A mental health professional is certainly required as the disorder stems from perceptions and beliefs about body image and control.^1,2,8  For this reason, a therapist trained in Cognitive Behavior Therapy (CBT) may be an option to consider.  A meta-analysis of CBT for symptoms of anxiety and depression alongside primary care was shown to be more effective than primary care alone for the treatment of symptoms.^9,10  This could begin to address some of the underlying concepts that have lead to anorexic behaviors.

Conclusion

As with many disorders, anorexia is a complex multi-faceted condition that needs the care of a multi-membered team in support of the individual.  Anorexia is not a food restriction disorder alone, but a disorder that finds its roots extending into distortions of exercise, mental thought, and emotions as well.  If you or someone you know may be affected, learn more at websites like www.nimh.nih.gov/eatingdisorders.

 

References

1. Ross K. Eating Disorders. Presented as part of a Masters in Clinical Nutrition Program. SCNM, Tempe, AZ.  Accessed 3-21-22.
2. Stump SE. Nutrition and Diagnosis Related Care. 8th Editio. (Klein EM, ed.). Wolters Kluwer Health/Lippincott Williams and Wilkins; 2015.
3. Marzola E, Nasser JA, Hashim SA, Shih P an B, Kaye WH. Nutritional rehabilitation in anorexia nervosa: review of the literature and implications for treatment. BMC Psychiatry. 2013;13:290. doi:10.1186/1471-244X-13-290
4. Hart S, Marnane C, McMaster C, Thomas A. Development of the “Recovery from Eating Disorders for Life” Food Guide (REAL Food Guide) - a food pyramid for adults with an eating disorder. J Eat Disord. 2018;6(1). doi:10.1186/S40337-018-0192-4
5. Kass AE, Kolko RP, Wilfley DE. Psychological treatments for eating disorders. Curr Opin Psychiatry. 2013;26(6):549-555. doi:10.1097/YCO.0B013E328365A30E
6. De La Fuente-Arrillaga C, Martinez-Gonzalez MA, Zazpe I, Vazquez-Ruiz Z, Benito-Corchon S, Bes-Rastrollo M. Glycemic load, glycemic index, bread and incidence of overweight/obesity in a Mediterranean cohort: the SUN project. BMC Public Health. 2014;14(1). doi:10.1186/1471-2458-14-1091
7. Misra M, Klibanski A. Bone health in anorexia nervosa. Curr Opin Endocrinol Diabetes Obes. 2011;18(6):376. doi:10.1097/MED.0B013E32834B4BDC
8. Ozier AD, Henry BW, American Dietetic Association. Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Eating Disorders. J Am Diet Assoc. 2011;111(8):1236-1241. doi:10.1016/J.JADA.2011.06.016
9. Twomey C, O’Reilly G, Byrne M. Effectiveness of cognitive behavioural therapy for anxiety and depression in primary care: a meta-analysis. Fam Pract. 2015;32(1):3-15. doi:10.1093/FAMPRA/CMU060
10. Mulkens S, Waller G. New developments in cognitive-behavioural therapy for eating disorders (CBT-ED). Curr Opin Psychiatry. 2021;34(6):576-583. doi:10.1097/YCO.0000000000000745